Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patr

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Chapter 01: Professional Nursing Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which action by the nurse demonstrates implementation of Florence Nightingale’s original

theories about nursing care? a. The patient is gently bathed and given fresh linens after giving birth. b. The nurse forms a close therapeutic relationship with the patient. c. The nurse helps the patient conserve energy for healing processes. d. The nurse views the patient as a unique, ever-changing energy field.

ANS: A

Florence Nightingale worked to improve sanitation and healing environments for patients.

Gently bathing and providing fresh linens to patients is an example of Nightingale’s theory in practice. Formation of a close therapeutic relationship with the patient, energy conservation, and viewing patients as energy fields were not concepts included in Nightingale’s theory of nursing practice.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the influence of social, political, and economic changes on nursing practices.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 2. The nurse is mandated by the state to complete 25 contact hours of nursing education before

the nursing license may be renewed. Which term best describes this requirement? a. In-service education NURSINGTB.COM b. Advanced education c. Continuing education d. Certification education ANS: C

Continuing education is required for professionals in many states. Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses’ associations, professional nursing organizations, and educational and health care institutions. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the importance of education in professional nursing practice.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 3. The nurse is caring for a patient who suddenly becomes acutely short of breath. The nurse

elevates the head of the patient’s bed, checks the patient’s pulse oximetry, and administers 2 L of oxygen before notifying the patient’s physician. Which term best describes the actions of the nurse? a. Accountability

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 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 NCLEX-RN® 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the characteristics of professionalism in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 4. Which type of program is appropriate to educate staff about new fall prevention protocols that

are to be implemented on the nursing unit? a. In-service education b. Advanced education c. Continuing education d. Certification 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 em pNl o yR thGe i nBs .

Ued SbIy N T t iOtCu t i oMn . Some roles for RNs in nursing require advanced graduate degrees, such as a clinical nurse specialist or nurse practitioner. Continuing education is required for professionals in many states. Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses’ associations, professional nursing organizations, and educational and health care institutions.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the importance of education in professional nursing practice.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Management of Care 5. Which program is appropriate for a nurse who wishes to become an expert in ostomy and

wound care? a. Specialty certification b. Master of Science program c. Doctoral degree program d. Continuing education program ANS: A

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Specialty certification programs are appropriate for nurses who wish to become experts in certain areas of nursing care such as perioperative care, wound care, or occupational health.

Master of Science programs prepare nurses for advanced practice roles as educators, administrators, or clinical nurse leaders. Doctoral programs prepare nurses for advanced clinical practice and research. Continuing education is required for professionals in many states. Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses’ associations, professional nursing organizations, and educational and health care institutions.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the roles and career opportunities for nurses.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Management of Care 6. Which action of the nurse demonstrates coordination of care for the patient? a. The nurse creates a warm, therapeutic relationship with the patient by actively

listening to what the patient has to say. b. The nurse works with the physical therapist to determine how to best transfer the

patient from the bed to the chair. c. The nurse educates the patient about energy conservation techniques to increase activity tolerance. d. The nurse uses clear and objective language when documenting assessment findings in the patient’s medical record.

ANS: B

Coordination of care involves working with other health care professionals to meet the needs of the individual patient. The nurse can do this by working with the physical therapist to B.C determine how to best transferN UtheRSp aIt iNeGn t T from t M hO e bed to the chair. Developing a warm therapeutic relationship demonstrates caring and effective communication. Educating the patient about energy conservation and charting clearly are not examples of coordination of care.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the roles and career opportunities for nurses.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 7. The nurse feels that an assigned duty is outside the scope of nursing practice. Which

document is the best source to answer the nurse’s concern? a. ANA Code of Ethics b. State Nurse Practice Act c. QSEN Initiative Act d. Nurse’s Bill of Rights ANS: B

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

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 ANA’s 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 Quality and Safety Education for Nurses (QSEN) initiative responds to reports about safety and quality patient care by the National Academy, Health and Medicine Division. The Nurses’ Bill of Rights is a statement about the professional rights of nurses and does not dictate the scope of practice for nurses.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the purpose of professional standards of nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 8. Which professional nursing organization ensures that nursing programs adequately prepare

students to enter the nursing profession? a. Federal Nurses Association (FNA) b. International Council of Nurses (ICN) c. National League for Nursing (NLN) d. National Student Nurses Association (NSNA) ANS: C

The National League for Nursing (NLN) oversees nursing educational programs to help ensure that students are well prepared to enter the nursing profession. The Federal Nurses Association (FNA) is for nurses who are on active duty within the American Armed Forces.

The National Student Nurses Association (NSNA) provides a voice for nursing students and does not oversee nursing programs. The International Council of Nurses (ICN) is a global N R Ising GTcare B.Cf oO Mr all people. organization that promotes quaU litySnurN DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss the importance of education in professional nursing practice.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. Which actions of the nurse demonstrate the nursing role of leader? (Select all that apply.) a. The nurse implements a new skin-care protocol to reduce decubitus ulcers. b. The nurse develops a therapeutic relationship with the patient’s family members. c. The nurse ensures that the patient assignments are created fairly for each shift. d. The nurse works to meet the patient’s cultural preferences for personal care. e. The nurse clearly communicates expected standards of care for the patients.

ANS: A, C, E

The nurse functions as a leader by implementing new protocols, ensuring that patient assignments are made fairly and clearly communicating the expected standards of care.

Developing a therapeutic relationship and meeting the cultural preferences of patients are both caring behaviors of the nurse.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the roles and career opportunities for nurses.

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 TOP: Nursing Process: Implementation

MSC: NCLEX: Management of Care

2. Which actions of the nurse demonstrate the nursing role of educator? (Select all that apply.) a. The nurse teaches the patient’s family how to perform sterile dressing changes. b. The nurse includes the patient in clinical decision making whenever possible. c. The nurse provides written teaching materials in the patient’s preferred language. d. The nurse speaks about diabetes management at a professional conference. e. The nurse assesses for adequate protein intake for a patient on a vegetarian diet.

ANS: A, C, D

The nurse acts as an educator by teaching the patient’s family about care and speaking at professional conferences. Written teaching materials should be provided in the patient’s preferred language to maximize learning and retention of information. Determining protein intake is part of the assessment process. Including the patient in clinical decision making demonstrates the role of nurse as advocate.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the roles and career opportunities for nurses.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3. . Which nursing actions incorporate informatics into nursing practice? (Select all that apply.) a. The nurse uses written materials to teach a patient who is hard of hearing. b. The nurse uses an online database to learn more about the patient’s disease. c. The nurse uses a bar-code scanner to prevent medication administration errors. d. The nurse teaches the patient’s family how to perform range of motion. e. The nurse checks the electronic record to review the patient’s medical history.

ANS: B, C, E

NURSINGTB.COM

Informatics is the use of technology such as electronic medical records, online databases for research and bar-code scanning to prevent medication errors. Informatics does not apply to patient teaching through written materials or demonstration of range of motion.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the influence of social, political, and economic changes on nursing practices.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 4. Which action of the nurse demonstrates patient-centered care? (Select all that apply.) a. The nurse elevates the head of the bed when the patient becomes short of breath. b. The nurse and patient work together to determine the patient’s health goals. c. The nurse checks the patient’s name and birthdate before giving medications. d. The nurse maintains privacy when conversing with the patient and providing care. e. The nurse respects the patient’s choice to refuse transfusion of blood products.

ANS: B, D, E

Patient-centered care is demonstrated by maintaining privacy, respecting the patient’s choices and working together to determine the patient’s health goals. Checking the patient’s identifiers and elevating the head of the bed are routine nursing interventions that do not demonstrate patient-centered care.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the characteristics of professionalism in nursing.

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

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Chapter 02: Health and Wellness Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which statement by the patient indicates to the nurse that the patient is in the preparation

stage of smoking cessation? a. “I don’t ever want to quit smoking.” b. “I hope to quit smoking sometime before I die.” c. “I am really working hard to stop smoking.” d. “I stocked up on nicotine patches and gum.”

ANS: D

“I stocked up on nicotine patches and gum” indicates that the patient is in the preparation stage of behavior change. “I hope to quit smoking sometime before I die” indicates that the patient is in the contemplation stage. “I am really working hard to stop smoking” indicates that the patient is in the action stage. “I don’t ever want to quit smoking” indicates that the patient is in the precontemplation stage.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss 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 2. Which patient assessment finding must be addressed first according to Maslow’s hierarchy of

needs?

N R I G B.C M a. The patient is cyanotic andUfeeS l s shNort T of breatO h. b. The patient refuses to participate in physical therapy. c. The patient verbalizes anxiety about upcoming surgery. d. The patient is unable to reposition in bed without assistance.

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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss 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 3. Which patient action demonstrates the concept of health promotion? a. The patient receives the influenza vaccination every year. b. The patient participates in cardiac rehabilitation after a heart attack. c. The patient has yearly mammograms to screen for breast cancer. d. The patient follows a macrobiotic, vegetarian diet with organic foods.

ANS: D

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Health promotion includes activities to increase well-being and maximize health potential.

Patients can do this by following a healthy diet free of chemicals and preservatives. Influenza vaccination, mammograms, and cardiac rehabilitation are examples of health protection to avoid illness, detect it early or maintain function despite chronic illness.

DIF: Cognitive Level: Apply (Application) OBJ: Describe health promotion and illness prevention activities.

TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 4. Which assessment finding is an example of an internal variable that influences the patient’s

health beliefs? a. The patient’s spiritual beliefs prohibit the use of blood transfusions. b. The patient’s family is homeless after being evicted from their apartment. c. The patient relies on a pharmacy assistance program to pay for medications. d. The patient and community prefer natural medicines over prescription drugs.

ANS: A

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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the variables influencing health beliefs, health practices, and illness behaviors.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. Which action by the patient best represents primary prevention? a. The patient utilizes a cane when walking to prevent falls. b. The patient receives the iN nfU luR enSzI aN vaG ccTinBa. tioCnOeM very year. c. The patient participates in physical therapy after having a stroke. d. The patient takes prescribed blood pressure medication every morning.

ANS: B

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 and using a cane for ambulation are considered tertiary prevention as they prevent further complications.

DIF: Cognitive Level: Apply (Application) OBJ: Compare and contrast the three levels of prevention.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. Which assessment finding is a modifiable risk factor for disease? a. The patient has a family history of breast cancer. b. The patient smokes two packs of cigarettes every day. c. The patient was born with a congenital heart defect. d. The patient’s childhood home contained high levels of radon.

ANS: B

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Modifiable risk factors for disease may be changed to prevent the patient from becoming ill.

Tobacco use is an example of a modifiable risk factor. Childhood exposure to radon, congenital heart defect and family history of cancer are examples of nonmodifiable risk factors.

DIF: Cognitive Level: Apply (Application) OBJ: Explain how different types of risk factors affect a person’s health.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 7. Which is an example of an acute illness? a. Type 2 diabetes b. Multiple sclerosis c. Alcohol addiction d. Bacterial meningitis ANS: D

Acute illnesses are considered to last for a short time before resolving, such as bacterial meningitis. Chronic illness lasts longer than 6 months and includes diseases such as diabetes, addiction, and multiple sclerosis.

DIF: Cognitive Level: Apply (Application) OBJ: Explain how illness affects a patient and family.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 8. The diabetic patient sees the podiatrist regularly to prevent development of ulcers in the feet.

Which term best describes this action of the patient? a. Health promotion b. Primary prevention NURSINGTB.COM c. Secondary prevention d. Tertiary prevention ANS: C

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 and using a cane for ambulation are considered tertiary prevention as they prevent further complications. Health promotion includes activities to increase well-being and function rather than to prevent complications from existing disease.

DIF: Cognitive Level: Apply (Application) OBJ: Compare and contrast the three levels of prevention.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. Which statement indicates the patient’s perception of susceptibility to illness as described by

the Health Belief Model? a. “I am never going to get lung cancer so I refuse to stop smoking.” b. “Cancer is no big deal with all of the new treatments available now.” c. “I have been smoking for so many years that I will never be able to quit.” d. “I cannot afford the nicotine patches so I might as well keep on smoking.”

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 ANS: A

The first component of the Health Belief Model involves the patient’s assessment of susceptibility to illness. An example of this is the patient who denies the risk of lung cancer due to smoking. The second component of the Health Belief Model is the perception of the seriousness of the illness. An example of this is the patient who believes that cancer is no big deal. The third component of the Health Belief Model is the likelihood that the patient will take corrective action. An example of this is the patient who sees no need to quit smoking.

The Health Promotion Model includes the readiness for the patient to change. In this case, the patient has no intention to quit smoking.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss 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 action by the patient reflects a cultural influence on health practices? a. The patient uses seaside purification rituals to ease arthritis pain. b. The patient refuses to take blood pressure medicine due to the side effects. c. The patient has annual mammograms to screen for breast cancer. d. The patient avoids eating red meat due to a family history of heart disease.

ANS: A

Cultural background influences a person’s beliefs, values, and customs. It influences personal health practices. An example of this is the patient’s use of seaside purification rituals to ease arthritis pain. The patient’s preventative screening tests and refusal to take medications due to side effects are not due to cultural influences. Family history is separate from cultural influence.

NURSINGTB.COM

DIF: Cognitive Level: Apply (Application) OBJ: Describe health promotion and illness prevention activities.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 11. Which is an example of how a psychosocial variable affects the patient’s health beliefs? a. The patient was diagnosed with rheumatoid arthritis as a young child. b. The patient has always been terrified of needles and so never goes to the doctor. c. The patient’s neighborhood has few opportunities to buy fresh fruits or vegetables. d. The patient requires three antihypertensive medications to control blood pressure.

ANS: B

Fear of needles is an example of how a psychosocial variable affects the patient’s health beliefs. Diagnosis of arthritis, neighborhood availability of fresh fruits and the use of antihypertensive medications are not psychosocial variables.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the variables influencing health beliefs, health practices, and illness behaviors.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 12. Which statement by the nurse will help the patient progress to the preparation stage for

smoking cessation? a. “You will die of emphysema or lung cancer if you do not stop smoking.” b. “Research has shown that smoking causes emphysema and lung cancer.”

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 c. “The physician will give you nicotine patches to help you start to quit smoking.” d. “You need to avoid people who smoke so you will not be tempted to start again.”

ANS: C

Providing nicotine patches will help the patient to prepare to quit smoking. Threatening the patient with death and reminding the patient of the health risks due to smoking are not helpful.

Encouraging the patient to avoid smokers to avoid temptation to start smoking again indicates that the patient is in the maintenance or action stage already.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss 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 13. Which is an example of a Healthy People 2020 goal? a. Women and men will receive equally aggressive care for suspected heart attack. b. The patient will participate in a physical therapy program after suffering a stroke. c. The nurse will identify and address stressors unique to multicultural families. d. The nurse will organize mobile mammograms for female patients in the local area.

ANS: A

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. Eliminating differences in care for women and men with suspected heart attack is an example of a Healthy People 2020 goal. Identifying stressors and organizing mammograms are examples of interventions.

Healthy People 2020 focuses on health promotion and protection at the community level rather than recovery of the individual patient after acute illness.

N R I G B.C M

U S N T O DIF: Cognitive Level: Apply (Application) OBJ: Discuss the nurse’s role in caring for people, communities, and populations in various states of health and illness.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 14. Which action of the nurse addresses Maslow’s need for love and belongingness? a. The nurse uses a gait belt and assists the patient to use a walker for ambulation. b. The nurse encourages a widowed patient to join a bereavement support group. c. The nurse plans daily care to allow for rest periods for the patient as needed. d. The nurse reorients the patient to time and place during periods of acute confusion.

ANS: B

The widowed patient can help to achieve Maslow’s need for love and belongingness by joining a bereavement support group. Use of a gait belt for ambulation meets the patient’s basic physiological needs. Reorientation of a confused patient and allowing for rest periods do not facilitate the patient to achieve the feeling of belonging in a group.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss 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 15. Which action by the nurse helps to meet the aesthetic needs of the patient as described by

Maslow?

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 a. b. c. d.

The nurse uses a drawsheet to carefully reposition the patient in bed.

The nurse puts a beautiful handmade quilt on the bed for the patient to enjoy.

The nurse collaborates with the health care team when scheduling care activities.

The nurse assesses the patient’s readiness to learn before beginning teaching.

ANS: B

Aesthetic needs address the patient’s desire to appreciate things of beauty and balance.

Meeting the patient’s aesthetic needs can include putting a beautiful handmade quilt on the bed for the patient to enjoy. Using a drawsheet helps to meet the patient’s physiological need for protection from injury. Collaboration with the health care team and assessing readiness for learning do not address aesthetic needs.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss 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 16. Which action by the nurse helps to meet the cognitive needs of the patient as described by

Maslow? a. Encouraging early ambulation after surgery to prevent formation of blood clots. b. Providing a calm environment when the patient becomes agitated and confused. c. Teaching the patient’s family how to perform sterile dressing changes. d. Performing careful perineal care to avoid development of a urinary tract infection.

ANS: B

Providing a calm environment when the patient becomes agitated and confused helps to meet the cognitive needs of the patient. Encouraging postoperative ambulation meets physiological needs of the patient to prevenNt i nR j u r yI. TeGachB in.g C the M patient’s family how to do dressing U S N T O changes and performing careful perineal care do not facilitate cognitive function of the patient.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss 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 17. Which action of the nurse demonstrates the concept of the Holistic Health Model? a. The nurse incorporates the patient’s religious restrictions, economic status and

personal preferences when developing the nutrition plan. b. The nurse has the patient demonstrate how to perform a sterile dressing change after teaching about the procedure. c. The nurse consistently uses a 0-10 objective pain rating scale to achieve consistent pain management for the patient. d. The nurse assists the patient to sit up slowly when getting out of bed to avoid fainting from orthostatic hypotension.

ANS: A

The nurse considers the patient’s physical, emotional, and spiritual needs to plan care within the Holistic Health Model. The use of return demonstration, objective pain rating scales, and hypotension prevention measures address only the physical needs of the patient.

DIF: Cognitive Level: Apply (Application)

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 OBJ: Discuss 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 18. Which is an example of an environmental risk factor? a. The patient’s drinking water contains high levels of lead. b. The patient has a strong family history of autoimmune diseases. c. The patient carefully follows a lactose-free, gluten-free diet. d. The patient drinks one glass of red wine every night before bed.

ANS: A

Environmental risk factors include exposure to toxic chemicals through drinking water.

Family history, dietary preference, and alcohol intake are not examples of environmental risk factors.

DIF: Cognitive Level: Apply (Application) OBJ: Explain how different types of risk factors affect a person’s health.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 19. Which assessment finding indicates that the family processes were interrupted by the patient’s

illness? a. The patient must now follow a gluten-free, low-carbohydrate diet. b. The patient must use a walker for ambulation to prevent a fall or injury. c. The patient’s spouse had to return to work to maintain the family’s income. d. The patient must take three antihypertensive drugs to control high blood pressure ANS: C

The need for the patient’s spouse to I return work M demonstrates that a family process was N RS G to B.C U N T interrupted by the patient’s i l l n es s . Th e n e e d to chOange the patient’s diet, need for multiple antihypertensive drugs, and use of a walker do not indicate changes to the family process.

DIF: Cognitive Level: Apply (Application) OBJ: Explain how illness affects a patient and family.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 20. Which assessment finding indicates that the patient’s body image has been altered due to

illness? a. The patient developed a strong dislike for any kind of spicy foods. b. The patient feels uncomfortable wearing a swimsuit after colostomy surgery. c. The patient refuses to take antihypertensive medications due to the side effects. d. The patient drinks six glasses of cranberry juice daily to prevent bladder infections.

ANS: B

An example of altered body image after illness is the patient’s discomfort when wearing a swimsuit after colostomy surgery. Dislike of spicy foods, refusal to take medication, and drinking cranberry juice do not illustrate altered body image.

DIF: Cognitive Level: Apply (Application) OBJ: Explain how illness affects a patient and family.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 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 attain better health b. Detect the presence of illness c. Promote health behaviors in a patient d. Assess a family’s response to illness e. Stimulate relational transcendence 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. Transcendence is the final stage in Maslow’s hierarchy and does not relate to the Health Promotion Model. The Health Promotion Model does not focus on illness.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe health promotion and illness prevention activities.

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

NURSINGTB.COM

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Chapter 03: The Health Care Delivery System Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which is an example of tertiary care? a. The patient has annual mammograms to screen for breast cancer. b. The patient sees the podiatrist monthly to prevent diabetic foot ulcers. c. The patient is seen at an urgent care clinic to treat a badly sprained wrist. d. The patient is treated in the intensive care unit following a gunshot injury.

ANS: D

Tertiary care includes intensive care after a gunshot injury. Primary care is centered on prevention of disease such as annual mammograms and podiatry visits. Secondary acute care treats existing disease such as sprained wrist care.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the six levels of health care.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 2. Which agency would be most appropriate for a patient who requires rehabilitation services for

right-sided hemiplegia after a stroke? a. Respite center b. Primary care center c. Restorative care center d. Assisted-living center ANS: C

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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 people who provide full-time care to an older adult.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role of nurses in various health care settings.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3. Which form of insurance is appropriate for a single mother who is unable to work and her

three children? a. State Medicaid b. Federal Medicare c. Private insurance d. Managed care program 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.

DIF:

Cognitive Level: Apply (Application)

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 OBJ: Discuss the factors that affect a person’s access to health care.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. Which is an example of a patient-centered medical home team? a. Occupational and physical therapists come to the patient’s home to provide

rehabilitation services. b. The patient’s primary care physician coordinates care with the patient’s social worker and respiratory therapist. c. The nurse assesses the patient’s home environment for irritants that can worsen the patient’s respiratory status. d. A home care company is employed to provide the patient with a nebulizer and supplemental oxygen equipment.

ANS: B

The patient-centered medical home model focuses on smooth coordination of care between various health care disciplines. An example of this would be the physician’s coordination of care with the social worker and respiratory therapist. The patient-centered medical home does not focus on care provided at the patient’s home.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the features of an integrated health care system.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 5. Which is an example of a tertiary health care provider? a. An outpatient rehabilitation center b. A nurse-managed urgent care clinic c. A university-based research hospital

d. A community center offeN rinUgRaS duIltNdG ayTcBa. reCseOrM vices ANS: C

A university-based teaching hospital is an example of a tertiary health care provider as it provides care from specialized consultants. A nurse-managed urgent care clinic is a primary health care provider. An outpatient rehabilitation center is a secondary health care provider. A community center offering adult day care services is a continuing care provider.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the six levels of health care.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 6. Which assessment question allows an administrator to determine the level of patient

satisfaction after hospitalization? a. “Did the nursing staff treat you with respect and maintain your privacy?” b. “Were you able to keep the follow-up appointment with your physician?” c. “Did you have any difficulty filling your prescriptions after discharge?” d. “Has the occupational therapist come to your home to start therapy yet?”

ANS: A

Asking the patient about treatment by the nursing staff during hospitalization is an excellent way for the administrator to determine the level of patient satisfaction. Asking about follow-up appointments, prescriptions, and home therapy will not determine the level of patient satisfaction.

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 DIF: Cognitive Level: Apply (Application) OBJ: Explain approaches nurses can use to improve patient satisfaction.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 7. The patient is nauseated and vomiting when the nurse attempts to provide discharge teaching.

Which is the most appropriate action of the nurse? a. Administer antinausea medication and provide discharge teaching later. b. Provide written materials to the patient to read when the nausea has subsided. c. Provide discharge teaching to the family members while the patient rests. d. Assist the patient with mouth care and proceed with the discharge teaching.

ANS: A

Patients cannot effectively learn when they are in discomfort or nauseated. The nurse should administer antinausea medication and provide discharge teaching later when the patient is ready. Providing written materials, teaching family members, and proceeding with teaching after mouth care are not appropriate actions of the nurse in this situation.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the elements of discharge planning.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 8. How will the hospital be reimbursed by Medicare for an elderly patient admitted with

pneumonia? a. Based upon the DRG for pneumonia b. Based upon the cost of the patient’s care c. Based upon the patient’s length of stay d. Based upon the types of therapies required ANS: A

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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 patient’s length of stay or use of services in the hospital or the number of medications.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the concept of “pay for value” used to reward hospitals financially.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 9. Which is an example of capitation in health care? a. The patient’s rheumatologist is reimbursed for services provided at each

consultation appointment with the patient. b. The discharge planner arranges for a home respiratory care company to deliver

home oxygen supplies before the patient leaves the hospital. c. The patient’s care is managed by a nurse practitioner rather than an attending

physician. d. The patient’s primary care physician is paid a flat monthly fee no matter how

many appointments are scheduled with the patient.

ANS: D

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

The purpose of capitation is to build a payment plan for a provider that is not dependent upon the amount of health care services provided to the patient. An example of capitation is a flat monthly fee paid to the physician no matter how many appointments are scheduled with the patient. Reimbursement for individual appointments with the patient is referred to as fee for service. Capitation does not refer to care management by nurse practitioners or discharge planning.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the concept of “pay for value” used to reward hospitals financially.

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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the six levels of health care.

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

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11. The nurse has taught the patient about how to perform sterile dressing changes. Which action

by the nurse best assesses whether or not the patient’s discharge teaching was effective? a. The nurse watches the patient perform the sterile dressing change and provides feedback as needed. b. The nurse provides additional written instructions as a reminder of how to correctly perform the procedure. c. The nurse includes the patient’s spouse when teaching the patient how to perform the sterile procedure. d. The nurse asks the patient and spouse if they have any further questions about how to perform the procedure.

ANS: A

Return demonstration is the most effective way for the nurse to determine that the patient is able to perform the procedure correctly. Providing additional instructions, teaching the spouse, or asking if there are additional questions will not allow the nurse to determine that the patient is able to perform the procedure correctly.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the elements of discharge planning.

MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Evaluation

12. Which patient will be treated in a Critical Access Hospital (CAH)? a. The cancer patient who requires a bone marrow transplant

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 b. The victim of a serious car accident that occurred in a remote area c. The pregnant patient whose baby will require neonatal intensive care d. The patient who requires minimally invasive heart valve replacement ANS: B

A Critical Access Hospital (CAH) is designed to provide emergent care to patients in rural areas before they are transferred to larger urban facilities. The CAH will not provide bone marrow transplant, heart surgery, or neonatal intensive care services.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the factors that affect a person’s access to health care.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 13. Which type of patient is an appropriate candidate for restorative care services? a. A patient who uses supplemental oxygen for emphysema b. A patient who is actively dying of metastatic cancer c. A patient with right-sided hemiplegia after a recent stroke d. A patient with depression who tried to commit suicide ANS: C

A patient with right-sided hemiplegia after a recent stroke is an appropriate candidate for restorative care services to hopefully regain lost function. Patients who are actively dying should be referred to hospice care. Suicidal patients require mental health services. A patient who uses supplemental oxygen requires delivery of equipment from a home respiratory therapy company.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the six levels oN f he R alth I c a r eG . B.C M U S N T NCLEX: O Management of Care TOP: Nursing Process: Implementation MSC: 14. Which information is included in the Minimum Data Set? a. The patient has a history of gout and macular degeneration. b. The average length of stay for pneumonia is 3 days in the hospital. c. The hospital has a 14% nosocomial urinary tract infection rate. d. Approximately 40% of American adults exercise at least 30 minutes daily.

ANS: A

The Minimum Data Set is a comprehensive patient assessment that is utilized to create the plan of care for residents in nursing homes. The Minimum Data Set does not include information about hospital infection rates, American exercise habits, or average length of stay.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss the role of nurses in various health care settings.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 15. Which patient is appropriate for an assisted-living agency? a. A patient who requires tube feeding and frequent tracheostomy suctioning after a

massive stroke b. A patient with dementia who requires supervision during the day when family

members are at work c. A patient with severe depression who has made three suicide attempts in the last 6

months

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 d. A patient who can perform activities of daily living independently but requires

assistance with daily medications ANS: D

A patient who can perform activities of daily living independently but requires assistance with daily medications is an appropriate candidate for an assisted-living agency. A patient who requires tube feeding and frequent tracheostomy suctioning after a massive stroke requires placement in a skilled nursing facility. A patient with dementia who requires supervision during the day when family members are at work requires adult day care services. A patient with severe depression who has made three suicide attempts in the last 6 months requires placement in a mental health agency.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role of nurses in various health care settings.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16. Which patient is the highest priority for the discharge planner? a. A patient who will require home IV antibiotics for the next 6 weeks b. A patient who will be taking antihypertensive medications after discharge c. A patient who will be discharged after routine tonsillectomy surgery d. A patient who will be returning to a local skilled nursing facility ANS: A

The patient who will require home IV antibiotics for the next 6 weeks is the highest priority for the discharge planner as several home care services will have to be arranged prior to discharge. Patients with new prescriptions, patients who are returning to skilled nursing facilities, and patients going home after routine surgeries are lower priority for the discharge planner.

NURSINGTB.COM DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the elements of discharge planning.

MSC: NCLEX: Management of Care

TOP: Nursing Process: Planning

17. Which is an example of respite care? a. A patient with dementia attends an adult day care center so that the patient’s

family can go to work. b. The respiratory therapist comes to the patient’s house to ensure that the oxygen equipment is functioning correctly. c. The nurse teaches the patient’s spouse how to check blood sugar levels and administer insulin to the patient. d. The patient is seen in an urgent care clinic for stitches and wound care after being bitten by a dog.

ANS: A

Respite care allows caregivers a break from caring for the patient. A patient with dementia attends an adult day care center so that the patient’s family can go to work is an example of respite care. Respiratory home care services, urgent care services, and patient education are not examples of respite care.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the types of settings in which professionals provide various levels of health care.

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

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 18. Which is the expected action of the nurse who is caring for a patient in a hospice agency? a. The nurse teaches the patient how to administer home IV antibiotics through an

intravenous line. b. The nurse educates the patient’s family about what to expect as the patient

progresses through the dying process. c. The nurse reviews the patient’s daily laboratory results before preparing to

administer the next dose of chemotherapy. d. The nurse teaches the patient about the importance of swallow precautions to avoid

the development of aspiration pneumonia.

ANS: B

Hospice nurses assist patients and families through the end stages of terminal illness. The nurse works to keep the patient comfortable and educates the patient’s family about what to expect as the patient progresses through the dying process. Hospice nurses do not administer chemotherapy, teach patients how to administer home IV antibiotics, or teach the importance of swallow precautions.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role of nurses in various health care settings.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 19. Which is an example of a diagnosis-related group (DRG)? a. Patients recovering from orthopedic surgery are placed on the same nursing unit. b. Specialty hospitals are utilized to treat patients with life-threatening illnesses. c. The speech therapist is consulted to see every patient admitted with dysphagia. d. Hospitals will be paid $4 500 to c are for pa ti ents with uncomplicated pneumonia ANS: D

N RU I S NG TB . CO M

When a diagnosis-related group (DRG) is used, the hospital is reimbursed a flat fee for treatment of patients with each diagnosis. For instance, a hospital will be paid $4500 to care for patients with uncomplicated pneumonia. Consulting the speech therapist for dysphagia, placing patients with similar surgeries on the same unit and specialty hospital use are not examples of DRGs. DIF: Cognitive Level: Apply (Application) OBJ: Explain the concept of “pay for value” used to reward hospitals financially.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 20. Which is a responsibility of the Centers for Medicare and Medicaid (CMS)? a. Create teaching materials to educate health care professionals. b. Research evidenced-based practices to improve health care for patients. c. Accredit and certify hospitals in order to ensure safe health care for patients. d. Manage health insurance coverage for elderly, disabled, and low-income patients.

ANS: D

The Centers for Medicare and Medicaid (CMS) manage health insurance coverage for elderly, disabled, and low-income patients. CMS is not responsible for educating health care providers, researching evidence-based practices, or accrediting hospitals.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss the factors that affect a person’s access to health care.

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 TOP: Nursing Process: Implementation

MSC: NCLEX: Management of Care

21. Which action by the nurse helps to achieve the goals of the Hospital Readmissions Reduction

Program? a. The nurse ensures that the patient understands how to take prescribed medications correctly. b. The nurse develops a close therapeutic relationship with the patient and provides privacy when care is provided. c. The nurse uses therapeutic touch to promote relaxation, reduce anxiety, and promote healing. d. The nurse elevates the head of the patient’s bed and administers oxygen when the patient feels short of breath.

ANS: A

The goal of the Hospital Readmissions Reduction Program is to prevent patients from returning to the hospital after discharge. The nurse can do this by ensuring that the patient understands how to take prescribed medications correctly. Developing a therapeutic relationship with the patient, using therapeutic touch, and elevating the head of the bed during dyspneic episodes will not help prevent readmission after discharge.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the concept of “pay for value” used to reward hospitals financially.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 22. Which is an example of a Bundled Payment for Care Improvement? a. The insurance company combines services for several patients into one single

payment.

N R I G B.C M

b. The hospital is paid a pred eUt erm Si n eNd luTmp sumO for all costs related to the patient’s

open-heart surgery.

c. The hospital is paid an additional bonus if the patient’s surgical outcome exceeds

national standards. d. The insurance company will withhold all payments for the patient until

accreditation is achieved.

ANS: B

Insurance companies may bundle payments together in order to improve health care and reduce costs. All of the costs for a patient’s surgical procedure are bundled together into one predetermined lump sum. Combining services for several patients into one single payment is not an example of a Bundled Payment for Care Improvement. Patients do not receive bonuses if the patient’s surgical outcome exceeds national standards. Bundled payments do not lead insurance companies to withhold payment until accreditation is achieved.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Explain the concept of “pay for value” used to reward hospitals financially.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 23. Which feature of the hospital enables it to qualify for Magnet Recognition Program? a. The hospital cafeteria is open 24 hours to accommodate staff on every shift. b. The nurses utilize evidence-based practice and flexible staffing plans. c. The hospital radiology technicians have received additional certifications. d. The hospital physicians provide mentoring services for interns and residents.

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 ANS: B

Magnet status is awarded by the American Nurses Credentialing Center to hospitals with excellent nursing care. This includes the use of evidence-based practice and flexible staffing plans. Magnet status is not about radiology certification, mentoring of medical staff, or hospital cafeteria hours.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss the role of nurses in various health care settings.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 24. The patient uses a special telephone connection to allow the cardiologist to assess the patient’s

pacemaker function while the patient stays at home. Which term is used to describe this type of health care? a. Capitation b. Telemedicine c. Magnet Recognition Program d. Utilization review ANS: B

Telemedicine is the use of technology to improve the patient’s health status. This includes the use of telephone connections for pacemaker assessment. Utilization review committees evaluate hospital admissions to ensure that resources are used appropriately. Magnet status is achieved by hospitals with high nursing standards. Capitation is a form of insurance reimbursement.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the types of settings in which NntatR I Gprofessionals B.C M provide various levels of health care.

S TOP: Nursing Process: ImplemeU i on N MTS C : NCOLEX: Management of Care 25. Which is an example of health care disparity? a. The physician treats cardiac patients with insurance more aggressively than

noninsured patients. b. The patient takes longer to recover from surgery due to a history of aggressive

rheumatoid arthritis. c. The nurse prioritizes care so that additional time is spent with patients who require

more intensive interventions. d. The registered nurse is able perform more advanced interventions than the licensed

practical nurse.

ANS: A

Health care disparities occur when patients receive substandard care due to socioeconomic, cultural, or ethnic characteristics. Delayed surgical recovery, prioritization of nursing care, and nursing scope of practice are not examples of health care disparity.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the effects of health disparities on the health of a community.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 26. Which type of health care agency is appropriate for a patient who sustained a back injury

while at work? a. Respite care center

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 b. Skilled nursing facility c. Occupational health clinic d. Outpatient surgical center ANS: C

The occupational health clinic is the appropriate agency for a patient who sustained a back injury while at work. Respite care centers provide relief for caregivers. Skilled nursing facilities are long-term care centers. There is nothing in the scenario to indicate that the patient requires surgery.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the types of settings in which professionals provide various levels of health care.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. Which goals are appropriate for a patient in a restorative care agency? (Select all that apply.) a. The patient will be able to transfer to the wheelchair with one person assist. b. The patient’s family will verbalize understanding of the dying process. c. The patient will be able to eat independently using specially molded utensils. d. The patient will be transferred to a trauma hospital within 1 hour of arrival. e. The patient’s family will verbalize feeling of relief from strains of caregiving.

ANS: A, C

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.

Appropriate goals for restorative care include the patient’s ability transfer to the wheelchair NUden R Stly I G MOl utensils. Understanding of the dying with one assist and eat indepen uNsinB.C T g specia process is appropriate for hospice care. Transfer to a trauma hospital is appropriate for Critical Access Hospitals. Respite care goals include feelings of relief for caregivers.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the types of settings in which professionals provide various levels of health care.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 2. Which health care professionals will participate in discharge planning for the patient? (Select

all that apply.) a. Registered nurse b. Radiology technician c. Social worker d. Physical therapist e. Laboratory technician ANS: A, C, D

The registered nurse, social worker, and physical therapist all participate in discharge planning for patients. Radiology and laboratory technicians provide specific services for patients during hospitalization and do not participate in discharge planning for patients.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the elements of discharge planning.

MSC: NCLEX: Management of Care

TOP: Nursing Process: Planning

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Chapter 04: Community-Based Nursing Practice Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which is an appropriate goal within the scope of Healthy People 2020? a. Uninsured patients will receive the same level of care as patients with private

health insurance. b. The patient will be able to transfer to the wheelchair with a gait belt and assistance of one person. c. The patient’s family will verbalize reduction of stressors when respite care is provided for the patient. d. Family members are taught how to assist the patient with feeding and other activities of daily living.

ANS: A

Healthy People 2020 focuses on health promotion and elimination of disparities in health care. Equal treatment for insured and uninsured patients is an appropriate goal within the scope of Healthy People 2020. Improvement in the patient’s condition after illness and family involvement in care are not goals within the scope of Healthy People 2020.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate community health nursing from community-based nursing.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 2. Which is an example of an incidence rate? B.C M N R I0 G a. The patient was able to am U b ulaSte 5N feTet in 10Ominutes. b. 65% of the hospital’s registered nurses are bachelor-prepared. c. The hospital has a 12% ventilator-associated pneumonia rate. d. The patient’s hemoglobin rate is 50% lower than the previous day.

ANS: C

Incidence rates identify the frequency with which certain events occur. An example of an incidence rate is 12% of the patients in the hospital develop ventilator-associated pneumonia.

Drop in hemoglobin levels, rate of ambulation, or percentage of bachelor-prepared nurses are not examples of incidence rates.

DIF: Cognitive Level: Apply (Application) OBJ: Describe elements of a community assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. Which is an appropriate goal for the public health nurse working in the community? a. At least 95% of children in the elementary schools will be up to date on

immunizations. b. The family will learn how to transfer the patient to the toilet and assist the patient to dress each morning. c. The patient’s white blood cell count will return to normal by the time the antibiotic treatment has been completed. d. Nursing assistants will be allowed to administer routine medications to residents of assisted care facilities.

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 ANS: A DIF: Cognitive Level: Apply (Application) OBJ: Explain the relationship between public and community health nursing.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 4. Which is the priority goal for a patient who is being abused by the spouse? a. The patient’s dignity will remain intact. b. The patient will remain free from injury. c. The patient will develop a sense of trust with the nurse. d. The patient will be able to verbalize fears to the nurse.

ANS: B

The highest priority goal for this patient is to remain free from injury. The other needs are psychosocial and less important than the patient’s safety.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the role of the nurse in community-based practice.

TOP: Nursing Process: Planning MSC: NCLEX: Safety and Infection Control 5. The nurse identified the source of food poisoning as a local restaurant and ensured that no

further patrons became ill. Which community health nursing role was demonstrated by these actions? a. Caregiver b. Educator c. Epidemiologist d. Case manager ANS: C

As epidemiologist, c o m m u n iN t yUhRe aSl t I hN nuGrsTeB s u.sC e bOaM sic 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 patient’s well-being across a continuum of care. The scenario does not indicate that the community health nurse provided direct care to the food poisoning victims.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role of the nurse in community-based practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 6. Which problem is the highest priority for a family who has just moved to the United States

and does not speak any English? a. Risk for acute confusion b. Disturbed energy field balance c. Impaired verbal communication d. Readiness for enhanced decision making ANS: C

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

The highest priority for the family is the need for effective communication because they do not speak English. This will cause difficulties with employment, health care and daily activities of living. Nothing in the scenario indicates that a family member is at risk for confusion. Enhanced decision making and energy field balance can be addressed after the language barrier is resolved.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the characteristics of patients from vulnerable populations that influence a nurse’s approach to care.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 7. Which is the highest priority problem for a homeless patient without family in December? a. Risk for loneliness b. Risk for hypothermia c. Risk for social isolation d. Risk for compromised human dignity ANS: B

Safety and physiological needs are more important than psychosocial needs. Therefore hypothermia is higher priority than loneliness, social isolation, or dignity.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the characteristics of patients from vulnerable populations that influence a nurse’s approach to care.

TOP: Nursing Process: Implementation MSC: NCLEX: Diagnosis 8. Which is an appropriate action of the community-based nurse when functioning in the role of

case manager? a. The nurse calculates the iN m mR unS iI z aN t i oGTn rB at. e fO Co r jMunior high-school students in the U district. b. The nurse arranges for a transportation service to take the patient to physician appointments. c. The nurse uses therapeutic touch to help relieve the patient’s chronic low back pain. d. The nurse helps the patient to sit upright and use pursed lip breathing during periods of dyspnea.

ANS: B

The nurse fulfills the role of case manager by arranging and organizing medical services for the patient including transportation to and from appointments. Calculating the immunization rate is the role of epidemiologist. Therapeutic touch and relieving dyspnea are caring nursing interventions.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role of the nurse in community-based practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which are socioeconomic factors that contribute to the health of a community? (Select all that

apply.) a. The community covers a total area of 14 square miles.

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 b. c. d. e.

Almost 25% of the residents are of Native American descent.

Nearly 35% of the residents are eligible for free school lunches.

Approximately half of the residents work in the local automobile factory.

The community recently built a new hospital and medical office building.

ANS: B, C, D, E

Eligibility for free school lunches, racial makeup of the residents, new hospital, and employment are all socioeconomic factors that contribute to the health of a community. The square mileage of the town is not a socioeconomic factor that contributes to the health of the community.

DIF: Cognitive Level: Apply (Application) OBJ: Describe elements of a community assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. Which patients are considered to belong to vulnerable populations? (Select all that apply.) a. An HIV-positive young adult working as a finance expert b. A college graduate living in his parents’ basement c. A registered nurse who works at two different clinics d. An unemployed single mother with four small children e. A family that just moved to Florida and speaks no English ANS: A, D, E

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 working two jobs are not examples of vulnerable populations.

NURSINGTB.COM

DIF: Cognitive Level: Apply (Application) OBJ: Explain the characteristics of patients from vulnerable populations that influence a nurse’s approach to care.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. Which findings are included in the nurse’s community assessment? (Select all that apply.) a. Approximately 15% of the residents are college graduates. b. The community’s water system is free of arsenic and lead. c. The community’s mayor has been in office for the last 18 years. d. The community average summer temperature is 78 F. e. The community has paid police officers and volunteer firefighters.

ANS: A, B, E

Community assessment includes educational level, water purity, and emergency services. The tenure of the mayor and average summer temperatures are not included in the nurse’s community assessment.

DIF: Cognitive Level: Apply (Application) OBJ: Describe elements of a community assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. Which communication methods will the community nurse use when interacting with recent

immigrants who do not speak English? (Select all that apply.) a. The nurse will obtain the assistance of a speech pathologist.

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 b. c. d. e.

The nurse will speak in a louder tone of voice than usual.

The nurse will be sensitive to nonverbal communication cues.

The nurse will identify the preferred language for each family member.

The nurse will utilize an interpreter when explaining health care procedures.

ANS: C, D, E

The nurse should be sensitive to nonverbal communication cues, identify the preferred language for each family member, and utilize an interpreter when explaining health care procedures. Speaking loudly will not facilitate communication with patients who are not hard of hearing. A speech pathologist will not be helpful for communicating with family members who do not speak English.

DIF: Cognitive Level: Apply (Application) OBJ: Describe competencies important for success in community-based nursing practice.

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

NURSINGTB.COM

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

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

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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 2. The nurse is frustrated with an agitated patient and tells him “Now stay in that bed or I will

make you stay there!” Which tort has the nurse just committed?

NURSINGTB.COM a. Assault b. Battery c. Incursion d. Onslaught ANS: A

The nurse has committed assault by threatening the patient. No actual contact is required for an assault to occur. Battery occurs when the patient is touched without consent. Onslaught and incursion are not legal terms.

DIF: Cognitive Level: Apply (Application) OBJ: Describe 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 3. Which organization will discipline the nurse for abandoning patients during an assigned shift? a. The Joint Commission b. The State Board of Nursing c. The State Department of Health d. The National League for Nursing ANS: B

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

The State Board of Nursing sets rules, regulations, and guidelines that specifically define the standard of care in nursing practice. An example is the guideline that defines patient abandonment. The State Board of Nursing also investigates allegations of nursing misconduct and disciplines nurses who have failed to comply with the state Nurse Practice Act. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the legal concepts of standard of care and informed consent.

TOP: Nursing Process: Evaluation MSC: NCLEX: Evaluation 4. The nurse is accused of stealing narcotic pain medications from patients. Which type of crime

may the nurse be charged with? a. Tort b. Felony c. Malpractice d. Misdemeanor ANS: B

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 person’s 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 N Ro uIsNe Gt hTB.C Me of care that a reasonable nurse would use nursing malpractice as the failuUre tS e degreO under the same or similar circumstances.

DIF: Cognitive Level: Apply (Application) 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 cuts an unconscious patient’s long hair in order to wash and brush it. The patient

wakes up and is very upset after seeing the short hair. Which tort did the nurse commit? a. Battery b. Assault c. Slander d. Negligence ANS: A

Battery is intentional offensive touching without consent or lawful justification. 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. Negligence is an unintentional tort. Slander is making malicious statements that can damage an individual’s reputation.

DIF: Cognitive Level: Apply (Application) OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: Nursing Process: Evaluation

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 MSC: NCLEX: Management of Care 6. The patient suffers a large hematoma at the site after arterial blood gases (ABGs) are drawn

by the respiratory therapist. Which statement is appropriate to enter in the patient’s chart? a. Patient has a painful, raised 2-inch  2-inch hematoma inside his right wrist after ABGs were drawn there. b. The patient must have moved during the ABG draw because there is a huge bruise inside his wrist. c. The respiratory therapist had a hard time getting the patient’s ABGs drawn and caused bruising. d. The respiratory therapist obviously didn’t know what he was doing and traumatized the patient’s wrist.

ANS: A

Narrative notes must be objective without opinions, speculation, or blame. The nurse should chart the location and size of the hematoma along with the reason. The nurse should not speculate that patient moved or that the respiratory therapist did not know how to perform the skill.

DIF: Cognitive Level: Apply (Application) OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 7. Which situation gives the patient cause to sue for malpractice due to injury or harm? a. The patient developed an itchy rash after receiving a prescribed antibiotic. b. The patient died after being struck in the head by an oxygen tank during an MRI. c. The patient developed a sN oU reR thSroIaN t aGftT erBb.eiC ngOiMn t ub at e d for emergency surgery. d. The patient developed permanent joint deformity due to severe rheumatoid

arthritis.

ANS: B

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 nurse’s breach of duty, and (4) the patient has accrued damages as a result of the injury. Patient death due to injury from an oxygen tank in the MRI room is an example of malpractice as the professionals should have taken the proper precautions. Itchy rash after antibiotic use is a side effect. Sore throat after intubation is an expected complication. Permanent joint deformity due to severe rheumatoid arthritis is an unfortunate outcome of chronic illness.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the concept of negligence and identify the elements of professional negligence.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 8. What is the primary difference between negligence and malpractice? a. Malpractice is intentional while negligence is unintended. b. Malpractice is a felony while negligence is a misdemeanor. c. Malpractice leads to more serious patient injury than negligence. d. Malpractice is committed by a licensed professional while negligence is not.

ANS: D

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Malpractice may sometimes be referred to as professional negligence. Negligence occurs when the level of care provided to the patient falls below the generally accepted standard.

When negligence is committed by a licensed professional, it is termed malpractice.

Malpractice may be intentional or unintended. Malpractice may be considered a felony or a misdemeanor depending on the circumstances. Both negligence and malpractice can lead to serious patient injury.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Explain the concept of negligence and identify the elements of professional negligence.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 9. A nurse wants to follow nursing standards of care. Which document should the nurse follow? a. National League for Nursing manuscript b. World Health Organization guiding principles c. Health care agency’s written procedure manual d. US Department of Health and Human Services guidelines ANS: C

The health care agency’s 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 nurse’s health care agency. Manuscripts are not standards of care. The World Health Organization and US Department of Health and Human Services are not state or federal hospitals or professional and specialty organizations for nurses.

DIF: Cognitive Level: Understand (Comprehension) OBJ: List sources for standardN sU ofR caSreIfN orGnT urB se. s. C TO OPM: MSC: NCLEX: Management of Care

Nursing Process: Evaluation

10. The patient sued the hospital for malpractice after developing a postoperative DVT and PE.

The nurse’s notes did not state that TED hose and sequential compression devices (SCDs) were applied even though they were ordered. Why did the court rule in favor of the patient in the case? a. DVT and PE can develop even if TED hose and SCDs are applied. b. The patient was informed that DVT and PE are known surgical risks. c. The nurse testified that SCDs and TED hose were applied as ordered. d. The nurse failed to document that TED hose and SCDs were applied as ordered.

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 person’s memory. Failure to document application of TED hose and SCDs as ordered violates the nursing standard of careful, complete charting of patient care. Oral testimony of the nurse is not as reliable as written documentation. The nurse’s testimony that the SCDs and TED hose were applied might have led the court to find in favor of the nurse. The patient’s informed consent did not lead the court to find in favor of the patient in the malpractice trial. DVT and PE can develop even if TED hose and SCDs are applied but the nurse’s failure to document application of TED hose and SCDs led the court to rule in favor of the patient.

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain the concept of negligence and identify the elements of professional negligence.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 11. The nurse filled out an incident report after a patient fall but makes no mention of the incident

report in her notes in the patient’s chart. What is the reason for this? a. The incident report includes the nurse’s interpretations of what probably led the patient to get out of bed. b. A copy of the incident report is filed in the patient’s chart along with the nurse’s notes about the fall. c. The incident report is confidential and not intended to be used as evidence in a malpractice suit. d. The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report.

ANS: C

Incident reports are used by facilities to investigate the event and prevent possible recurrence.

The nurse does not include presumptions or speculations about the incident in the patient chart or the incident report. The incident report is submitted to the unit manager, administration, and/or agency attorney for review. The incident report is never filed in the patient’s chart. The presence of an incident report will not increase risk of a malpractice lawsuit.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify nursing interventions to improve patient safety.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 12. Which sentence is appropriate to write in an incident report for a patient who got out of bed

NURSINGTB.COM and fell? a. The patient probably urinated on the floor and slipped due to the wet floor. b. The patient’s nurse assistant always takes forever to answer patient call lights. c. The patient never follows directions and always causes trouble for the nurses. d. The patient was found lying on the floor with his urinal on the floor next to him.

ANS: D

The nurse will objectively record the details of the event and any statements the patient makes including how the patient was found on the floor. The nurse should not attempt to blame the patient or other staff members for the incident. The nurse should not make conjectures about how the incident occurred.

DIF: Cognitive Level: Apply (Application) OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 13. While at the grocery store, the nurse witnesses another shopper collapse near the checkout.

The nurse performs CPR and the patient survives after being treated at the hospital. The patient later attempts to sue the nurse for malpractice because several ribs were broken as a result of chest compressions. Why will the patient’s lawsuit be thrown out of court? a. The patient should not have been at the grocery store with a history of heart disease. b. The patient needed to disclose her history of heart disease to the nurse before she

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

collapsed. c. The patient’s rib fractures occurred as a result of properly performed CPR by the

nurse. d. The nurse’s personal liability insurance company decided to settle rather than face

a jury.

ANS: C

The nurse is covered by the Good Samaritan law as long as the care provided meets expected standards. The patient’s rib fractures occurred as a result of properly performed CPR by the nurse so the nurse may not be sued for malpractice. The insurance company would not settle because the patient did not have a case for malpractice. The patient was not expected to disclose the history of heart disease before collapsing. A history of heart disease does not preclude the patient from going shopping for groceries.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe 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. Providing assistance to which victim would be covered under the state’s Good Samaritan law? a. The unit secretary at the hospital suffers an anaphylactic reaction after eating nuts

as a morning snack. b. A patient has a grand mal seizure in the hospital foyer when saying goodbye to his

family. c. A patient at the clinic where the nurse is working suffers a cardiac arrest after

walking in the door.

d. Two people are badly hu r t in a c a r accident on t h e nurse’s way to work in the

morning.

N UR SIN GT B.CO M

ANS: D

Good Samaritan laws encourage health care professionals to provide aid in case of emergencies outside of the workplace. An example of this would be two people who are badly injured in a car accident on the nurse’s way to work. The nurse is legally bound to provide care to patients in the workplace. Providing assistance to another hospital employee is not covered under the Good Samaritan laws.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe 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 15. The nurse is at the shopping mall when the sales clerk collapses in cardiac arrest. The nurse

assists the victim and performs CPR until the paramedics arrive. Which action by the nurse could lead to a malpractice suit even though the state has a Good Samaritan law? a. The nurse went to visit the victim in the hospital the following day. b. The nurse accepted a small gift from the store in appreciation for her help. c. The nurse sent a bill to the victim to request payment for services rendered. d. The nurse provided both chest compressions and rescue breathing for the victim.

ANS: C

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Good Samaritan laws cover health care professionals who voluntarily provide aid in emergency situations. The nurse is no longer protected by the state’s Good Samaritan law if a bill is sent to the victim to request payment for services rendered. The nurse is allowed to accept a small gift from the store in appreciation but cannot accept cash payment of any kind in order to be covered by the state’s Good Samaritan law. There is nothing wrong with the nurse visiting the patient the next day. CPR guidelines call for rescue breathing and chest compressions.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe 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 16. The nurse is caring for a preoperative patient before hysterectomy surgery. The patient tells

the nurse that she plans to have lots of children in the future and is glad that the surgery won’t keep her from getting pregnant in the future. Which is the best action of the nurse? a. Continue preparing the patient for the upcoming surgery. b. Contact the operating room and cancel the patient’s scheduled surgery. c. Inform the surgeon so the patient can be provided with more information. d. Explain to the patient that the surgery will make her unable to get pregnant.

ANS: C

The nurse should inform the surgeon so the patient can be provided with more information.

The patient does not understand the surgery to be performed as she thinks pregnancy will still be an option afterward. Obtaining informed consent is the responsibility of the surgeon so the nurse should not explain to the patient that pregnancy will not be possible after the surgery.

The nurse should not continue the preoperative preparations as the patient is not informed IN G Tould B.Cn oM about the upcoming surgery. TN Uh eRnSurs e sh Ot cancel the patient’s surgery unless directed to do so by the surgeon.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain the legal concepts of standard of care and informed consent.

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 patient’s diagnosis with the patient’s health care provider c. Providing patient information to the nursing assistant caring for the patient d. Sharing a patient’s diagnosis and prognosis with other nurses in the cafeteria ANS: D

Although HIPAA does not require things such 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 bloodborne 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.

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 DIF: Cognitive Level: Apply (Application) OBJ: Describe 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 18. The patient undergoes surgery for a herniated disk and is paralyzed afterward. What must the

patient prove to the court in order to win a malpractice lawsuit based on lack of informed consent? a. The patient’s paralysis was not due to the surgeon’s technique. b. The patient’s signature on the consent form was witnessed by his nurse. c. The surgeon performed a laminectomy but the patient consented to a fusion. d. The surgeon performed a surgical procedure that was known to be high risk.

ANS: C

If the patient consented to a fusion but the surgeon performed a laminectomy, the patient may win a malpractice suite based on lack of informed consent. The surgeon must perform the procedure indicated on the patient’s consent form. The risk of the surgical procedure does not correlate with lack of informed consent. The patient’s signature on the consent form may be witnessed by the surgeon or the nurse. The patient cannot win a malpractice lawsuit based on lack of informed consent because the paralysis was not caused by the surgeon.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain the legal concepts of standard of care and informed consent.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 19. In which case might the patient be ordered by the court to receive treatment? a. The patient has infectious TB and refuses to take the prescribed antibiotics. b. The patient’s mother r e f uNs eUs Ra S vaIcN ciG neTfB or.hC erOcM hild because he is allergic to it. c. A Jehovah’s Witness refuses a blood transfusion based on religious convictions. d. A patient refuses treatment to slow the advancement of an inoperable brain tumor.

ANS: A

Patients whose refusal of treatment may endanger the health of the public may be ordered by the court to receive treatment. An example of this is a patient who has infectious TB and refuses to take prescribed antibiotics. The court will not require Jehovah’s Witness patients to receive blood transfusions or require surgery for inoperable tumors. Allergy to a vaccine is a valid reason for refusal.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe 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. The nurse is directed to take an unsafe patient assignment. What is the most appropriate first

action of the nurse? a. Contact the State Board of Nursing. b. Contact the nursing supervisor on duty. c. Contact the hospital administrator on call. d. Refuse to accept the assignment and leave.

ANS: B

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

If a nurse is assigned to care for more patients than is reasonable for safe care, the appropriate first action is to contact 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. 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.

DIF: Cognitive Level: Apply (Application) 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. Which patient scenario allows the physician to perform needed procedures without the need to

obtain informed consent first? a. An unconscious patient is brought into the ER after an auto accident. b. The patient speaks only Russian and requires the services of a translator. c. The patient is deaf and communicates through sign language or lip reading. d. The patient is not an American citizen and does not have any health insurance.

ANS: A

Informed consent may not be obtained from an unconscious trauma patient. Informed consent must be obtained with a translator for patients who do not speak English. Deaf patients require sign language translators. Lack of health insurance does not eliminate the need for informed consent.

DIF: Cognitive Level: Apply N (AU pR pliS caI tiN onG ) TB.COM OBJ: Explain the legal concepts of standard of care and informed consent.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 22. The nurse is caring for a patient who will have surgery. The nurse witnesses the patient sign

the informed consent document, and then the nurse adds her signature as a witness. What does the nurse’s signature on the document mean? a. The patient signed the form, not someone else. b. The patient accepts the potential risks of the procedure. c. The patient fully understands the procedure to be performed. d. The patient agrees with the surgeon’s planned treatment approach.

ANS: A

The nurse’s signature on the consent form indicates only that the patient signed the form, not someone else. The nurse’s signature on the consent form does not indicate that the patient accepts the potential risks of the procedure, fully understands the procedure to be performed or agrees with the surgeon’s planned treatment approach.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Explain the legal concepts of standard of care and informed consent.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 23. Which situation will enable a nurse to use restraints?

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 a. b. c. d.

To punish a patient To ensure staff convenience To ensure the patient’s safety To retaliate against poor behavior

ANS: C

Regulations set the standard that all patients have the right to be free from seclusion and physical or chemical restraints except to ensure the patient’s safety in emergency situations.

The standards specifically prohibit restraining patients for staff convenience, punishment, or retaliation.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify nursing interventions to improve patient safety.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 24. When is the nurse covered by the health care agency’s malpractice insurance? a. While caring for scouts at summer camp b. When providing first aid at a car accident c. While assisting a fellow passenger on a flight d. While providing care to patients in the agency ANS: D

If a nurse works for a health care institution, generally the institution’s insurance will cover the nurse during employment. The nurse is not covered by the agency’s malpractice insurance when volunteering at a scout camp. The nurse will need to carry additional insurance for this situation. Providing assistance on a flight or at the scene of a car accident may be covered by the state’s Good Samaritan law.

NURSINGTB.COM

DIF: Cognitive Level: Apply (Application) 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. The home care nurse suspects that the patient’s bedsores are due to neglect from family

caregivers. Which is the appropriate action of the nurse? a. Inform the caregivers that their actions are illegal. b. Report it to the proper legal authority immediately. c. Call the agency’s security department to handle the problem. d. Prevent the caregivers from being responsible for the patient’s care.

ANS: B

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 abuse or neglect can cause a nurse to be liable in civil or criminal legal actions. It is not the nurse’s responsibility to inform the caregivers of illegal activity or to prevent the caregivers from seeing the patient. The nurse is responsible for reporting the suspected abuse, not call security to handle the problem.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the legal obligations and role of nurses regarding federal and state laws that affect health care.

TOP: Nursing Process: Implementation

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034 MSC: NCLEX: Management of Care 26. The nurse is caring for a patient who has a do-not-resuscitate order from the physician in the

chart. The patient stops breathing and his skin turns blue. What is the best action of the nurse to avoid a lawsuit for malpractice or wrongful death? a. Call the Rapid Response Team in case the patient’s wife changes her mind. b. Stay with the patient and offer support to the family members in the room. c. Verify that the do-not-resuscitate order is signed by the physician and valid. d. Review the nursing policy and procedure manual for resuscitation guidelines.

ANS: B

The nurse should follow the do-not-resuscitate order and allow the patient to die without lifesaving intervention. The nurse should stay with the patient and offer support to the family members in the room. The Rapid Response Team should not be called. The nurse should validate the do-not-resuscitate order before the patient stops breathing. The nurse should review the nursing policy and procedure manual for resuscitation guidelines before starting the shift.

DIF: Cognitive Level: Apply (Application) 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 27. Which information must be obtained from the patient upon admission to the hospital? a. Patient’s religious preference b. Health insurance authorization c. Presence of an advanced directive d. Primary physician telephN onUe R nuSmIbN erGTB.COM ANS: C

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. Asking how payment will be made is not required by law and is not the responsibility of the nurse.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe 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 28. The nurse is caring for a patient who attempted to get out of bed and fell to the floor, causing

a fractured hip. The nursing supervisor asks the nurse to rewrite her entry into the patient’s chart to show that the patient’s bed was lowered to the floor even though it was not. What is the best action of the nurse? a. Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed. b. Ask the nursing assistant to chart that the patient’s bed was lowered to the floor before the patient fell. c. Ask the nursing assistant if the patient’s bed was lowered to the floor at the time of the fall. d. Remind the nursing supervisor that it is against regulations to alter or falsify the

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

patient’s chart.

ANS: D

It is against the standards of nursing care to alter or falsify information in the patient’s chart.

The nurse should not ask the nursing assistant to chart that the patient’s bed was lowered either.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. The nurse has received an order to administer warfarin 100 mg PO today to the patient. This

amount seems high to the nurse. Which are the appropriate actions of the nurse? (Select all that apply.) a. Clarify the order with the physician. b. Document suspicion about the order. c. Notify the nursing supervisor on duty. d. Administer the medication as ordered. e. Question the pharmacist about the dosage.

ANS: A, C, E

Nurses are responsible for carrying out medical treatment unless the physician’s or health care provider’s 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 frN om thS eI phN yG sicTiaBn.oC r hOe M a l t h care provider. 100 mg is not an UR appropriate dosage of warfarin so it should not be administered to the patient. Do not carry out the order if there is a risk that harm will come to your patient; therefore do not administer the medication. The nursing supervisor should be notified. The pharmacist should be contacted about the order. Inform the nurse manager or the nursing supervisor. The nurse does not document suspicions or opinions, just objective, factual information.

DIF: Cognitive Level: Apply (Application) OBJ: Identify nursing interventions to improve patient safety.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 2. Which actions by the nurse violate the American Nurses Association’s Social Media Policy?

(Select all that apply.) a. The nurse posts a professional profile on LinkedIn. b. The nurse describes a patient’s injury on Facebook. c. The nurse posts opinions about co-workers on Twitter. d. The nurse writes a blog about the need for staffing ratios. e. The nurse posts a picture of a patient’s wound on Instagram.

ANS: B, C, E

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

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.

The nurse is allowed to write a blog about staffing ratios and post a professional profile on LinkedIn. DIF: Cognitive Level: Apply (Application) OBJ: List sources for standards of care for nurses.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3. The nurse is caring for a patient who climbed out of bed and fell to the floor. What will the

nurse do in regard to the incident report? (Select all that apply.) a. Include a recommendation for fall prevention interventions. b. Note in the patient’s chart that an incident report was completed. c. Document how the patient was found and a description of the injuries. d. Indicate that the nursing assistant wasn’t paying attention to the patient. e. Document fall prevention steps that were in place before the patient fell.

ANS: C, E

The nurse will document how the patient was found and a description of the injuries. The nurse will also document fall prevention steps that were in place before the patient fell in order to aid the investigation into the event. The nurse will not suggest that the nurse assistant was not paying attention, chart that an incident report was completed, or make recommendations for fall precautions.

DIF: Cognitive Level: Apply (Application) OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer.

TOP: NN urU sinRgS PI roN ceG ssT : CBo. mC mO unM ication and Documentation MSC: NCLEX: Management of Care

Test Bank for Essentials for Nursing Practice 9th Edition by Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall, Patricia Castaldi, ISBN; 978-0323533034

Essentials for Nursing Practice 9th Edition Potter Test Bank

Chapter 06: Ethics Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which ethical principle is violated when the patient is not told the truth about the medical

diagnosis and therefore is not able to decide on the course of treatment? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence ANS: A

Autonomy refers to a person’s independence. As a principle in bioethics, autonomy represents an agreement to respect a patient’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 2. Which ethical principle is upheld when uninsured patients receive the same level of care as

patients with private health insurance?

NURSINGTB.COM 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3. Which ethical principle is violated when the nurse promises to administer pain medication to

the patient every 2 hours throughout the shift and then fails to do so? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence ANS: C

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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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe patient advocacy and the nurse’s role.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 4. Which ethical principle is upheld when the surgeon refuses to operate on the patient because

potential benefit is minimal compared to the pain that the patient will endure? 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

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

NURSINGTB.COM

5. Which ethical principle is upheld when the registered nurse provides medical assistance to

victims of an accident? a. Veracity b. Fidelity c. Autonomy d. Beneficence ANS: D

Beneficence refers to helping others. The nurse demonstrates this by providing medical assistance to victims of an accident. Autonomy is the right to personal freedom. Fidelity is keeping promises and veracity is telling the truth.

DIF: Cognitive Level: Apply (Application) OBJ: Describe patient advocacy and the nurse’s role.

MSC: NCLEX: Management of Care

TOP: Nursing Process: Caring

6. Which ethical principle is violated when the nurse is overhead talking about the patient’s

prognosis in the elevator? a. Judgment b. Advocacy c. Accountability d. Confidentiality ANS: D

Confidentiality is the protection of patient information so that it is not shared with others. The nurse violated the ethical principle of confidentiality when the patient’s prognosis was overhead in the elevator. Judgment refers to the ability to make appropriate decisions based on the situation. Advocacy refers to the nurse’s responsibility to speak up for and protect the rights of patients. Accountability means that the nurse must be responsible for actions and decisions.

DIF: Cognitive Level: Apply (Application) OBJ: Describe patient advocacy and the nurse’s role.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 7. Even though immunization injections are momentarily painful to the patient, they are

recommended because they will protect the community from infectious diseases. Which ethical system supports this practice? a. Duty ethics b. Deontology c. Utilitarianism d. Situation ethics 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. Situation ethics considers the unique characteristics of an individual person or situation in order to reach the most ethical decisio n. D u t y e t h i c s r e f e r s to universal obligations such as telling the N R I G B.C M truth and respecting human l i f eU. S N T O DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 8. Which ethical area is challenged when the nurse feels bound to refuse to assist with an

abortion procedure? a. Values b. Culture c. Confidentiality d. Social networking ANS: A

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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe patient advocacy and the nurse’s role.

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

9. Which ethical area is involved when the clinic releases genetic test results to the patient’s

employer without the patient’s consent? a. Veracity b. Bioethics c. Justice d. Beneficence ANS: B

Bioethics is a division of ethics that deals with appropriate use of medical technology.

Bioethics includes decisions regarding organ transplants, genetic testing, and quality of life.

Beneficence refers to helping others. Justice refers to the principle of fairness: fair treatment and fair distribution of health care resources. Veracity is telling the truth.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 10. Which ethical principle is upheld when the nurse refuses to administer a placebo pill to the

patient? a. Justice b. Culture c. Veracity d. Competency ANS: C

Veracity is telling the truth. The nurse upholds the ethical principle of veracity by refusing to administer a placebo pill to the patient. Competency refers to the ability to perform a procedure to the accepted st aN nd aR feC rs toMshared beliefs and values of the group.

Gu r e Bre. Urd.S CINu l tT O Justice refers to the principles of fairness.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 11. The patient’s family members disagree about which treatment is most appropriate for the

terminally ill comatose patient. Which nursing intervention is most appropriate for this situation? a. The nurse will provide statistical information about the patient’s odds of survival. b. The nurse will promote effective communication between the family members. c. The nurse will ask the family members to leave medical decisions to the physician. d. The nurse will wait until the patient is able to make the decisions about treatment.

ANS: B

The nurse should promote effective communication between the family members so that they can come to an agreement about the patient’s treatment. Providing statistical information about survival odds is not helpful for moral decision making in this case. The family members should not leave the medical decision to the physician as the treatment may not be consistent with their beliefs. The patient will not be able to make decisions about treatment.

DIF: Cognitive Level: Apply (Application) OBJ: Describe patient advocacy and the nurse’s role.

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

12. Which is the appropriate action for the nurse manager when a nurse refuses to assist with an

abortion due to personal ethical beliefs? a. Assign the nurse to care for other patients. b. Counsel the nurse about professional responsibility. c. Report the nurse’s refusal to the State Board of Nursing. d. Inform the nurse that the refusal will lead to termination.

ANS: A

The nurse manager should assign the nurse to care for other patients so that the nurse does not have to go against personal ethical beliefs. Counseling the nurse about professional responsibility will not resolve the current staffing issue and the nurse will not change ethical beliefs about abortion. Reporting the nurse to the State Board of Nursing and threatening termination are not appropriate as nurses are allowed to refuse assignments such as abortions based on their personal ethical beliefs.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 13. Which action by the nurse is an example of a legal issue rather than an ethical principle? a. Failing to shut the door completely when bathing the patient b. Providing lower doses of pain medications to patients with red hair c. Working as a registered nurse without a current nursing license d. Deciding not to stop and provide medical care at an accident scene ANS: C

Working as a registered nursN e wiRt h o I u t a Gcu r B r e. n t Cn urM si ng license is a legal issue rather than an U S N T O ethical issue. Failure to provide privacy violates the ethical principle of confidentiality. The ethical principle of justice is violated when redheaded patients are given lower doses of pain medication. Deciding not to stop and provide medical care at an accident scene violates the ethical principle of beneficence.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 14. After a massive earthquake, the emergency room staff focuses to provide care to the patients

who are likely to survive rather than expending maximum effort on a few critically injured patients. Which ethical theory is demonstrated in this situation? a. Deontology b. Feminist ethics c. Utilitarianism d. Ethics of care ANS: C

Utilitarianism determines the value of something based primarily on its usefulness and benefit for the greater good. In this case, the emergency room staff focuses on saving the many rather than working to save the few. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 15. A patient with a rare neurological disease is misdiagnosed by the physician and told that the

symptoms are psychosomatic. The patient’s sense of self is shattered after being told “You are a waste of a hospital bed.” Which ethical theory is violated in this situation? a. Liberty b. Fidelity c. Ethics of care d. Confidentiality ANS: C

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.

The physician in this situation did not demonstrate any care or compassion for the patient and violated the ethics of care. Liberty is the freedom to choose without intimidation or oppression from others. Confidentiality was not breached as the physician did not share patient N R I G B.C M information with others or fail U to pSr o v iNd e pTrivacy.OFidelity is an agreement to keep a promise.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Caring MSC: NCLEX: Management of Care 16. The nurse respects the patient’s wish not to be intubated even though the patient will most

likely die as a result of the decision. Which ethical theory is demonstrated by the action of the nurse? a. Autonomy b. Justice c. Utilitarianism d. Responsibility ANS: A

Autonomy refers to the patient’s right to make decisions and determine a course of action.

This is upheld when the nurse respects the patient’s wish not to be intubated. Justice refers to the principle of treating all patients fairly. Utilitarianism determines the value of something based primarily on its usefulness and benefit for the greater good. Responsibility refers to reliability and dependability in the performance of duties.

DIF: Cognitive Level: Apply (Application) OBJ: Describe patient advocacy and the nurse’s role.

MSC: NCLEX: Management of Care

TOP: Nursing Process: Caring

17. The nurse often forgets to administer the patient’s medication exactly on time, frequently

giving it 1 or 2 hours after it is due. Which ethical principle is violated by the nurse? a. Justice b. Judgment c. Responsibility d. Confidentiality ANS: C

Responsibility refers to trustworthiness and constancy in the performance of duties. The nurse is violating the principle of responsibility by failing to consistently administer the patient’s pain medication on time. Justice refers to the principle of treating all patients fairly.

Confidentiality is the protection of patient information so that it is not shared with others.

Judgment is the ability to make sound decisions based on the available information.

DIF: Cognitive Level: Apply (Application) OBJ: Describe patient advocacy and the nurse’s role.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 18. The nurse administers the wrong dose of medication and then blames the mistake on a

co-worker. Which ethical principle is violated by the nurse? a. Fidelity b. Accountability c. Confidentiality d. Social networking ANS: B

Accountability refers to the nNu r s eR’ s aIb i l iGt y toBt. akCe reMsponsibility for actions or decisions. The U S N T O nurse in this situation failed to be accountable for the medication error by blaming it on a co-worker. Confidentiality is the protection of patient information so that it is not shared with others. Fidelity is an agreement to keep a promise. Social networking refers to the use of social media to connect with patients, family members, and friends.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the foundations of ethics and ethical practice in nursing.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. The family is unsure what treatment is appropriate for the comatose patient who is terminally

ill. Which steps will the nurse take to help the family process this ethical dilemma? (Select all that apply.) a. Consider all possible treatment options. b. Calculate the odds of the patient’s survival. c. Clarify own values and opinions about the issues. d. Provide personal opinions about treatment options. e. Gather all relevant information about the situation.

ANS: A, 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 one’s 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. Calculating the odds of the patient’s survival and providing personal opinions about treatment options are not steps of the process.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the process for recognizing and resolving an ethical dilemma.

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

Chapter 07: Evidence-Based Practice Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which action by the nurse demonstrates the use of evidence-based practice to positively

impact the quality and cost of health care? a. The nurse performs decubitus ulcer dressing changes the way they have always been done at the agency. b. The nurse pioneers a new oral care protocol that has been demonstrated to reduce the risk of ventilator-associated pneumonia. c. The nurse enters the physician’s orders into the computer system because the physician refuses to learn how to do it. d. The nurse works on a medical-surgical unit for 4 years before becoming certified in critical care nursing.

ANS: B

Nursing evidence-based practice is demonstrated by the introduction of new protocols that have been demonstrated to be more effective than previous methods. Continuing to use standard methods of practice despite new superior methods does not positively impact the quality, safety, and cost of health care. Entering the physician’s orders into the computer system because the physician refuses to learn how to do it is not effective nursing practice.

Nursing experience before becoming certified in critical care does not demonstrate accountability.

B.C M OBJ: Discuss the relationship b eUt w eS e n eN v i d eT n c e - bas O e d practice and the improvement of the safety DIF:

Cognitive Level: Apply N (ApR plicaI tionG )

and quality of nursing practice.

MSC: NCLEX: Management of Care

TOP: Nursing Process: Implementation

2. A new central line care protocol to prevent site infection is instituted after it has been shown

to be significantly more effective than previous approaches. Which term best describes this action? a. Inductive reasoning b. Qualitative research c. Evidence-based practice d. Process measurement ANS: C

Evidence-based practice is the adoption of methods and procedures based on science and research rather than historical precedent or status quo. The new central line care protocol was instituted because it was shown to be more effective than previous protocol, demonstrating the use of research findings. Inductive reasoning is the practice of making generalizations based on individual observations or findings. Qualitative research is the study of nonobjective events, experiences or trends such as patient experiences of chronic illness. Process measurement is a test to determine whether or not a new protocol is implemented correctly.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the relationship among nursing research, evidence-based practice, and quality improvement.

TOP: Nursing Process: Evaluation

MSC: NCLEX: Management of Care 3. Where is the best place for the nurse to obtain the latest information about prevention of

catheter-associated urinary tract infections? a. Online information b. Peer-reviewed nursing journal c. Latest edition of a nursing textbook d. Most recent edition of a popular magazine ANS: B

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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the levels of evidence in the literature.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 4. After a new handwashing protocol is instituted, patients are asked to complete surveys about

whether or not providers performed hand hygiene before and aftercare is provided. Which term best describes this action? a. Process measurement b. Peer-reviewed research c. Experimental study NURSINGTB.COM d. Outcomes research ANS: A

Process measurement is a test to determine whether or not a new protocol is implemented correctly. An example of process measurement is a survey to help determine whether or not providers are complying with the new handwashing protocol. Research articles are reviewed by peers to ensure that they are accurate and correct before they are published. An experimental study is performed to determine whether or not a new handwashing protocol is effective for lowering infection rates. Outcomes research focuses on the effectiveness of a protocol for patient care rather than staff compliance with a protocol.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss ways to measure outcomes for an evidence-based practice change.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 5. After the implementation of a new protocol, the nursing unit had a central line site infection

rate of 3%. This rate is well below the agency’s expected standard of 5%. Which term best describes this evaluation? a. Research bias b. Control group c. Benchmarking d. Descriptive research ANS: C

Benchmarking is the comparison of an achieved result against a predetermined standard. The nursing unit’s 3% infection rate was found to be well below the agency’s benchmark of 5%.

Research bias occurs when researchers are not objective and the results are not accurate.

Descriptive research studies characteristics of individuals or populations. The control group is used in the scientific process to determine the effects of an intervention.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the relationship among nursing research, evidence-based practice, and quality improvement.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 6. The nurse manager will use evidence-based practice to address a recent increase in

catheter-associated urinary tract infections on the unit. Which type of trigger did the nurse manager use? a. Literature-focused b. Problem-focused c. Knowledge-focused d. Expectations-focused 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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the rela ti ons hi p N beUtwReS enIeN viG deT ncBe -.baCs O e dMpractice and the improvement of the safety and quality of nursing practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 7. Which is an example of a PICO question? a. How does the agency’s monthly catheter-associated urinary tract infection rate

compare with the national average? b. Which types of topical antibiotic irrigation solutions may be used to reduce healing

time for stage 4 decubitus pressure injuries? c. Does oral care with chlorhexidine solution more effectively reduce the incidence

of ventilator-associated pneumonia in intubated patients than saline solution? d. Which emotions are commonly felt by patients upon learning that they were diagnosed with a terminal illness?

ANS: C

A PICO question includes the following: P: Patient population of interest = intubated patients I: Intervention of interest = oral care with chlorhexidine solution C: Comparison of interest = oral care with saline solution O: Outcome = reduced incidence of ventilator-associated pneumonia DIF: Cognitive Level: Analyze (Analysis) OBJ: Develop a PICO or PICOT question.

TOP: Nursing Process: Assessment

MSC: NCLEX: Management of Care

8. Which is an example of a qualitative research question? a. Will a school hand-hygiene program reduce the frequency of head lice outbreaks? b. What are the experiences of young children diagnosed with type 1 diabetes? c. How does crossing the legs affect the accuracy of blood pressure measurement? d. What is the incidence of side effects after administration of the influenza vaccine?

ANS: B

Qualitative research is the study of nonobjective events, experiences or trends such as patient experiences of chronic illness. Defining the experiences of young children diagnosed with type 1 diabetes is an example of qualitative research. Studies about the frequency of head lice, blood pressure measurement, and incidence of side effects are all quantitative research studies.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the steps of evidence-based practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 9. The nurse is researching the use of music therapy for patients with dementia and finds that

many research articles have been published about the topic. Which single source will provide the best evidence for the nurse? a. The opinion of an expert committee b. Meta-analysis of randomized control trials c. One well-designed randomized control trial d. Systematic review of qualitative nursing studies ANS: B

Systematic reviews or meta-aNn a l R y s e sIa r eGs t aB t e.

- oCf - thM e-science summaries from an individual U S T highest O level of the hierarchy. These research researcher or panel of experts and are N on the 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the levels of evidence in the literature.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 10. Which type of study is appropriate to investigate patients’ perceptions about quality of life

after a diagnosis of liver cancer? a. Quantitative study b. Randomized trial c. Qualitative study d. Case control study ANS: C

Qualitative research offers analysis of interviews, observations, and/or surveys to measure people’s 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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the steps of evidence-based practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 11. Which type of research study is most appropriate to determine if premedication with

diphenhydramine is more effective than acetaminophen to reduce the incidence of aseptic meningitis after intravenous globulin infusion? a. Randomized trial b. Qualitative study c. Historical review d. Descriptive report ANS: A

Randomized trial has participants divided into groups to determine if there is a difference in the effect of a treatment or intervention compared with another. A randomized trial would be appropriate to compare the effectiveness of diphenhydramine versus acetaminophen to reduce Nrese RSarc IN G fers B.CanaM Olysis of interviews, observations, and/or aseptic meningitis. Qualitative U h ofT surveys to measure people’s perceptions, feelings, or views of phenomena about which little is known. A descriptive study is done to measure the characteristics of a population. Historical research is done to learn about past events.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the relationship between evidence-based practice and the improvement of the safety and quality of nursing practice.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 12. The nurse is researching oral care protocols to reduce the incidence of ventilator-associated

pneumonia on the unit. Which section allows the nurse to quickly determine if the study is relevant without having to read the entire article? a. Abstract b. Literature review c. Data collection method d. Theoretical framework ANS: A

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. The literature review will show the current knowledge about the topic at the time that the article was written by the author. The literature review, data collection method, and theoretical framework will not allow the nurse to quickly determine if the study is relevant.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the levels of evidence in the literature.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 13. After a careful literature review, the nurse manager creates a new fall prevention protocol to

reduce patient fall rates on the unit. What is the nurse manager’s logical next step? a. Discuss the protocol with the patients and families on the unit. b. Present the protocol to the nursing policy and procedure committee. c. Post an entry about the protocol on the agency’s social networking page. d. Submit an article about the protocol to be published in the agency newsletter.

ANS: B

The nurse manager should present the protocol to the nursing policy and procedure committee for review. The committee will determine if the new protocol should be adopted for patient care within the agency. The nurse manager should not post the protocol in the newsletter, social networking page as it should be reviewed by the nursing policy and procedure committee first. The protocol should not be discussed with patients and families until it is formally adopted by the agency.

DIF: Cognitive Level: AnalyzN eU (ARn S a l yIs N i s)G T B.C O M OBJ: Discuss ways to apply evidence in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 14. After careful research, the nursing staff have implemented a new fall prevention protocol on

the unit. Which is the logical next step of the staff? a. Review the available literature. b. Encourage abstract thinking. c. Measure the patient fall rate. d. Execute the theoretical framework.

ANS: C

After applying evidence in practice, the next step is to evaluate the effect. The nursing staff will evaluate the patient fall rate to determine if the new fall prevention protocol is effective.

Reviewing the available literature is not appropriate as the new protocol has already been implemented. A theoretical framework is used to guide the research process rather than to evaluate effectiveness of the intervention. Abstract thinking is not needed as the protocol has already been implemented.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss ways to measure outcomes for an evidence-based practice change.

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

15. Researchers conduct a study to determine if the use of chlorhexidine mouthwash is more

effective than the use of normal saline for oral care to reduce the incidence of ventilator-associated pneumonia. Which action by the researchers makes the study a randomized controlled trial? a. The researchers do not know which patients will be treated with saline and which patients will be treated with chlorhexidine. b. The researchers do not know which treatment will be more effective before the interventions are tested. c. The researchers randomly select nurses at several local health care facilities to implement the mouth-care protocols. d. The researchers do not know which statistical tests will be used to evaluate the effectiveness of the oral care protocols.

ANS: A

The researchers are conducting a randomized controlled trial if they do not know which patients will be treated with saline and which patients will be treated with chlorhexidine. This is done to reduce the risk of bias that could interfere with the validity of the results. The researchers are conducting the study to determine treatment will be more effective. Random selection of nurses to provide the oral care to the patients does not make the study a randomized controlled trial. The researchers will definitely know which statistical tests will be used to evaluate the effectiveness of the oral care protocols.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the relationship among nursing research, evidence-based practice, and quality improvement.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16. After the implementation of aNw UeRllS-rI esN eaG rcThB ed.fC alO l pMrevention protocol, patients at the agency

have a lower incidence of falls than the national average. Which term will the nurse use to describe this finding? a. Sentinel 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 people’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss ways to measure outcomes for an evidence-based practice change.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 17. A researcher tests a new fall prevention protocol on a nursing unit with patients who are at

very low risk of falling. Which term describes the problem with this study?

a. b. c. d.

This type of study is better suited for qualitative research.

The subjects are at risk of being harmed by participating in the study.

The study is biased because the subjects are already at low risk of falling.

The study results will be inaccurate due to placebo effects on the subjects.

ANS: C

The researcher’s study is biased because the patients selected to participate in a fall reduction protocol are already at very low risk of falling. The researcher will not be able to determine if low fall rates after implementation of the protocol are due to the intervention or the low fall risk characteristic of the subjects. Placebo effect is not a factor in this research study. Fall risk studies are examples of quantitative research. The patients would not be harmed by a fall prevention protocol.

DIF: Cognitive Level: Apply (Application) OBJ: Explain how critiquing the scientific literature leads to best evidence for practice changes.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 18. Which is an example of a sentinel event? a. The patient suffers a fatal air embolism after a central line is removed incorrectly. b. The nurse identifies a patient’s urinary tract infection before symptoms develop. c. The unit’s urinary tract infection rate is 5% lower than the national average. d. The pilot study indicates potential effectiveness of a new oral care protocol.

ANS: A

A sentinel event is an unexpected incident leading to death or injury of a patient. A fatal air embolism after an incorrectly removed central line is an example of a sentinel event. Early identification of an infection indicates excellent nursing assessment. Lower-than-average infection rate indicates b en chNmU aR r kSi nI gN. PT GromBis.inO Cg reMsults of a pilot study indicate the need for additional research.

DIF: Cognitive Level: Apply (Application) OBJ: Explain how critiquing the scientific literature leads to best evidence for practice changes.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. Which sources may be found in the Cumulative Index of Nursing and Allied Health Literature

(CINAHL) database? (Select all that apply.) a. Literature review about complementary therapies for rheumatoid arthritis b. Randomized trial to study the use of honey to treat decubitus ulcers c. Satirical article about the risk of dihydrogen monoxide exposure to humans d. Blog written by a patient recently diagnosed with myasthenia gravis e. Meta-analysis to analyze coffee intake with risk of developing dementia ANS: A, B, E

CINAHL is a research database that includes literature reviews, randomized trials, and meta-analyses. Blogs and satirical articles are not included in the CINAHL database.

DIF: Cognitive Level: Apply (Application) OBJ: Explain how critiquing the scientific literature leads to best evidence for practice changes.

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

2. Which statements are examples of hypotheses? (Select all that apply.) a. Hospitals staffed with primarily bachelor-prepared nurses will have lower

mortality rates than hospitals staffed with primarily associates-prepared nurses. b. More than 80% of the patients with catheter-associated urinary tract infections did

not have any signs or symptoms of infection. c. Patients who receive ondansetron preoperatively will experience lower rates of

nausea and vomiting than patients who do are not premedicated. d. The greatest risk factor for developing ventilator-associated pneumonia was the

length of time that the patient was intubated. e. Ultraviolet light disinfection of equipment is a nontoxic, effective method for

prevention of Clostridium difficile infection.

ANS: A, C

The hypothesis is a prediction made by researchers about what the study results will show.

Predictions about rates of mortality and postoperative nausea and vomiting are examples of hypotheses. Statements of fact about the effectiveness of ultraviolet light, pneumonia risk factors, and infection symptoms are not hypotheses.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the steps of evidence-based practice.

MSC: NCLEX: Management of Care

NURSINGTB.COM

TOP: Nursing Process: Evaluation

Chapter 08: Critical Thinking Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who is having severe pain despite regular doses of narcotic

pain medication. The nurse suspects that the patient may be experiencing neuropathy and obtains an order for gabapentin which relieves the patient’s pain. Which term most accurately describes the action of the nurse? a. Intuition b. Reflection c. Perseverance d. Critical thinking ANS: D

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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Implementation G B.C M N R I MSC: NCLEX: PharmacologicalUandSParN enteT ral TherO apies 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. Which term most accurately describes the thought process of the nurse? a. Reflection b. Curiosity c. Discipline d. Confidence ANS: A

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. Intuition is an inner sensing or “gut feeling” that something is so. Confidence is the belief that an intuition or belief is correct.

Discipline is thoroughness and control over one’s actions.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe how reflection improves clinical decision making.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Adaptation

3. The nurse suspects that a patient is being abused by the spouse based on the presence of many

unexplained bruises and the nonverbal behavior of the patient. Which critical thinking technique was used by the nurse? a. Intuition b. Humility c. Curiosity d. Fairness 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 patient’s room and, by looking at the patient’s appearance without the benefit of a thorough assessment, senses that he or she has worsened physically. Curiosity is the desire to learn more about something. Fairness is the ability to remain impartial. Humility is the quality of being modest or unassertive.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the characteristics of a critical thinker.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Diagnosis

4. Which behavior demonstrates basic critical thinking expected of beginning nursing students? a. Creating a personalized bowel elimination program for a patient with constipation

due to narcotic pain medications b. Elevating the patient’s leg and applying ice packs when the patient’s postoperative

pain is not relieved with prescribed pain medications c. Asking the instructor for assistance when having difficulty inserting the urinary

catheter into the male pat ient ’s b l add er N R I G B.C M d. Advocating for delay in theUpatSientN ’s dTis chargO e when the nurse suspects that a serious surgical complication has developed ANS: C

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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the components of a critical thinking model for clinical decision making.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 5. The nurse becomes very skilled at feeding patients with dysphagia after working on a

rehabilitation unit for many years. Which component of critical thinking allows the nurse to function at this high level of practice? a. Integrity b. Experience c. Risk taking d. Responsibility

ANS: B

The nurse has become very skilled at feeding stroke patients due to many years of experience.

The nurse is not taking a risk with patients as the nurse is very skilled. The nurse demonstrates integrity and responsibility by carefully maintaining high professional standards of care for patients.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain how experience and professional standards influence a nurse’s critical thinking.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 6. The nurse feels strongly that the patient may be suffering from physical abuse. The nurse

reports the situation to protective services even though the physician insists that the patient is simply accident-prone. Which component of critical thinking leads the nurse to file the report even though the physician believes it is not needed? a. Fairness b. Creativity c. Discipline d. Confidence ANS: D

The nurse’s confidence in the assessment of the patient’s situation leads the nurse to file a report with protective services even though the physician believes it is not needed. Fairness is the ability to listen to both sides of a discussion. Discipline is demonstrated when the nurse takes the time to do the job thoroughly. Creativity is demonstrated when the nurse uses imagination skills to come up with new solutions or ideas.

DIF: Cognitive Level: Apply N (ApR plicaItionG ) B.C M N Tthinker.

O OBJ: Describe the characteristicsUof S a critical TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. The nurse comes up with creative methods to help soothe agitated patients with dementia

when the usual approaches fail. Which term best describes the action of the nurse? a. Concept mapping b. Diagnostic reasoning c. Scientific method d. Effective problem solving ANS: D

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 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 patient’s condition. Nurses do not make medical diagnoses; they make nursing diagnoses, which is a part of diagnostic reasoning.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice.

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

8. The experienced trauma nurse determines that the patient may have suffered a cervical spinal

cord injury as the patient is unable to feel or move the arms or legs. Which term best describes the nurse’s ability to make this conclusion? a. Data collection b. Clinical inference c. Scientific method d. Standardized criteria ANS: B

The nurse demonstrated clinical inference by using extensive experience to reach the conclusion that the patient had suffered a spinal cord injury. 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. Standardized criteria do not assist the nurse to realize that the patient suffered a spinal cord injury.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice.

MSC: NCLEX: Physiological Adaptation

TOP: Nursing Process: Diagnosis

9. The nurse implements interventions to address risk for falls after noting that the patient is

unsteady when getting out of bed. The nurse is using which skill in this situation? a. Medical diagnosis NURSINGTB.COM b. Scientific method c. Diagnostic reasoning d. Data collection ANS: C

The nurse used diagnostic reasoning by using data (unsteady patient) to arrive at a patient’s health problem/nursing diagnosis (risk for falls). Diagnostic reasoning is the analytical process for determining a patient’s 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 falls.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the relationship of the nursing process to critical thinking.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Safety and Infection Control 10. Which action of the nurse demonstrates clinical decision making? a. The nurse performs a detailed health history and physical assessment when the

patient is admitted to the unit. b. The nurse determines that the patient is at risk for constipation due to use of

postoperative narcotic pain medication. c. The nurse applies a hydrocolloid dressing to the patient’s decubitus ulcer as

ordered by the physician. d. The nurse assesses the patient’s oral mucus membranes each morning to check for

candida infection or ulceration.

ANS: B

The nurse demonstrates clinical decision making when solving problems and formulating nursing diagnoses for patients. An example of this is the determination that the patient is at risk for constipation due to use of postoperative narcotic pain medication. Application of a hydrocolloid dressing is implementation of the physician’s order. Assessment (health history and mucus membranes) forms the starting point for clinical decision making.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice.

MSC: NCLEX: Reduction of Risk Potential

TOP: Nursing Process: Evaluation

11. Which patient’s need constitutes the highest priority for the nurse? a. The patient who is waiting for discharge teaching in order to go home b. The constipated patient who has not had a bowel movement in 3 days c. The patient with sudden onset of slurred speech and right-sided weakness d. The patient who requires linen changes after being incontinent of urine and stool ANS: C

The patient with sudden onset of slurred speech and right-sided weakness has signs of an acute stroke. This patient must be treated immediately to preserve neurological function and prevent permanent deficits. The discharged patient and the constipated patient will have to wait until the nurse has takenNcarR e oS fIt hNeGsT t r oBk.e O CpatiMent. The nurse can delegate care for the U incontinent patient to the nursing assistant.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 12. Which action by the nurse best demonstrates independent thinking? a. Removing and carefully cleaning the patient’s dentures every night b. Initiating swallow precautions when the patient shows signs of aspiration c. Teaching the diabetic patient how to self-administer insulin injections d. Actively listening to the patient when recording the patient’s health history ANS: B

The nurse demonstrates independent thinking by initiating swallow precautions when the patient shows signs of aspiration. The nurse took the initiative to act when signs of aspiration were noted. Independent thinking is not demonstrated by performing routine oral care, teaching the patient how to inject insulin, or using active listening skills.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 13. Which action by the nurse is an example of a workaround? a. In order to save time, the nurse scans medication bar codes after administration to

the patient. b. The nurse prioritizes care for patients so that the most urgent patient needs are

addressed first. c. The nurse helps the nursing assistant to change the linens after a patient is

incontinent of stool and urine. d. The nurse seeks assistance from another nurse when having difficulty advancing

the urinary catheter into the bladder.

ANS: A

A workaround is a shortcut that may endanger patients in an attempt to save time. Medication bar codes should always be scanned before administration to patients to prevent errors.

Scanning bar codes after administration in an attempt to save time is a workaround.

Prioritization of patient care, assisting other staff members, and seeking assistance are not examples of workarounds.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss critical thinking skills used in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 14. The nurse asks another nurse for assistance when trying to determine the best way to manage

a postoperative patient’s pain. Which critical thinking attitude is demonstrated by the nurse? a. Humility b. Confidence c. Risk taking d. Fairness ANS: A

Critical thinkers who use hu m w hBa t.O t hCe y M do not know and try to find the knowledge NilitU Ry aSdImNi tGT 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 provider’s 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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the critical thinking attitudes used in clinical decision making.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 15. The new nurse keeps a diary to record experiences, patient encounters, and feelings when

beginning work in the nursing profession. Which critical thinking action is used by the nurse? 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe how reflection improves clinical decision making.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16. Which is the best tool that the nurse can use to make sense of the patient’s multiple medical

diagnoses, assessment findings, and medications? a. Plan of care b. Concept map c. Reflective journal d. Intellectual standards ANS: B

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.

NapS R Ia t GhiTghlight B.C OMthe meanings of these relationships. The U Concept maps are visual road m s thN 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the relationship of the nursing process to critical thinking.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 17. The nurse inappropriately assumed that the patient did not require pain medication due to a

history of substance abuse. Which critical thinking concept did the nurse fail to use? a. Criticism b. Maturity c. Analysis d. Organization ANS: C

Analysis is demonstrated when the nurse keeps an open mind when forming judgments about patient assessment findings. The nurse failed to carefully analyze assessment findings by mistakenly assuming that the patient did not require pain medication due to a history of substance abuse. Criticism and organization are not critical thinking skills. Maturity is reflecting on your own judgments and realizing multiple solutions are acceptable.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the importance of clinical judgment in a nurse’s ability to make clinical decisions.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 18. A nurse uses personal experience as well as knowledge of body mechanics and medical

equipment in order to determine the safest way to transfer the paraplegic patient from the bed to the wheelchair. Which critical thinking concept is demonstrated by the nurse? a. Evaluation b. Explanation c. Development d. Self-regulation ANS: B

Explanation is demonstrated when the nurse uses personal experience and applicable knowledge bases to determine the best plan of care for the patient. Scientific knowledge and experience to choose strategies you use in the care of patient is explanation; it supports your findings and conclusions. 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. Development is not a critical thinking skill.

DIF: Cognitive Level: AnalyzN eU (ARnS a lyIsN i s)GTB.COM OBJ: Discuss critical thinking skills used in nursing practice.

MSC: NCLEX: Safety and Infection Control

TOP: Nursing Process: Planning

19. The nurse readily accepts an opportunity to become certified in wound care and ostomy

management. Which critical thinking concept is demonstrated by the nurse? a. Maturity b. Analyticity c. Systematicity d. Inquisitiveness ANS: D

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 learning’s sake. 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, focusing, and working hard in any inquiry.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the critical thinking attitudes used in clinical decision making.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Safety and Infection Control

20. In a facility with an outbreak of Clostridium difficile, the nurse manager determines that staff

members are continuing to use alcohol-based hand sanitizer when caring for patients with Clostridium difficile infection despite the policy which requires hand hygiene using soap and water. Which step of the scientific method was performed by the nurse manager? a. Identification of the problem b. Formation of the hypothesis c. Investigation of the hypothesis d. Evaluation of the intervention ANS: A

The problem is identified when the nurse manager determines that staff members are not following agency policy about hand hygiene. The nurse manager could hypothesize that a reminder program will increase employee compliance with the hand-hygiene policy. The nurse manager could implement a patient/visitor survey to determine if employees are compliant with the hand-hygiene policy. Evaluation is done after the reminder program is implemented to determine the rate of employee compliance.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the components of a critical thinking model for clinical decision making.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 21. Which action by the nurse demonstrates the use of fairness for critical thinking? a. Adherence to the six rights when administering medication to a patient b. Clarification of an unusually high dosage medication with the prescriber c. Effective pain management is provided for all patients regardless of background d. Development of a personalized swallowing precautions protocol for the patient ANS: C

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Fairness means the nurse deals with situations justly. This means that bias or prejudice does not enter into a decision. All patients are provided with the same pain-management standards regardless of their background, ethnicity, or insurance status. Creativity involves original thinking. This means you find solutions outside of the standard routines of care while still following standards of practice. A critical thinker’s favorite question is, “Why?” and represents curiosity. Clarifying an unusually high dosage of a medication with a prescriber demonstrates risk taking. Following the “six rights” is being responsible and accountable.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the critical thinking attitudes used in clinical decision making.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 22. Which statement is true about critical thinking? a. It is the same thing as the nursing process. b. It is moving from writing a plan of care to thinking. c. It is a haphazard method of providing nursing care. d. It is a continuous process characterized by open-mindedness.

ANS: D

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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice.

MSC: NCLEX: Management of Care

TOP: Nursing Process: Planning

23. The nurse carefully performs a careful physical assessment and health history for the patient,

making sure not to miss any body systems. Which attitude for critical thinking is demonstrated by the nurse? a. Integrity b. Planning c. Discipline d. Diagnosis ANS: C

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.

DIF: Cognitive Level: Apply N (AU pR plS icaI tiN onG ) TB.COM OBJ: Discuss the critical thinking attitudes used in clinical decision making.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse noted a rise in skin infections on the nursing unit. After a literature review was

completed, a new bathing protocol using disposable wash basins and pH balanced skin cleansers was suggested. Which steps of the scientific process were used by the nurse? (Select all that apply.) a. Identify the problem. b. Collect the data. c. Answer the question. d. Evaluate the results. e. Publish findings.

ANS: A, B

The nurse identified the problem as a rise in skin infections. Data collection was done with the literature review. The question will be answered after implementation of a new bathing protocol. The results will be evaluated after the bathing protocol is implemented. The findings may be published after the protocol has been shown to be effective for preventing skin infections.

DIF:

Cognitive Level: Analyze (Analysis)

OBJ: Describe the components of a critical thinking model for clinical decision making.

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

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Chapter 09: Nursing Process Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse carefully enters a new patient’s medical history and current medication list into the

agency’s electronic health record (EHR). Which step of the nursing process is being performed by the nurse? a. Assessment b. Implementation c. Evaluation d. Diagnosis ANS: A

Assessment is the thorough and systematic collection of data about a patient. The data will reveal a patient’s 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 patient’s condition or well-being improves.

DIF: Cognitive Level: Apply (Application) OBJ: Describe each step of the nursing process.

TOP: Nursing Process: Assess men t MSC: NCLEX: Management of Care

N RI G B.C M U S N T O

2. The nurse is caring for a patient who has just arrived at the hospital with chest pain. Which is

the most important question for the nurse to ask the patient? a. “Did your family doctor tell you to come to the hospital?” b. “When did your chest pain begin?” c. “Do you have a family history of heart disease?” d. “Did someone come to the hospital with you?”

ANS: B

The nurse’s first priority is to assess the patient’s current health status including when the chest pain began. This information will be communicated to the physician to facilitate appropriate care for the patient. Determining a family history of heart disease or if the patient is accompanied by a friend or family member is less important than assessing the patient’s chest pain. It is helpful to know if the primary care physician sent the patient to the emergency department, but it is not the highest priority.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 3. The nurse is caring for a patient who came to the hospital with acute shortness of breath. What

is the priority action of the nurse as the assessment process is started? a. Pull the curtain around the bed and ensure patient privacy. b. Listen to the patient’s lung sounds and check the pulse oximetry level.

c. Tell the patient that the physician will be in shortly to start treatment. d. Reassure the patient that the shortness of breath will be relieved shortly.

ANS: B

The priority action of the nurse caring for the patient who has just presented with shortness of breath is to listen to the patient’s lung sounds and check the pulse oximetry level. This information will be presented to the physician in order to facilitate appropriate treatment.

Providing privacy and telling the patient when to expect the physician is not as important as assessing the patient’s respiratory status. The patient’s shortness of breath may not be relieved shortly and the nurse should avoid providing false assurance.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 4. The nurse is caring for a nonverbal patient who just had surgery. The nurse notes that the

patient moans with position changes, the hands are clenched, and the skin is very sweaty. The nurse decides that the patient is in pain and decides to administer an analgesic. What is the correct term for this nursing action? a. Setting priorities b. Recognizing inconsistencies c. Using empathy d. Making inferences ANS: D

The nurse made an inference that the patient is experiencing pain. An inference is a nurse’s judgment or interpretation of a cue. The nurse did not have to determine if relieving the patient’s pain was the highesN t priU i nGtT hisBs.i O tC u ati M on. Empathy was not an issue as it refers to RoritSIy N the nurse’s ability to understand the patient’s perspective. There was no inconsistency in the patient’s assessment data.

DIF: Cognitive Level: Apply (Application) 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. The patient’s catheter drained 400 mL of urine during the last 8 hours. b. The patient’s incision is clean, dry, and intact with staples. c. The patient reports having sharp, burning pain with urination. d. The patient refused breakfast after vomiting 200 mL green emesis.

ANS: C

Subjective data are patients’ verbal descriptions of their health problems. The description of sharp, burning pain with urination is subjective as it could only be felt and reported by the patient. Only patients provide subjective data. Urinary output, incision appearance, and emesis are all objective data. Objective data are observations or measurements of a patient’s health status.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Differentiate between subjective and objective data.

TOP: Nursing Process: Assessment

MSC: NCLEX: Management of Care

6. The nurse has just completed an assessment for a patient. Which data will the nurse categorize

as objective? a. The patient felt less short of breath after receiving a nebulizer treatment. b. The patient’s lung sounds are diminished bilaterally with expiratory wheezes. c. The patient worries that the insurance company will not pay the hospital bill. d. The patient wonders if supplemental oxygen at home would be beneficial.

ANS: B

Objective data are observations or measurements of a patient’s health status. Diminished lung sounds are objective data. Subjective data are patients’ verbal descriptions of their health problems. Only patients provide subjective data.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Differentiate between subjective and objective data.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 7. The nurse is completing the charting after a patient suffered a fall. Which statement is

appropriate for the nurse to include in the description of the incident? a. The patient was found on the floor and his urinal was on the floor next to him. b. The patient’s nurse assistant always took her time to answer his call lights. c. The patient probably urinated on the floor and slipped on the wet floor. d. The patient is grouchy and inappropriate, always causing trouble for the nurses.

ANS: A

When a nurse collects objective data, he or she should apply critical thinking intellectual standards (e.g., clear, preciseN , a nR d c oIn s i sGt e n B U S N T t ) ..N OCu r sMe s 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 and inappropriate are personal interpretive statements and should be avoided.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the types of conclusions resulting from data analysis.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Safety and Infection Control 8. Every time the nurse asks the patient a question for the admission assessment, the patient’s

husband interrupts and answers the question for her. What is the best action of the nurse? a. Enter the husband’s responses into the patient’s chart. b. Request that the husband leave the room. c. Complete the admission assessment after the husband has gone home. d. Allow time for the patient to answer each question.

ANS: D

A patient is usually the best source of information. A patient who is alert and answers questions appropriately 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. The nurse should not wait to complete the assessment as that may delay treatment. The patient’s husband should not be asked to leave the room unless he becomes disruptive to the patient’s care.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 9. The nurse is caring for a toddler who will be having surgery. Which will provide the best

primary source of information about how to comfort the child after surgery is completed?

Patient’s chart Patient Parents Surgeon

a. b. c. d.

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 patient’s chart is a source but not a primary source. The parents are a better source than the surgeon.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: A s s e s sN mU e nRt SINGMTSB C. : C NC OLMEX: Management of Care 10. The nurse completes the assessment for a patient who has just been admitted to the hospital.

The nurse carefully documents the patient’s current drug list and asks about the use of any herbal supplements or over-the-counter medications. Which phase of the interview does this occur in? a. Orientation b. Working c. Reasoning d. Termination ANS: B

Information about the patient’s health status and medications are gathered during the working phase of the interview. The orientation phase begins with introducing oneself and one’s 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. When the interview comes to an end, this is called termination. Reasoning is part of clinical judgment, not a phase of the interview.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss approaches to data collection in nursing assessment.

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

11. The nurse is assessing a patient with chest pain who has just come to the hospital. Which

open-ended question will provide the nurse with helpful information about the patient’s health status? a. “How long have you been experiencing chest pain?” b. “Do you have a family history of heart disease?” c. “Are you having any difficulty breathing right now?” d. “What does your chest pain feel like?”

ANS: D

Open-ended questions cue patients to answer questions with first-hand descriptions in their own words. They allow patients to tell their story to providers, facilitating clinical decision making. Closed-ended questions limit patient answers to one or two words and limit the amount of information that the patient is asked to reveal.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 12. Which question is the most appropriate for the nurse to use to start the health history

assessment? a. “Does your family doctor know that you are here?” b. “Did you drive yourself to the hospital?” c. “What brings you to the hospital today?” d. “Did you give your insurance card to the receptionist?”

ANS: C

Providers should use open-ended questions/comments to begin the health history assessment.

The use of open-ended q u e s t N i o n sR/ c o m eGn t sBp. r oCm p tMs patients to describe a situation in more INm T U S O 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 patient’s perspective.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 13. Which statement by the nurse is an example of back-channeling? a. “I completely understand. Can you tell me more?” b. “When did you first seek health care for your symptoms?” c. “I am sure the doctor will answer all of your questions shortly.” d. “Try not to worry. I’m sure that you will be just fine.”

ANS: A

Back-channeling is the practice of giving positive comments of reassurance to indicate that a nurse has heard what the patient says and is attentive to hear the full story. Asking when the patient first sought health care is a closed-ended question and not back-channeling.The nurse should not provide false assurance or promises that may not be kept.

DIF:

Cognitive Level: Apply (Application)

OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 14. The nurse is conducting an admission assessment for a patient who was brought to the

hospital after having a seizure. Which question will the nurse ask to quickly focus on the patient’s symptoms? a. “Have you been to this hospital before?” b. “How long did the seizure last?” c. “Are you currently seeing a neurologist?” d. “You don’t abuse drugs, do you?”

ANS: B

“How long did the seizure last?” is the question that will quickly focus on the patient’s symptoms. Once patients tell their story, use a problem-seeking interview technique. This approach takes the information provided in the patient’s 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 patient’s answers to one or two words such as “yes” or “no” or a number or frequency of a symptom. Whether or not the patient is currently seeing a neurologist or if the patient has been to the hospital previously will not provide information about the patient’s current health status. The use of leading questions about drug use will make the patient uncomfortable and limit the information that the patient is willing to provide to the nurse.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control

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15. The nurse is caring for a trauma patient who has just arrived to the emergency room. The

nurse listens to the patient’s lung sounds, palpates the patient’s peripheral pulses, and obtains vital signs. What is the best description of the nurse’s actions? a. Establishing priorities for outcomes b. Performing a physical examination c. Demonstrating diagnostic reasoning d. Setting time frames for interventions ANS: B

A physical examination involves use of the techniques of inspection, palpation, percussion, auscultation, and smell. A complete examination includes a patient’s height, weight, vital signs, general appearance and behavior, and a head-to-toe examination of all body systems.

Establishing priorities for outcomes, setting time frames for interventions, and diagnostic reasoning occur after the nursing assessment and physical examination are completed.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 16. The nurse is caring for a patient who denies having any pain. The nurse notes that the patient

is restless and the patient’s hands are tightly clenched. The nurse also heard the patient moaning before walking into the room. What will the nurse take into consideration as the patient assessment is completed?

a. b. c. d.

Unclear communication techniques Unrealistic patient expectations Inappropriate empathic response Conflicting assessment findings

ANS: D

The patient’s report of pain may not accurately reflect the discomfort that the patient is experiencing. The nurse assesses the patient’s nonverbal behavior to determine the patient’s comfort level in addition to the patient’s subjective report of pain. There is nothing in the scenario to suggest that the patient has unrealistic expectations or that the nurse used unclear communication techniques. Empathy is the nurse’s appreciation of the patient’s pain experience rather than the assessment of the patient’s present level of discomfort.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the types of conclusions resulting from data analysis.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 17. The nurse becomes frustrated when a patient insists on taking herbal remedies rather than

prescribed medications and spends certain hours of each day in prayer. The patient also prefers the care of the spiritualist healer over the attending physician. Which factor may be responsible for the nurse’s frustration? a. Cultural differences in health-related practices b. Delay in the patient’s psychosocial development c. Impaired ability of the patient to cope with acute illness d. Incorrect organization of health assessment findings ANS: A

Cultural differences in healthN -r elU c t i cBe s.

Ra t eSdIpNr aGT OcCa n cMause significant frustration between patients and providers. Culture affects the way people express themselves, practice their religion, and address their health. Providers must respect cultural differences and find ways to effectively work with patients for treatment and health promotion. Nothing in the scenario indicates a developmental delay for the patient or an inability to cope with chronic illness.

Incorrect organization of health assessment findings would not lead to the nurse’s frustration over the patient’s cultural preferences.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 18. The nurse is caring for a patient who will be having surgery shortly. The patient requests that

a religious bracelet be worn in the operating room to help ensure a good surgical outcome.

Which is the most appropriate action of the nurse? a. Call the operating room staff to determine if the bracelet can stay on during surgery. b. Insist that the patient remove the bracelet and give it to a family member during surgery. c. Notify the patient’s surgeon of the patient’s refusal to remove the bracelet before having surgery. d. Remove the bracelet from the patient’s wrist after sedating medication has been administered.

ANS: A

The nurse should call the operating room staff to determine if the bracelet can stay on during surgery. The nurse should not insist on removal of the bracelet unless it will interfere with the surgical procedure. The surgeon should be notified only if the bracelet will interfere with surgery but the patient refuses to have it removed. It is unethical to remove the bracelet without the patient’s knowledge or consent.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 19. The nurse is caring for a patient with sepsis. The nurse includes potential complications:

septic shock in the plan of care. Why is this nursing diagnosis considered a collaborative problem? a. The patient must be closely monitored in an intensive care unit. b. The patient has a history of noncompliance with prescribed therapeutic regimens. c. Prevention of septic shock is not a measurable patient outcome. d. Both nursing and physician-prescribed interventions are required.

ANS: D

A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status. When collaborative problems develop, nurses collaborate with personnel from other health care disciplines, such as social workers and dietitians and physicians. History of patient noncompliance and intensive care monitoring do not make the nursing diagnosis collaborative.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe differences amN onU gR prS obIleN mG -fT ocB us. edCnOuM rsing diagnoses.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Adaptation 20. Which nursing diagnosis is the highest priority for a patient with pneumonia? a. Activity intolerance related to fatigue and shortness of breath b. Knowledge deficit related to pneumonia risk factors c. Pruritus related to side effects of prescribed medications d. Impaired gas exchange related to alveolar inflammation and infection ANS: D

Impaired gas exchange is the highest priority as it addresses the basic physiological need for oxygen. Pruritus is uncomfortable but not life-threatening. Knowledge deficit and activity intolerance may be addressed once physiological needs are met.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the criteria used in setting priorities.

MSC: NCLEX: Physiological Adaptation

TOP: Nursing Process: Diagnosis

21. Which nursing diagnosis is the highest priority for a patient with multiple sclerosis? a. Chronic sorrow related to loss of independence b. Disturbed sensory perception related to nerve cell damage c. Risk for powerlessness related to impaired fine- and gross-motor skills d. Risk for falls related to impaired mobility and sensation ANS: D

Risk for falls is the highest priority for a patient with multiple sclerosis. Falls can lead to serious injury so this diagnosis addresses a basic physiological need. Chronic sorrow, disturbed sensory perception, and risk for powerlessness are all lower priority as they address psychological needs.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the criteria used in setting priorities.

MSC: NCLEX: Reduction of Risk Potential

TOP: Nursing Process: Diagnosis

22. The nurse is caring for a patient who has been unable to have a bowel movement for the last 4

days after taking prescribed narcotic pain medication. Which nursing diagnosis is appropriate for this patient? a. Risk for constipation related to irregular defecation habits b. Perceived constipation related to expectation of daily bowel movements c. Constipation related to side effects of pain medication d. Impaired bowel elimination related to abdominal muscle weakness ANS: C

Constipation related to side effects of pain medication is the correct diagnosis for this patient as there has been no bowel movement for the last 4 days. Risk for constipation and perceived constipation are not appropriate because the constipation problem has already been developed. Impaired bowel elimination is not the correct nursing diagnostic term and the patient’s constipation problem is not due to abdominal muscle weakness.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain how the nurse uses defining characteristics and etiological factors to individualize a nursing diagnosis.

TOP: Nursing Process: Diagnosis NdUapRtaStiI MSC: NCLEX: Physiological A o nNGTB.COM 23. The nurse observed a postoperative patient trying to take her friend’s narcotic pain pills in

addition to the pain medication administered by the nurse. Which nursing diagnosis is the highest priority for this patient? a. Health-seeking behaviors b. Risk-prone health behavior c. Readiness for enhanced comfort d. Situational low self-esteem ANS: B

The patient’s life was put at risk by taking the friend’s narcotic pain medication so risk-prone health behavior would be the most appropriate nursing diagnosis. Readiness for enhanced comfort and situational low self-esteem are lower priority than risk-prone health behavior.

Health-seeking behaviors indicate that the patient is attempting to improve health, not put it at risk.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain how the nurse uses defining characteristics and etiological factors to individualize a nursing diagnosis.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Reduction of Risk Potential 24. The nurse is caring for a patient with the nursing diagnosis ineffective airway clearance

related to narrowed airways and thick sputum. Which is an appropriate goal for this patient?

a. b. c. d.

“The patient will be resting comfortably by the morning.”

“The patient’s airway will remain clear throughout the night.”

“The patient will not experience any feelings of shortness of breath or anxiety.”

“The patient’s respiratory rate and pulse will remain within normal limits.”

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. Resting comfortably is not measurable. Within normal limits is not specific. There is no time frame for feeling short of breath or anxious.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify examples of nursing-sensitive outcomes.

MSC: NCLEX: Physiological Adaptation

TOP: Nursing Process: Planning

25. The nurse is caring for an unconscious patient. The nurse repositions the patient at least every

2 hours and ensures that all of the patient’s bony prominences are padded. What is the rationale for these actions? a. The nurse is following the standing orders listed in the patient’s medical record. b. The nurse realizes the potential for bedsores and acts to prevent their development. c. The nurse identifies the patient care areas in which additional assistance is required. d. Nursing regulations do not allow these care tasks to be delegated to unlicensed personnel.

ANS: B

Repositioning patients at least every 2 hours and padding their bony prominences will help prevent development of b e d sN o r e sR. ThIe nG urseBr. eaC lizeM s this and acts to prevent these U S N T O complications for the patient. Repositioning may also be done by unlicensed personnel like certified nursing assistants. Repositioning patients is not included the standard orders for patients. Nothing in the scenario indicates that additional assistance from other personnel are required to reposition the patient.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 26. The nurse is caring for a patient with the nursing diagnosis constipation related to side effects

of medications. Which is an appropriate goal for this patient? a. “The patient will have a soft formed bowel movement by the end of the shift.” b. “The nursing assistant will ambulate the patient to the toilet as needed.” c. “The patient will not have any nausea, vomiting, or feeling of abdominal fullness.” d. “The nurse will palpate for abdominal distention and encourage oral fluid intake.”

ANS: A

The patient will have a soft formed bowel movement by the end of the shift is measurable, reliable, valid, and focuses on the patient’s needs. Expected outcomes are measurable criteria to evaluate goal achievement. These measurable effects relate to a change in a patient’s physical condition or behavior that results from individualized nursing interventions.

Outcomes should be measurable, reliable, valid, suited to the patient, and sensitive to change.

Ambulation to the toilet, assessing for abdominal distention, and encouraging oral fluid intake are interventions, not outcomes. There is no time frame to the patient to not have any nausea, vomiting, or abdominal fullness.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify examples of nursing-sensitive outcomes.

MSC: NCLEX: Physiological Adaptation

TOP: Nursing Process: Planning

27. The nurse is preparing to insert an indwelling urinary catheter into the patient. Where will the

nurse check to ensure that the packaging is sterile, intact, and not past the expiration date? a. In the clean utility room immediately after removing the package from the shelf b. At the patient’s bedside after verifying the patient’s name and birthdate c. At the nurses’ station after verifying the physician’s order for the procedure d. At the patient’s bedside after performing careful perineal care for the patient ANS: A

The nurse should check to ensure that the urinary catheter packaging is sterile, intact, and not expired immediately after removing the package from the shelf in the utility room. The nurse should not wait until the package has been brought to the patient’s room or the nurses’ station as another trip to the clean utility room may be required.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the process of seNleU ctR inS gI nuN rsG inT gB int. erC veOnM tions.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 28. A nurse is delegating care of patients to the certified nursing assistant (CNA) and a licensed

practical nurse (LPN). Which task assignment indicates that the nurse needs additional education about delegation? a. The LPN is assigned to change a sterile dressing. b. The CNA is assigned to provide skin care. c. The CNA is assigned to insert an indwelling urinary catheter. d. The LPN is assigned to administer a soapsuds enema.

ANS: C

A CNA cannot insert indwelling catheter as only 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 may be assigned to unlicensed personnel 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 dressing change and enema to an LPN. It is appropriate for an RN to delegate skin care to a CNA. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the process of selecting nursing interventions.

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

29. The patient has a goal of maintaining urinary output of at least 30 mL/hour as part of the

nursing care plan. However the patient’s urinary output for the shift was only 20 mL/hour.

What is the appropriate action of the nurse? a. Contact the physician to obtain an order for diuretics to increase urinary output. b. Reassess the patient to determine why the urinary output was less than 30 mL/hour. c. Change the goal to: patient will maintain urinary output of at least 20 mL/hour. d. Inform the patient that the urinary output goal for the shift was not met.

ANS: B

When there is failure to achieve a goal, no matter what the reason, the entire nursing process sequence should be repeated. The nurse should review the nursing diagnosis to discover changes that are needed for the plan of care. A complete reassessment of all patient factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. An order for diuretics should not be obtained before a careful assessment has been completed.

Informing the patient that the goal was not met will not be beneficial.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the relationship among goals of care, expected outcomes, and evaluative measures when evaluating and revising nursing care.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation 30. Which nursing care order is an example of a standing order? a. Monitor blood glucose level before meals and at bedtime. b. Administer a soapsuds enema if no bowel movement for 3 days. c. Instruct the patient how to self-administer insulin correctly. d. Bathe the patient daily w ith a ppl icati on of m ois turizer to all bony prominences.

ANS: B

N RU IS NG TB . CO M

Standing orders are preprinted lists of orders for specific patients with particular care needs.

The nurse can implement the orders when the specific care needs are identified, such as administration of a soapsuds enema when there has been no bowel movement for 3 days.

Orders for blood glucose monitoring and education about insulin administration are not included in standing orders as they are written for individual patients. Bathing and personal care are not included in the order list for the patient.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 31. The extended care agency administers the flu vaccination to all of the patients who do not

have contraindications to the injection. What is the reason that the nurses do not have to obtain orders from each patient’s physician for vaccination each year? a. The agency’s medical director placed a standing order for patients to receive the flu vaccination yearly unless contraindicated. b. The Centers for Disease Control and Prevention highly recommend yearly flu vaccinations for all individuals over the age of 65. c. The State Licensing Board for extended care facilities requires annual flu vaccinations for all residents and staff. d. The administrator of the agency has the authority to order annual flu vaccinations for all residents and staff.

ANS: A

Standing orders are preprinted documents with orders for routine therapies, monitoring guidelines and treatments for certain patients in the agency. Extended care agency medical directors can have standing orders in place for annual flu vaccinations for all residents. The agency administrator, state licensing board, and Centers of Disease Control and Prevention do not have the authority to order flu vaccinations for patients in the agency.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. Which actions by the nurse are examples of dependent nursing interventions for a

postoperative patient? (Select all that apply). a. Calculating the patient’s fluid intake and output at the end of every shift b. Encouraging fluid and fiber intake to prevent constipation from pain medications c. Administering a mild stool softener daily to prevent constipation d. Assessing the patient’s abdomen for distention, bowel sounds, and passage of flatus e. Reinserting of the patient’s urinary catheter for retention of greater than 500 mL of urine ANS: C, E

Administration of medications and insertion of urinary catheters are dependent nursing interventions as they must be prescribed by a physician. This is true even if the medications are available over the counteN r. U CR alcSuI laN tinGgTinBt. akC e O anMd output, encouraging fiber intake, and abdominal assessment are all independent nursing interventions.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 2. Which actions by the nurse are examples of independent nursing interventions for a

postoperative patient? (Select all that apply). a. Teaching patients with heart failure how to do accurate daily weights b. Administering intravenous fluids when the patient is unable to eat or drink c. Advancing a patient’s diet from clear liquids to solid foods after surgery d. Elevating the head of the patient’s bed to facilitate use of the incentive spirometer e. Switching the patient’s injected pain medication to oral tablets before discharge ANS: A, D

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. Advancing the patient’s diet and implementing invasive procedures such as intravenous lines and urinary catheters are examples of such interventions.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3. The nurse enters the patient’s room to begin teaching the patient about wound care

management. The nurse notes that the patient is nauseated due to medication side effects.

What are the priority actions of the nurse? (Select all that apply). a. Begin teaching the patient about wound care management, taking care to avoid using terms that the patient might find upsetting. b. Provide measures to relieve the patient’s nausea and return to teach about wound care when the patient is feeling better. c. Document in the patient’s chart that teaching about wound care management was not done because the patient refused to learn. d. Check the patient’s order list to determine if antiemetic medication has been prescribed for the patient. e. Apply a cold cloth to the patient’s forehead and maintain a quiet, odor-free environment for the patient.

ANS: B, D, E

Patients are not able to learn well when they are nauseated and uncomfortable. The nurse should act to relieve the patient’s nausea and delay teaching about wound care until the patient is feeling better and ready to learn. The patient did not refuse to learn about wound care management and documentation of such in the patient’s chart would be incorrect.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the process of selecting nursing interventions.

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

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Chapter 10: Informatics and Documentation Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. What is the best method for to The Joint Commission to demonstrate that it is assessing

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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify key reasons for reporting and recording patient care.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 2. The patient’s daughter requests to see the patient’s medical record. What is the nurse’s

appropriate response?

N R I G B.C M a. “Come with me and we wi lUl l o S ok aN t it T togetheO r .” b. “I’m sorry but that information is confidential.” c. “Let me ask my supervisor if it is okay.” d. “The doctor will have to give permission first.”

ANS: B

Nurses may not disclose information about patients’ status to other patients, family members unless specifically granted in writing by the patient. Looking at the medical record together is not acceptable because confidentiality would be broken. Asking a supervisor is inappropriate because the nurse should already know the legalities for confidentiality. The doctor does not give permission for the daughter to look at the patient’s medical records.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal and ethical implications associated with documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 3. Which patient information may be included in the nursing student’s assignment that will be

turned in to the instructor after the clinical shift has ended? a. Room number b. Date of birth c. Medical record number d. Nursing diagnosis ANS: D

The nursing diagnosis is acceptable information to give to a nursing instructor. To maintain confidentiality and protect patient privacy, instructors must 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal and ethical implications associated with documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 4. Which agency creates standards that require nursing documentation to be accurate, timely, and

patient-centered? a. Centers for Disease Control and Prevention b. World Health Organization c. The Joint Commission d. Agency for Healthcare Research and Quality 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. The World Health Organization is concerned with international public health. The Centers for Disease Control and Prevention are concerned with the spread of infections. The Agency for Healthcare Research and Quality performs research to make health care safer for patients and providers.

DIF: Cognitive Level: UndersN taU ndR(S CoImNpG reT heB ns. ioC n)OM OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 5. Which is the primary purpose of a patient’s medical record? a. To invoice the nursing services for hospital reimbursement b. To protect the patient in case of a malpractice suit c. To facilitate professional communication and safe health 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify key reasons for reporting and recording patient care.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 6. Which chart entry represents appropriate documentation about the patient’s pain assessment?

a. b. c. d.

The patient appears not to be in any pain.

The patient is sleeping comfortably.

The patient always complains about being in pain.

The patient rated the pain at 2 on a 0-to-10 scale.

ANS: D

States pain as 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 7. Which statement by the nurse accurately reflects a benefit of installing a new electronic

medical record system? a. “I am thankful that I won’t have to keep changing my passwords all the time.” b. “I’ll be able to see my son’s medical record using my password and user ID.” c. “I won’t have to worry about reading the doctor’s messy handwriting anymore.” d. “It will take me so much less time than writing everything out on paper.”

ANS: C

One of the main benefits of electronic medical record systems is that nurses and ancillary staff do not have to decipher illegibly written orders from providers. Electronic charting has not been shown to decrease documentation time. It will still be against HIPAA policy for the nurse to view family members’ medical records. Passwords must be changed regularly for all new electronic medical recorN d syR stem o mM a i n t a i n security of the documents.

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DIF: Cognitive Level: Apply (Application) OBJ: Compare paper-based and electronic documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 8. Which chart entry reflects appropriate documentation of patient data? a. The patient voided a moderate amount of urine. b. The patient voided 220 mL of clear yellow urine. c. The patient was incontinent. d. The patient voided an adequate amount of urine for the shift.

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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care

9. Which is the correct military time entry for a medication that was administered at 8:30 p.m.? a. 0830 b. 140 c. 2030 d. 2230 ANS: B

The correct military time entry for 8:30 p.m. is 2030.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 10. The patient requests that her chart be destroyed as soon as she is discharged. What is the best

response of the nurse? a. “The hospital can give you the chart after you are discharged.” b. “Your chart will be kept secure and confidential.” c. “The information must be reported to the health department first.” d. “Your chart can be shredded if you give consent.”

ANS: B

The patient’s hospital record may not be destroyed after the patient is discharged. The patient should be reassured that all of the information in the record will be kept secure and confidential.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal and ethicalN implications with documentation.

RionINa nGdassociated B.C Ontation M TDocume TOP: Nursing Process: CommunUicatS MSC: NCLEX: Management of Care 11. The nurse realizes that the wrong patient’s name was written on several important paperwork

forms that were already signed by the attending physician. How will the nurse correct this error? a. Black out the error with a thick marker and enter the correct information. b. Use correction tape to write over the incorrect information. c. Draw one line through the error, make the correction and initial it. d. Shred the forms with the incorrect information and write on new ones.

ANS: C

The nurse should make draw one line through the error, make the correction, and initial it so there is no attempt to cover up the mistake. The error should not be blacked out or covered with correction tape as it will hide the information. The forms should not be shredded as they were already signed by the physician. Agency policy may indicate the physician should initial each change as well.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care

12. The patient was not able to continue along the migraine headache critical pathway after

suffering a stroke. Which terminology describes this deviation from the prescribed pathway? a. Negative variance b. Noncompliance with the treatment plan c. Risk-prone health behavior d. Care plan intolerance ANS: A

Any deviation from a critical pathway is termed a variance. A negative variance occurs when the patient develops a complication or new condition that leads to cessation or modification of the pathway. The patient did not demonstrate noncompliance with the treatment plan, risk-prone health behavior, or care plan intolerance.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 13. Before leaving at the end of the shift, the nurse realizes that a set of patient assessments were

taken earlier in the day but never charted. What is the appropriate action of the nurse? a. Enter the assessments in the chart the next day before receiving report. b. Do nothing because the other patient assessments were obtained during the shift. c. Direct the nursing assistant to enter the assessments into the patient’s chart. d. Enter the assessments into the chart as a late entry with a reason for the delay.

ANS: D

The nurse should enter the assessments into the chart as a late entry with a reason for the delay. The nurse should not wNa i t Ru n tI i l t hGe neBx. t dCa y M to enter the assessments or do nothing with U S N T O the information. The nursing assistant should never be directed to chart the nurse’s assessments.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal and ethical implications associated with documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 14. The patient developed a large hematoma where the laboratory technician drew blood earlier in

the shift. Which statement is appropriate to enter in the patient’s chart? a. The laboratory technician did not know what he was doing and traumatized the patient’s arm. b. The patient has a painful raised 2-inch  2-inch hematoma on the outer left arm after venipuncture. c. The laboratory technician must have had a hard time getting the blood sample drawn as the patient’s arm is now bruised. d. The patient must have moved during the blood draw because there is a huge bruise on his left arm.

ANS: B

Charting must be clear and factual without guesses or opinions. The patient has a painful raised 2-inch  2-inch hematoma on the outer left arm after venipuncture reflects objective documentation of the patient’s hematoma.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 15. After a patient fall, the supervisor asks the nurse to rewrite the entry in the patient’s chart to

show that the patient’s bed was lowered to the floor even though it was not. What is the best action of the nurse? a. Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed. b. Remind the supervisor that it is against regulations to alter or falsify the patient’s chart. c. Ask the nurse assistant to chart that the patient’s bed was lowered to the floor at the time of the fall. d. Rewrite the entry as requested but note that the patient’s bed was not lowered to the floor in the incident report.

ANS: B

It is against regulations to alter or falsify the patient’s medical record regardless of the intent or desire to avoid a malpractice lawsuit. The nurse should never ask the nurse assistant to falsify information. The information in the incident report and patient chart should be factual and consistent.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal and ethical implications associated with documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care

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16. Which entry in the patient’s chart will justify home nursing care reimbursement from

Medicare, Medicaid, and private insurance companies? a. The patient’s wound is improving slightly each day. b. The patient was receptive to the smoking cessation information. c. The patient’s family appreciated the nurse’s caring demeanor. d. The patient’s wound was 6 cm  4 cm and is now 4 cm  2 cm.

ANS: D

When you provide home care, your documentation must specifically address the category of care and your patient’s response to care. Receptive to teaching from the nurse and a gradually improving wound is not factual or objective information. Whether family liked the nurse or not does not affect reimbursement.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 17. Which action by the nurse minimizes the risk of unauthorized use of computer passwords for

the electronic medical record system? a. Using the same password for home and health care agency computers b. Writing each new computer password on the back of the name badge c. Periodically reusing previous computer passwords to prevent forgetting them

d. Using passwords of at least eight characters with at least one number and symbol ANS: D

Passwords should have at least eight characters with at least one number and symbol. Nurses should never use the same password for home and health care agency computers. Nurses should have one designated password for work that should be changed every few months.

Computer passwords should never be shared with anyone or written where they may be seen by others. Passwords should never be reused or recycled.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss methods for maintaining privacy and confidentiality of protected health information.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 18. Which information must be shared during the hand-off report to the oncoming nurse? a. The patient is nauseated and complaining of moderate generalized pain. b. The patient has six children and fourteen grandchildren. c. The patient will drink chicken broth but prefers to have lime gelatin. d. The patient sent back the dinner tray twice because the food was cold.

ANS: A

The hand-off information must communicate priority patient assessment data, changes in the patient’s condition, and any recent or anticipated changes to the treatment plan. The number of children and grandchildren in the patient’s family, clear liquid preferences, and returned dinner trays may be shared with the oncoming nurse but are not priorities.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care N s iRng SI Gce sB.C M unication settings.

TOP: Nu r U Pr o N sT : CommO and Documentation MSC: NCLEX: Management of Care 19. The nurse is working at a hospital whose electronic medical records system uses charting by

exception. Which entry would be appropriate to include in the narrative section of the patient’s chart? a. The patient voided 400 mL of clear yellow urine during the last 12 hours. b. The patient denies smoking, alcohol intake, or use of illicit substances. c. The patient states that the pain level in his right knee is 7 on a 1-to-10 scale. d. The patient’s lung sounds are clear bilaterally with no cyanosis or dyspnea.

ANS: C

Charting by exception allows nurses to enter narrative notes only for assessment findings that are unusual, unexpected, or abnormal. Assessment findings that are expected or within normal limits may simply be checked off as such. The patient’s severe knee pain is outside of the normal limits and should be described using a narrative note.

DIF: Cognitive Level: Apply (Application) OBJ: Compare different methods and forms used for documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 20. The nurse fills out an incident report after a patient fall but makes no mention of the report in

the patient’s medical record. What is the reason for this?

a. The nurse does not want to risk a malpractice lawsuit by mentioning the creation

of an incident report. b. The incident report includes the nurse’s interpretations of what probably led the

patient to get out of bed. c. A copy of the incident report is filed in the patient’s chart along with the nurse’s notes about the fall. d. The incident report is confidential and not intended to be used as evidence in a malpractice suit.

ANS: D

The incident report is never filed with the patient’s medical record. The incident report is used to facilitate investigation of the event within the agency. It is not intended to be part of the patient’s medical record as the findings of the investigation could potentially be used during a malpractice lawsuit. The incident report information should be factual without guesses or subjective interpretations. The presence of an incident report in the patient’s medical record would not lead to a malpractice lawsuit.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the purpose for incident (event, or occurrence) reports and why the existence of such reports should not be documented in the medical record.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 21. A nurse completes an incident/occurrence report after a patient fell. What is the reason for this

report? a. To compare patient fall rates between nursing units in the hospital b. To provide justification for the hospital to fire the nurse GaTlpBra.cC c. To prevent the patient froN mUfR iliS ngIaNm ticOeM lawsuit d. To aid in the hospital’s 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. The nurse does not complete the incident report to provide cause for the nurse to be fired from the hospital.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss the purpose for incident (event, or occurrence) reports and why the existence of such reports should not be documented in the medical record.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 22. What is the priority action of the nurse immediately after receiving a medication telephone

order from a physician? a. Withhold the medication until the physician signs the order. b. Authorize the physician’s order with the pharmacy. c. Read back the order to the physician for confirmation. d. Double-check the 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the relationship between informatics and quality health care.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 23. Which statement exemplifies important patient information in the change-of-shift report? a. The patient sent his dinner tray back to the kitchen twice because the food was

cold. b. The patient keeps taking his nasal cannula off and threading it around the side rails

of the bed. c. The patient prefers to drink coffee that has cooled to room temperature with two

sugars and two creamers. d. The patient took all of the prescribed morning medications with a big glass of

apple juice.

ANS: B

A change-of-shift report is a hand-off and provides information to ensure continuity and individualized care for patients. Important information should be communicated to make the most efficient use of the nurses’ time. The oncoming nurse must be told that the patient frequently takes off the nasal can nul a as t h e p at i ent m ay become hypoxemic. The other pieces N R I G B. C M of information are less importaU nt. S N T O DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation and reporting in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 24. Which specifics of care will be included in a patient’s critical pathway? a. Refer the patient to the outpatient cardiac rehabilitation program. b. Elevate the head of the patient’s bed to ease shortness of breath. c. Provide small meals throughout the day and encourage fluid intake. d. Teach the patient how to use relaxation techniques to ease shortness of breath.

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. Referral of the patient to the outpatient cardiac rehabilitation program would be included in the critical pathway. Elevating the head of the patient’s bed, providing small meals, and teaching relaxation techniques would be considered independent nursing interventions that fall outside the realm of the critical pathway.

DIF: Cognitive Level: Apply (Application) OBJ: Compare different methods and forms used for documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 25. The nurse has just completed teaching the patient how to self-administer insulin injections.

Which entry in the patient’s chart demonstrates that the teaching was successful? a. The patient correctly self-administered his next scheduled dose of insulin. b. The patient denied having any questions or concerns about the procedure. c. Additional written instructions about how to perform the injection was provided. d. The patient identified the steps and equipment used for the injection.

ANS: A

Having the patient self-administer the next dose of insulin in front of the nurse will demonstrate competence and any areas that require reinforcement or correction. Asking the patient if there are any questions will not demonstrate competency as the patient may not be truthful about concerns. Providing additional written materials or identifying pieces of equipment will not demonstrate patient competency in the skill.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for effective documentation in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 26. The nurse is entering a note in the patient’s medical record using the SOAP format. Which

statement belongs in the Assessment section? a. The patient stated “I started feeling short of breath after smelling strong perfume.” b. The patient is using accessory muscles and has wheezes in all lung fields. c. Ineffective airway clearance related to exposure to environmental allergen. d. Monitor pulse oximetry aN ndUaRdS mI inN isG teT r nBe. buCliO zeMd bronchodilators.

ANS: C

The Assessment section of the SOAP note describes the nurse’s assessment of the situation, usually in the form of a nursing diagnosis such as ineffective airway clearance. The patient’s feelings of dyspnea belong in the Subjective information section of the note. The patient’s wheezes and use of accessory muscles belongs in the Objective section of the note.

Monitoring pulse oximetry and administering bronchodilators belongs in the Plan section of the note.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Compare different methods and forms used for documentation.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 27. At the nursing station, the nurse receives a verbal order from the physician for a routine

medication. What is the best action of the nurse? a. Request that the doctor enter the order into the computer. b. Repeat the order to the doctor and enter it into the computer. c. Direct the unit secretary to enter the order into the computer. d. Call the pharmacy to determine that the drug dosage is appropriate.

ANS: A

Verbal orders should only be used when absolutely necessary such as patient emergencies.

They should never be used for the physician’s convenience. The nurse should direct the physician to enter the order into the computer to minimize the risk of an error. The nurse should not enter the order into the computer or direct the unit secretary to do it. Calling the pharmacy to determine the drug dosage may be done after the physician has entered the order into the computer.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the relationship between informatics and quality health care.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. Which information must be included in the patient’s discharge summary? (Select all that

apply.) a. The patient is to follow up with the primary care physician in 14 days. b. The patient arrived at the hospital by ambulance with acute shortness of breath. c. Supplemental oxygen was administered to the patient in the emergency room. d. The patient is to have a protime (PT) level drawn daily for the next 7 days. e. The patient is to take the prescribed antibiotic daily even after symptoms subside ANS: A, D, E

The discharge summary should include directions for medications, follow-up appointments with physicians, and ongoing laboratory testing. The patient’s condition on arrival to the hospital and emergency treatment do not need to be included.

N R I G B.C M

S N T O DIF: Cognitive Level: Analyze U (Analysis) OBJ: Describe guidelines for effective documentation in a variety of health care settings.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 2. The nurse is caring for a patient who climbed out of bed and fell on the floor. What will the

nurse do in regard to the incident report? (Select all that apply.) a. Document how the patient was found and a description of the injuries. b. Include recommendations for future fall prevention interventions. c. Note in the patient’s chart that an incident report was completed. d. Indicate that the nursing assistant wasn’t doing her job correctly. e. Document fall prevention steps that were in place before the patient fell.

ANS: A, E

The nurse should document exactly how the patient was found and a description of the injuries using clear, objective terms. Subjective or judgmental statements about other staff members are never included. Any fall prevention steps that were in place before the patient fell should be included as well. Recommendations for future fall prevention interventions are not included in the incident report. No mention of the incident report is included in the patient’s medical record.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the purpose for incident (event, or occurrence) reports and why the existence of such reports should not be documented in the medical record.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 3. Which patient situations require the completion of an incident report? (Select all that apply.) a. A patient almost receives the wrong medication due to unclear wording on the b. c. d. e.

packaging from the pharmacy.

A patient repeatedly refuses to eat food from the hospital kitchen because it is always too salty or too cold.

A visitor trips on an icy sidewalk in the hospital parking lot and suffers a fractured wrist.

The nurse accidentally enters the wrong vital signs into the patient’s medical record and corrects the error shortly afterward.

The patient dislikes male nursing staff and prefers to have only female nurses providing personal care.

ANS: A, C

Near misses such as medication errors that almost occurred should be documented with an incident report to help prevent the same problem from recurring in the future. Mishaps by visitors, vendors, or staff should always be documented in incident reports as well. Patient preferences for nursing care and food do not require incident reports. An incident report should not be completed if the nurse corrected the computer entry appropriately and there was no adverse impact on patient care.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the purpose for incident (event, or occurrence) reports and why the existence of such reports should not be documented in the medical record.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management oN fC UaRr eS I N G T B.C O M

Chapter 11: Communication Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse educates the patient about what to expect during insertion of a nasogastric tube.

Which term best describes the nurse’s 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 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 nurse’s spoken words in this scenario.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the elements of the communication process.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Caring

2. The nurse educates the patient about what to expect during suctioning of the tracheostomy

tube. Which term best describes the patient’s communication role? a. Channel NURSINGTB.COM b. Receiver c. Message d. Sender ANS: B

The patient is the receiver in this scenario, as they have received the message. The nurse is the sender in this scenario. The sender is the person who delivers the message. 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 nurse’s spoken words in this scenario.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the elements of the communication process.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Caring

3. The nurse manager rehearses what to say to a nurse who made a serious medication error.

Which form of communication is being used by the nurse manager? a. Intonation b. Nonverbal c. Intrapersonal d. Orientation ANS: C

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. Nonverbal communication uses body language, gestures, and eye contact to convey messages rather than spoken phrases. Intonation is inflection and pitch of the voice used to help convey a message. Orientation is the interview phase when the patient and nurse meet and get to know each other.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the levels of communication and their uses in nursing.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 4. The nurse informs the patient that a code pink is paged overhead when an infant is abducted

from the hospital. What is the best description of the use of the term code pink in this situation? a. Denotative meaning b. Perceptual stereotype c. Emotional inflection d. Sender territoriality ANS: A

Code pink in this instance is a denotative meaning in that the term refers to infant abduction to providers within the agency. Individuals who use a common language share the denotative meaning of a word or phrase. Perceptual stereotyping prevents accurate interpretation of messages from others. Inflection refers to the tone and pitch of the voice during verbal communication. Territoriality refers to t h e p h y s i cal space between the sender and the receiver.

N R I G B .C M U S N T O

DIF: Cognitive Level: Apply (Application) OBJ: Describe the levels of communication and their uses in nursing.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 5. Which action by the nurse demonstrates appropriate timing for effective communication? a. The nurse sits in a chair next to the patient’s bed to maintain eye contact. b. The nurse waits to begin teaching until the patient’s nausea has subsided. c. The nurse speaks slowly and loudly for a patient who is hard of hearing. d. The nurse maintains privacy during all conversations with the patient.

ANS: B

The nurse demonstrates appropriate timing by waiting to begin teaching until the patient’s nausea has subsided. Timing must be appropriate in order for the receiver to understand the message. The nurse demonstrates pacing by speaking slowly for a patient who is hard of hearing. Timing does not refer to ensuring privacy or maintaining eye contact.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate aspects of verbal and nonverbal communication.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 6. Which action by the nurse will help to reduce the fears of a hospitalized young child? 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 patient’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate aspects of verbal and nonverbal communication.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. Which action communicates to the patient that the nurse wants to leave the patient’s room to

care for other patients? a. Sitting in a chair next to the patient’s bed b. Making sure the door is completely shut for privacy c. Repeatedly checking the clock to see what time it is d. Holding the patient’s hand when the patient starts to cry ANS: C

Repeatedly checking the clock to see what time it is communicates to the patient that the nurse wishes to leave the room. Sitting next to the patient, ensuring privacy, and holding the patients hand are supportive nonverbal communications.

DIF: Cognitive Level: AnalyzN e (ARnalyIsis)G B.C M U S NthatTaffect communication.

O OBJ: Describe behaviors and techniques TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 8. Which assessment findings will the nurse communicate to the physician using the SBAR tool? a. The patient is having difficulty breathing and the pulse oximetry is 75%. b. The patient has not had a bowel movement since surgery eight hours ago. c. The patient’s family member initially refused to learn how to perform the dressing

changes. d. The patient sent the breakfast tray back to the kitchen because the food was cold.

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 is not used to communicate low-priority assessment findings such as constipation, initial refusal to learn, or cold breakfast trays.

DIF: Cognitive Level: Apply (Application) OBJ: Describe standardized communication tools used to facilitate safe, complete, and organized communication.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 9. Which statement by the nurse is an example of an SBAR recommendation?

a. b. c. d.

“The patient has become increasingly short of breath over the last few hours.”

“The patient has a history of chronic respiratory failure due to emphysema.”

“The patient’s pulse oximetry is 84% and crackles are heard over all lung fields.”

“The patient needs oxygen titrated to maintain oximetry between 90% and 92%.”

ANS: D

The SBAR recommendation statement is what the nurse believes should happen next for the patient to address the crucial situation at hand. The nurse recommends that the patient receive oxygen to maintain pulse oximetry between 90% and 92%. The SBAR situation statement is the increasing shortness of breath. The SBAR background statement is the patient’s history of respiratory failure. The SBAR assessment statement is the current pulse oximetry and lung sounds.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe standardized communication tools used to facilitate safe, complete, and organized communication.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 10. Which is the best strategy for the nurse to use when communicating with a patient from

different culture? a. Using a cultural joke to break the ice b. Stereotyping the patient within his or her culture c. Considering the context of the patient’s 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 patient’s background. Accept patients’NrigR hts I to a G d h erBe .t oCc u lMt u r al customs and norms. People of U S N T O 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 individual’s background. Avoid stereotyping people 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe behaviors and techniques that affect communication.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 11. Which is the most appropriate nursing diagnosis to use for a patient with expressive aphasia

following a stroke? a. Impaired verbal communication related to inability to speak and reply b. Readiness for enhanced comfort related to drooling and facial droop c. Deficient diversional activity related to lack of stimuli in hospital room d. Noncompliance related to inability to verbally answer questions ANS: A

Impaired verbal communication is the nursing diagnostic label used for 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. Readiness for enhanced comfort, deficient diversional activity, and noncompliance do not directly relate to the patient’s inability to speak.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the focus of communication within each phase of the nursing process.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 12. Which health care professional will be of most assistance to help the patient with aphasia

following a stroke? a. Speech therapist b. Medical interpreter c. Physical therapist d. Mental health nurse specialist ANS: A

Speech therapists help patients with aphasia. The nurse should collaborate with other health care providers who have expertise in communication strategies. Medical 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 therapists help with mobility issues.

DIF: Cognitive Level: Apply (Application) OBJ: Explain techniques used to assist patients with special communication needs.

CeOntMation TOP: Nursing Process: CommN unU icR atS ioI nN anG dT DB oc. um MSC: NCLEX: Management of Care 13. The patient verbalized frustration to the nurse about the lengthy recovery time after surgery.

The nurse’s response was “I understand how you want to be feeling better already.” Which communication technique was used by the nurse? a. Sympathy b. Empathy c. Focusing d. Self-disclosure ANS: B

Empathy is the ability to understand and accept another person’s perspective. Although no one can ever totally know another’s 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 patient’s experience, sympathy takes a subjective look at the patient’s world.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe behaviors and techniques that affect communication.

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

14. Which behavior best demonstrates active listening by the nurse? 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: Sit facing the patient.

Observe an open posture.

Lean toward the patient.

Establish and maintain eye contact.

Relax.

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

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate aspects of verbal and nonverbal communication.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 15. When the nurse takes the patient’s hand, the patient quickly pulls it back. How will the nurse

interpret this patient’s behavior? a. The patient is unable to express feelings. b. The patient is uncomfortable with being touched.

N SRskiI B.C M c. The patient has impaired soUcial Nlls GwTith othO ers. d. The patient has difficulty with nonverbal communication.

ANS: B

Nurses need to remain sensitive to their actions as well as the patient’s feelings. If a patient refuses to hold a nurse’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe behaviors and techniques that affect communication.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 16. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe behaviors and techniques that affect communication.

TOP: Nursing Process: Communication and Documentation 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. Courtesy c. Validation d. Intrapersonal ANS: D

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. Professional courtesy conveys respect between colleagues. The nurse should always utilize professional co urt esy when p ro vi di n g report to the oncoming shift.

N R U SI NG TB . CO M

DIF: Cognitive Level: Apply (Application) OBJ: Describe the levels of communication and their uses in nursing.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 18. A nurse is caring for a patient who is visually impaired. Which technique will 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.

DIF: Cognitive Level: Apply (Application) OBJ: Explain techniques used to assist patients with special communication needs.

TOP: Nursing Process: Communication and Documentation 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. Ask questions that require “yes” or “no” answers. b. Avoid communication aids to prevent embarrassment. c. Speak loudly and slowly to facilitate patient understanding. d. Finish the patient’s sentences when the patient is unable to.

ANS: A

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 patient’s sentences. Use communication aids as needed; do not avoid them.

DIF: Cognitive Level: Apply (Application) OBJ: Explain techniques used to assist patients with special communication needs.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 20. The emergency room nurse obtains report from the paramedics as the patient is on the way to

the hospital. The nurse is in which phase of the therapeutic relationship? a. Working b. Orientation c. Termination d. Preinteraction ANS: D

In the preinteraction stage the nurse gathers information from various sources about the patient such as from the paramedics. The orientation phase when you and the patient meet and get to know one another is t hNe t i m heG n t hB e c.oC ntraM ct is formed. The nurse and patient work RSe wI U N T O together during the working phase to solve problems and accomplish goals. During the termination phase the helping relationship is ended.

DIF: Cognitive Level: Apply (Application) OBJ: Describe a nurse’s focus within each phase of a therapeutic nurse-patient relationship.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 21. A nurse enters a patient’s room and sees the patient grimacing with each movement. When the

nurse asks how the patient is feeling, the patient states “I feel fine.” Which finding will the nurse classify as nonverbal communication? a. The patient states “I feel fine.” b. The nurse asks how the patient is feeling. c. The patient grimaces with each movement. d. The nurse is present at the patient’s bedside.

ANS: C

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. The nurse’s presence at the patient’s bedside is not nonverbal communication.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate aspects of verbal and nonverbal communication.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 22. The patient reports using history of ibuprofen for arthritis pain after telling the nurse about a

severe allergy to NSAID medications. The nurse asks the patient to further explain the allergy and use of ibuprofen. Which action is demonstrated by the nurse? a. Focusing b. Clarifying c. Summarizing d. Sharing observations ANS: B

The nurse’s request for more information is used to clarify the patient’s conflicting statements. 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 patient’s appearance a n d h o w he or s h e s ou nd s a nd acts such as, “I see you didn’t eat any N R I G B. C M U S N T O breakfast.”

DIF: Cognitive Level: Apply (Application) OBJ: Describe behaviors and techniques that affect communication.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 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. Use medical terminology to explain the concepts. d. Shift from subject to subject until the patient responds.

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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the principles of plain language for promoting health literacy.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Health Promotion and Maintenance

24. Which technique by the nurse will facilitate communication with an older adult? a. Allow reminiscing. b. Use long sentences. c. Ask several questions in a row. d. Play soft music in the background.

ANS: A

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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss effective communication for patients of varying developmental levels.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Which therapeutic communication techniques should the nurse use while communicating with

a small child? (Select all that apply.) a. Sit at the child’s eye level. b. Use simple, direct language. c. Use drawings and toys as needed. d. Tell the child exactly whaNt thR ey cIa n G do . B.C M U S N O e. Avoid sudden movements or gestures.T 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 children allows them to communicate nonverbally (making the drawing) and verbally (explaining the picture). Telling the child exactly what they can do is inappropriate. Remain calm and gentle and, if possible, let a child make the first move.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss effective communication for patients of varying developmental levels.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity

Chapter 12: Patient Education Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse includes “The patient will demonstrate correct technique for self-injection of

insulin” as a goal in the patient’s care plan. Which type of learning is addressed by this goal? a. Cognitive b. Affective c. Perceptive d. Psychomotor ANS: D

Psychomotor learning is the acquisition of motor skill such as injection of insulin. Cognitive learning is thinking in new ways. Affective learning is expression of emotions or beliefs.

Perceptive means the ability to sense of show insight.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the domains of learning.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Health Promotion and Maintenance 2. Which statement made by the patient indicates readiness for learning about colostomy care? a. “I don’t want to look at it and I can’t imagine caring for it.” b. “The sooner I can take care of it, the sooner I can go home.” c. “I never thought I would have to take care of something like this.” d. “I hope I can still wear a bath ing sui t wi th th is thing.”

ANS: B

N R UIS GN B T . C OM

“The sooner I can take care of it, the sooner I can go home” indicates that the patient is ready to learn about how to take care of the colostomy. The patient realizes that discharge from the hospital depends on the ability to care for the colostomy so the patient is amenable to teaching about how to care for it. “I don’t want to look at it and I can’t imagine caring for it” indicates that the patient does not wish to learn about colostomy care. “I never thought I would have to take care of something like this” is an emotional statement that indicates a need for support from the nurse. “I hope I can still wear a bathing suit with this thing” addresses a need for reassurance about appearance and activity after colostomy surgery.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe how to determine a patient’s readiness to learn.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. Which is the most appropriate learning goal for new parents who are learning infant CPR? a. The parents will demonstrate infant CPR skills. b. The parents will be able to understand CPR skills. c. The infant will not require further hospitalization. d. The parents will call the hospital if the infant stops breathing.

ANS: A

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 parent’s “understanding” is not measureable, and learning goals need to be measureable. The best learning goal in the case of a skill is to demonstrate that skill. 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. DIF: Cognitive Level: Apply (Application) OBJ: Identify methods for evaluating learning.

MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Planning

4. Which assessment finding best indicates to the nurse that the teaching about a dressing change

was successful? a. The patient understands how to change the dressing using sterile technique. b. The patient verbalizes understanding about how to change the sterile dressing. c. The patient correctly demonstrates the dressing change using sterile technique. d. The patient acknowledges the principles of sterile technique for dressing changes.

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 learn ing like a demonstration does.

N R I G B.C M U S N T O

DIF: Cognitive Level: Apply (Application) OBJ: Describe how to use the teach-back method.

MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Evaluation

5. Which chart entry documents patient achievement of cognitive learning? a. The patient verbalized decreased desire to commit self-harm. b. The patient described three symptoms of diabetic ketoacidosis. c. The patient demonstrated how to perform active range of motion. d. The patient expressed satisfaction with ability to share feelings with others.

ANS: B

Cognitive learning includes what the patient knows and understands. All intellectual behaviors are in the cognitive domain. Describing symptoms of DKA is an example of cognitive learning. Psychomotor learning occurs when patients acquire skills that require the integration of knowledge and physical skills. Examples of psychomotor learning include how to perform active range of motion. Affective learning includes the patient’s feelings, attitudes, opinions, and values such as decreased desires and satisfaction.

DIF: Cognitive Level: Apply (Application) OBJ: Describe appropriate documentation of teaching and learning.

TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 6. Which patient learning goal is measurable?

a. b. c. d.

The patient will understand the importance of daily iron supplements.

The patient will be able to learn sufficient information to be discharged.

The patient will feel comforted by the nurses’ presence during anxious periods.

The patient will verbalize responsibility for obtaining daily weights each morning.

ANS: D

Patient care plan goals must be measurable so that the nurse can determine whether or not the goal has been met. Measurable goals use objective terms such as verbalize, demonstrate, list, articulate, and perform. The patient’s verbalization of responsibility for obtaining daily weights each morning is a measurable goal. The nurse cannot objectively determine if the patient understands, feel comforted, or learn sufficient information in order to determine whether or not the goal has been achieved.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Apply the nursing process to the process of teaching.

MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Evaluation

7. The nurse attempts to teach the patient about wound care in a loud semiprivate room with

many distractions. Which is the appropriate action of the nurse? a. Explain to the patient that all of the information about wound care is in the handout provided. b. Take the patient to a quiet private treatment room to teach the patient about how to perform wound care. c. Ask the distraught roommate to please be considerate of the patient while the nurse is teaching about wound care. d. Arrange for the home-health nurse to provide teaching about wound care after discharge from the hospit al.

I G B.C M ANS: B

N R U S N T

O

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. Deferring patient teaching to the home-health nurse is not appropriate.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the characteristics of an environment that promotes learning.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 8. Which patient is appropriate for the nursing diagnosis readiness for enhanced knowledge

related to the prescribed treatment regimen? a. The patient who asks the nurse how a pill organizer can help to ensure that all medications are taken on time. b. The patient who insists that the blood sugar levels will never stabilize no matter how many medications are taken. c. The patient who believes that influenza was contracted as a result of the flu immunization last year. d. The patient who was just diagnosed with diabetes and has no idea about how to inject insulin.

ANS: A

Readiness for enhanced knowledge related to the prescribed treatment regimen indicates that the patient is already knowledgeable and wishes to learn more. Readiness for enhanced knowledge is appropriate for the patient who asks the nurse how a pill organizer can help to ensure that all medications are taken on time. Readiness for enhanced knowledge is not appropriate for patients who do not want to learn or who have not obtained a basic understanding of the concepts already.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the difference between readiness to learn and ability to learn.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. Which is the highest priority concern for the nurse who is educating the homeless patient

about medications, appointments, and therapies for management of diabetes? a. Motivation b. Health literacy c. Developmental stage d. Psychomotor learning ANS: B

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. The homeless patient is at high risk for having minimal health literacy. 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 a n e m o t i o n or need, w hich prompts, guides, and sustains human N R I G B.C M behavior.

U S N T O DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss ways to adapt teaching approaches for patients with low health literacy.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Health Promotion and Maintenance 10. Which approach will be most successful for the nurse to teach a preschooler about tube

feeding through a gastrostomy tube? a. Offer opportunities to discuss tube feeding options and answer questions. b. Hold the child while smiling and speaking softly to convey a sense of trust. c. Collaborate with the child to develop an individualized tube feeding schedule. d. Use simple terms and show the child a gastrostomy tube inserted into a teddy bear.

ANS: D

The nurse should allow the child to see and touch a gastrostomy tube inserted into a teddy bear to facilitate teaching about tube feeding. Holding the child while smiling is an appropriate teaching technique for an infant. The preschooler is not mature enough to develop an individualized tube feeding schedule or discuss tube feeding options.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify the principles of effective teaching and learning.

MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Caring

11. Which teaching approach is demonstrated when the nurse provides guidance while the patient

performs the sterile dressing change? a. Telling b. Entrusting c. Reinforcing d. Participating ANS: B

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 patient’s 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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify the principles of effective teaching and learning.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. Which type of reinforcement is used when the nurse gives a sticker to a pediatric patient every

time the incentive spirometer is used? 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 reinforceNrs (R e . g .I , s mGi l esB , c.o C m plM iments, words of encouragement, or U S N T O 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.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the principles of effective teaching and learning.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 13. Which action by the nurse will best allay a young child’s fear about auscultation of breath

sounds? 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 stethoscope is used to listen to air going in and out of the lungs. c. Allow the child to listen to sounds with the stethoscope before the nurse uses it for assessment. d. Ask the child’s 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 stethoscope will not hurt. 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. Involve the parents with young children.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe ways to incorporate teaching with routine nursing care.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 14. The nurse educator uses manikins to teach patients how to correctly perform CPR on a victim

of cardiac arrest. Which teaching technique is used by the nurse? a. Analogy b. Role play c. Simulation d. Enunciation ANS: C

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. In this case, the manikins are used to simulate a victim of cardiac arrest. 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. Enunciation is pronouncing words clearly.

DIF: Cognitive Level: AnalyzN eU ( ARn S a l yIs N i s )G T B.C O M OBJ: Identify the principles of effective teaching and learning.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 15. The nurse is providing discharge instructions to the patient. Which grade level should the

instructions be written at as the nurse does not know the patient’s educational background? a. Fifth-grade b. Seventh-grade c. Ninth-grade d. Eleventh-grade ANS: A

Individualize teaching materials to meet the patient’s needs and match the patient’s reading level; if a nurse does not know the patient’s reading level, information should be provided at a fifth-grade or lower level. Sixth-, eighth-, and ninth-grade levels are too high.

DIF: Cognitive Level: Apply (Application) OBJ: Describe ways to adapt teaching for patients with different learning needs.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. The nurse is providing discharge instructions to a patient with memory loss after a head

injury. What is the most appropriate action of the nurse? a. Teach the patient and a responsible family member at the same time. b. Teach the patient using simple terminology and a louder tone of voice.

c. Teach the patient the most important information first followed by lesser facts. d. Teach the patient immediately before discharge so the patient will remember it.

ANS: A

The discharge information should be provided to the patient’s responsible family member as well as the patient since the patient may not remember it. Speaking loudly will not help the patient to remember the information. Giving the most important information first immediately before discharge will not help the patient to remember the information.

DIF: Cognitive Level: Apply (Application) OBJ: Describe ways to adapt teaching for patients with different learning needs.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 17. Which is the first action of the nurse when teaching the patient how to perform colostomy

care? a. Determine the patient’s educational background and learning abilities. b. Identify a responsible family member to reinforce colostomy care teaching. c. Have the patient watch a video that demonstrates how to perform colostomy care. d. Assess the patient’s level of comfort with looking at and caring for the colostomy.

ANS: D

The first action of the nurse is to determine the patient’s readiness to learn about colostomy care. The nurse should assess the patient’s level of comfort with looking at and caring for the colostomy before initiating any teaching. Identifying a family member to assist, determining the patient’s educational background, and having the patient watch a video should all be done after assessing the patient’s readiness to learn.

DIF: Cognitive Level: AnalyzN e (ARnalyIsis)G B.C M S process N T of teaching.

O OBJ: Apply the nursing processU to the TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 18. Which nursing diagnosis indicates that the patient will have difficulty learning how to perform

sterile dressing changes at home? a. Deficient knowledge related to diabetic wound management b. Stress overload related to ongoing emotional abuse and bullying c. Readiness for enhanced knowledge related to diabetes management d. Impaired physical mobility related to need to use a cane for ambulation ANS: B

The patient who is overly stressed will have difficulty learning procedures or concepts. The nurse should expect to spend extra time helping the patient to learn. Impaired physical mobility will not impair learning ability. The patient’s deficient knowledge about wound management justifies the need for teaching. Readiness for enhanced knowledge indicates that the patient is ready to learn.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Apply the nursing process to the process of teaching.

MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

19. Which is the best method to begin teaching the adult patient how to self-administer tube

feeding through a new gastrostomy tube? a. Analogies

b. Detachment c. Role play d. Demonstration ANS: D

The nurse should begin to teach the patient by demonstrating how to administer tube feedings.

The patient is then encouraged to assist until a return demonstration of the skill can be performed. Detachment is not a teaching approach. Role playing and analogies are not appropriate for teaching tube feeding administration.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the principles of effective teaching and learning.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 20. The nurse is caring for a patient who had a stroke because of lack of understanding about how

to take the prescribed blood pressure medication. Which is the priority nursing diagnosis for this patient? a. Noncompliance related to patient’s refusal to follow the prescribed treatment regimen b. Ineffective therapeutic regimen management related to lack of understanding about prescribed medications c. Ineffective health maintenance related to lack of expressed interest in taking prescribed medications correctly d. Readiness for enhanced decision making related to desire to choose the course of action that best meets health needs ANS: B

Ineffective therapeutic regimN en U m t r.e lCaOt e dM t o lack of understanding about RanSaIgem NGenTB prescribed medications is the priority nursing diagnosis for the patient because the patient’s knowledge deficit about the prescribed medications led to the stroke. The nurse will help teach the patient about the medications and ensure that they are taken exactly as prescribed.

Nothing indicates that the patient refused to follow the prescribed treatment plan or that the patient was not interested in taking the prescribed medications. Readiness for enhanced decision making is not the priority diagnosis as it does not address the patient’s need to take prescribed medications correctly.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Apply the nursing process to the process of teaching.

MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

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.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the principles of effective teaching and learning.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which statements demonstrate that the patient is at the acceptance stage of learning? (Select

all that apply.) a. “I do not have to learn how to do the dressing. My wife will do it for me.” b. “I feel like such a failure for not consulting a podiatrist earlier about my foot.” c. “I’ll try to do the exercises you described if you will give me a cookie afterward.” d. “I want to learn how to do this myself so I do not have to go to a rehab center.” e. “I know that I have to give myself the injections because I could get a blood clot.”

ANS: D, E

The patient indicates acceptance by wanting to learn and understanding the importance of the teaching. Referring the care to the spouse, feeling like a failure, and wanting rewards do not demonstrate acceptance.

DIF: Cognitive Level: Apply N (ApR plicaI tionG ) B.C M OBJ: Use the nursing process t oUm a kSe a N teacT hing plaO n of care.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. A nurse prepares to teach the patient about strategies to minimize feelings of powerlessness.

Which techniques will 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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify the principles of effective teaching and learning.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Psychosocial Integrity

Chapter 13: Managing Patient Care Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. A registered nurse works as a case manager on an orthopedic unit. What primary role is

fulfilled by the nurse? a. Coordinating care for patients following joint replacement surgery b. Obtaining insurance preauthorization for joint replacement surgeries c. Providing bedside care to patients who have had joint replacement surgery d. Tracking infection rates and outcomes for patients after joint replacement surgery ANS: A

The case manager coordinates care for patients with various departments such as physical therapists, dietitians, social workers, and such. Case managers do not provide direct care.

Instead they collaborate with and supervise the care that other staff members deliver. The case manager does not obtain insurance preauthorization or track infection rates.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 2. Which patient’s needs must be addressed first by the registered nurse? a. The patient who is waiting for discharge teaching in order to go home b. The patient with chest pain after two doses of sublingual nitroglycerin c. The constipated patient who needs to use the toilet after receiving a laxative Nd aRSn dIvNom G Titing B.CaftMOer receiving narcotic pain medication d. The patient who is nauseateU ANS: B

The patient with chest pain that continues despite two doses of sublingual nitroglycerin should be addressed first by the registered nurse. The other patient needs can be addressed after the chest pain is resolved.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3. Which action by the nurse manager facilitates empowerment of the nursing staff? a. The nurse manager sets the policies for the nursing staff to follow. b. The nurse manager works with the staff to set annual goals for the unit. c. The nurse manager advocates for patients when care difficulties develop. d. The nurse manager prioritizes patient care needs when creating assignments.

ANS: B

The nurse manager facilitates empowerment of the nursing staff by using their input to set annual goals and provide the best possible care for patients. Empowerment is not facilitated by advocating for patients, prioritizing patient needs, or setting policies for the nursing staff to follow.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the elements of decentralized decision making.

TOP: Nursing Process: Implementation

MSC: NCLEX: Management of Care

4. Which nursing care concept is demonstrated when the nurse takes the time to correct

assessment information that was entered for the wrong patient? a. Delegation b. Empowerment c. Accountability d. Responsibility 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.

Delegation is the assignment of tasks to assistive personnel. Empowerment is the provision of self-esteem and confidence by management. Responsibility is the duty that the nurse is expected to perform.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 5. A nurse is using SBAR. Which information will the nurse report for the “B”? a. The patient has a fractured right leg with a cast that was applied 2 days ago. b. The patient’s toes are cool and pale and the patient reports that the foot feels numb. c. The patient is reporting severe pain 1 hour after pain medication was given. d. The nurse requests that the primary health care provider examines the patient.

ANS: A

“B” stands for background. TNh e R i nfoI rmaG tionBf. or theMpatient’s background is the following: the U Sa cast N applied T CO patient had a broken right leg with 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 pain—10 out of 10—even after pain medication was given. “A” is assessment. The patient’s toes are cool and pale. “R” is the recommendation. The nurse requests that the primary health care provider examines the patient.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe strategies to work effectively as a member of an interprofessional health care team.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Management of Care 6. Which characteristic qualifies the hospital for Magnet Recognition status? a. The hospital is affiliated with a nationally recognized medical school. b. The hospital participates in nursing research and implements the findings. c. The hospital is owned by a religious order that offers daily prayer services. d. The hospital receives federal grant funding for advanced medical research.

ANS: B

Magnet Recognition status is awarded by the American Nurses Credentialing Center to recognize hospitals that deliver high-quality nursing care. Magnet status does not reflect federal grant funding for medical research, religious order ownership, or affiliation with a medical school.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 7. Which action by the nurse best demonstrates the concept of right supervision? a. The nurse ensures that the scale is accurate before directing the nursing assistant to

obtain the patient’s weight. b. The nurse directs the nursing assistant to ambulate the patient at least 20 feet in the

hallway using the gait belt before lunch. c. The nurse checks if the hospital policy allows the licensed practical nurse to perform venipuncture before delegating the task. d. The nurse confirms that the patient’s urine output is entered into the medical record by the nursing assistant by the end of the shift.

ANS: D

The concept of right supervision includes appropriate evaluation to ensure that the assigned task was completed correctly and on time. The nurse demonstrates this by confirming that the patient’s urine output is entered into the medical record by the nursing assistant by the end of the shift. Ensuring the scale is working demonstrates right circumstances. Giving clear directions about how to ambulate the patient demonstrates right communication. Checking hospital policy about the role of the LPN demonstrates right person.

DIF: Cognitive Level: AnalyzN eU (ARnS a lyIsN i s)GTB.COM OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 8. Which patient assignment demonstrates the concept of team nursing? a. The RN, the LPN, and the nursing assistant work together to provide all the care

needed by eight patients for the shift. b. The RN cares for the same five patients every day during their stay following joint replacement surgery. c. The hospice RN works closely with the patient’s daughter to ensure that the patient’s dying requests are met. d. The RN coordinates care of the patient with the physician assistant to ensure that the clinical pathway is followed.

ANS: A

Team nursing is demonstrated when the RN, the LPN, and the nursing assistant work together to provide care needed by the patients. Primary care nursing is demonstrated when the RN cares for the same patients every day. Family-centered care is demonstrated when the RN works with the patient’s daughter. Interprofessional collaboration is demonstrated when the RN coordinates care with the physician assistant.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate among the types of nursing care delivery models.

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

9. Which nursing leadership approach demonstrates decentralized management? a. The nurse manager sets unit policies, conducts annual reviews, and disciplines the

staff as needed. b. The staff nurses work with the manager to review care options to prevent surgical

site infections. c. The nurse manager conducts regular staff meetings to provide updates about new

equipment and agency policies. d. The nurse manager makes rounds on the unit every day to monitor for problems

with patient care.

ANS: B

Decentralized management is demonstrated when the staff nurses take on leadership roles alongside the nurse manager so that decisions may be made at the staff level. Daily patient rounds, regular staff meetings, and manager-set policies do not demonstrate decentralized management.

DIF: Cognitive Level: Apply (Application) 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 10. Which action by the nurse demonstrates the concept of nurse autonomy? a. The nurse braids the patient’s long hair to prevent tangles. b. The nurse directs the nursing assistant to obtain the patient’s weight. c. The nurse counts the patient’s pulse before administering digoxin. d. The nurse checks the policy manual before changing the central line dressing.

ANS: A

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Autonomy is the nurse’s freedom to choose an appropriate action of care for the patient. The nurse demonstrates this by braiding the patient’s long hair to prevent tangles. Delegation is demonstrated by directing the assistant to obtain the patient’s weight. It is standard policy for nurses to check the patient’s pulse for a full minute before administering digoxin. Checking the policy manual before performing a procedure demonstrates accountability.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 11. Which nursing diagnosis has the highest priority for the patient following a stroke? a. Unilateral neglect related to disturbed perception about left side of body b. Risk for aspiration related to impaired swallowing and absence of gag reflex c. Constipation related to decreased physical activity and medication side effects d. Adult failure to thrive related to apathy and depression about physical disability ANS: B

Risk for aspiration is the highest priority diagnosis as aspiration pneumonia may be life-threatening. Unilateral neglect, constipation, and adult failure to thrive may be addressed after risk for aspiration.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Diagnosis

MSC: NCLEX: Management of Care

12. Once a week, staff members from all the disciplines caring for the trauma patients get together

to discuss their progress. Which term best describes this patient care action? a. Continuing staff education b. Nursing care delivery model c. Professional shared governance d. Interprofessional communication ANS: D

Interprofessional communication is demonstrated when professionals in various disciplines work together to promote quality patient care. Weekly meetings of professionals from various disciplines to discuss patient progress do not demonstrate continuing staff education, a nursing care delivery model, or professional shared governance.

DIF: Cognitive Level: Apply (Application) OBJ: Describe strategies to work effectively as a member of an interprofessional health care team.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 13. Which is the first action of the nurse when starting care for the patient at the beginning of the

shift? a. Administer prescribed medications. b. Conduct the patient’s health history. c. Perform a focused patient assessment. d. Create the nursing care plan for the patient.

ANS: C

Assessment is the first step oN f t h eRn uIr s i nGg prB oceC ss. TMh e focused patient assessment should be U S history N T may.be O completed completed first. The patient’s health after the focused assessment is done. Medications should not be administered without a focused patient assessment. The nursing care plan is created after the assessment is complete.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 14. Which preoperative task may be delegated to the nursing assistant? a. Apply the patient’s thromboembolism deterrent (TED) stockings. b. Teach the patient how to perform incentive spirometry exercises. c. Witness the patient’s signature on the informed consent document. d. Make sure that the patient swallowed the prescribed preoperative medication.

ANS: A

The nursing assistant may apply the patient’s thromboembolism deterrent (TED) stockings.

The nursing assistant may not teach the patient, witness the patient’s signature, or make sure that medication was swallowed.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.

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

15. The nurse notes that the nursing assistant did not provide oral care to the patient as directed.

Where is the best location for the nurse to address this lapse with the nursing assistant? a. In the patient’s room b. At the nurse’s station c. In the nursing unit hallway d. In a private conference room ANS: D

Give feedback in private to preserve the staff member’s dignity. The hallway, nurse’s station, and patient’s room are too public for effective constructive feedback.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16. Which is the highest priority nursing intervention for a patient with the nursing diagnosis risk

for suicide related to recent suicide attempt and desire to die? a. Assist the patient to identify sources of support in the community. b. Assess the patient’s readiness to sign a pledge to do no self-harm. c. Question the patient’s family members about previous suicide attempts. d. Remove dangerous items such as scissors from the patient’s environment.

ANS: D

The priority intervention is to maintain the patient’s safety by removing dangerous items from the patient’s environment. Identification of support sources, assessing readiness to sign a no-harm pledge, and family assessment may be completed once the patient’s environment is free of hazards.

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DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 17. Which action indicates the new nurse is fulfilling entry-level competencies? a. Communicating concerns to the patient’s physician b. Developing a theoretical framework for practice c. Creating a quality improvement plan for the unit d. Monitoring staff compliance with unit policies ANS: A

The entry-level nurse is expected to effectively communicate concerns to the patient’s physician. Developing a theoretical framework, creating a quality improvement plan, and monitoring staff compliance are not responsibilities of the entry-level nurse.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 18. A nurse must give feedback to a nursing assistant that did not take vital signs. How will the

nurse give feedback? a. “Did you miss the class about how to take vital signs?” b. “I refuse to work with you again if you cannot do your job.” c. “The patient’s vital signs were not taken. What happened?”

d. “I cannot trust you to complete tasks that you are assigned.”

ANS: C

The best approach is to determine why the vital signs were not taken. 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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. Which key elements are included in decentralized decision making? (Select all that apply.) a. Authority b. Autonomy c. Prioritization d. Responsibility e. Accountability ANS: A, B, D, E

Decentralized decision making includes responsibility, autonomy, authority, and accountability. Prioritization is not a key element but does help with organizing care.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the elements of decentralized decision making.

MSC: NCLEX: Management of Care

TOP: Nursing Process: Evaluation

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2. Which leadership skills will the nursing student use when caring for patients? (Select all that

apply.) a. Priority setting b. Time management c. Case management d. Careful 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3. Which approaches will the nurse use in order to effectively participate in interprofessional

collaboration? (Select all that apply.) a. Utilize a top-down communication strategy. b. Work to maintain a climate of mutual respect. c. Support a team approach to the maintenance of health. d. Use role-specific knowledge to address health care needs.

e. Apply relationship-building values and principles of team dynamics.

ANS: B, C, D, 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 one’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe strategies to work effectively as a member of an interprofessional health care team.

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

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Chapter 14: Infection Prevention and Control Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which term is used to describe the nares of a patient after a nasal culture is positive for

MRSA? a. Reservoir b. Portal of entry c. Susceptible host d. Mode of transmission ANS: A

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 care–acquired 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 individual’s 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.

N R I G B.C M

U (Comprehension) S N T O DIF: Cognitive Level: Understand OBJ: Describe characteristics of each link of the infection chain.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 2. Which mode of transmission is demonstrated when the nurse spreads an infection with the

hands after neglecting to perform hand hygiene? a. Direct b. Automatic c. Spontaneous d. Uninterrupted ANS: A

Hands of health care workers often transmit microorganisms. This mode of transmission is called direct transmission. Automatic, spontaneous, and uninterrupted are not modes of infection transmission.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe characteristics of each link of the infection chain.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 3. Which is an example of normal flora? a. The patient has a tapeworm living in the large intestine. b. The patient’s colon contains bacteria to help assist digestion. c. The patient’s incision is infected with Staphylococcus bacteria.

d. The patient has a viral infection causing nasal congestion and sore throat.

ANS: B

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 body’s 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. Bacteria within the colon that help digestion are an example of normal flora.

Microorganisms that cause infection are not considered normal flora.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the normal defenses of the body against infection.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 4. Which term is used to describe the body’s protection against whooping cough after receiving

the pertussis vaccination? a. Natural passive immunity b. Natural active immunity c. Acquired active immunity d. Acquired passive immunity ANS: C

Acquired active immunity is caused when the body creates antibodies after receiving a vaccination. Acquired passive immunity is when antibodies are administered via injection to the patient. Natural passive immunity is when antibodies are passed from mother to fetus via the placenta. Natural active immunity is when the body creates antibodies after exposure to an infection.

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DIF: Cognitive Level: Apply (Application) OBJ: Identify the normal defenses of the body against infection.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 5. Which is an example of suprainfection? a. The patient develops Clostridium difficile diarrhea after taking broad-spectrum

antibiotics. b. The immunocompromised patient develops an upper respiratory despite protective

isolation precautions. c. The bacteria in the patient’s wound are resistant to cephalosporin and penicillin

antibiotics. d. The patient’s upper respiratory infection progresses to pneumonia with right-sided

pleural effusion.

ANS: A

Suprainfection develops when the body’s normal bacterial flora have been altered due to the use of broad-spectrum antibiotic. Clostridium difficile diarrhea is an example of suprainfection. Suprainfection is not infection of immunocompromised patients, resistant bacteria, or development of complications.

DIF: Cognitive Level: Apply (Application) OBJ: Explain conditions that promote development of health care–associated infections (HCI).

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

6. The patient’s urine cultures tested positive for Escherichia coli (E. coli) following urinary

catheterization. Which term describes this type of infection? a. Protozoan b. Endogenous c. Diagnostic d. Bactericidal ANS: B

An endogenous infection occurs when bacteria that are normally found in one part of the body are moved to another site that should normally be sterile. E. coli is normally found in the patient’s stool and causes infection when introduced to the urinary tract. Protozoan infections are caused by parasites. Bactericidal and diagnostic infections do not exist.

DIF: Cognitive Level: Apply (Application) OBJ: Explain conditions that promote development of health care–associated infections (HCI).

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 7. Which action of the nurse will minimize the onset and spread of infection? a. Insert indwelling urinary catheters to prevent incontinence. b. Use aseptic technique when providing mouth care to the patient. c. Keep the patient’s mucus membranes dry to prevent maceration. d. Use masks and gowns sparingly to reduce the patient’s sense of isolation.

ANS: B

Invasive treatment devices such as intravenous (IV) catheters or indwelling urinary catheters impair or bypass the body’s natural defenses against microorganisms. Efforts to minimize the onset and spread of infection are based on the principles of aseptic technique. Aseptic technique is an effort to keepNthe M exposure to infection-causing pathogens URpat S Iient N GTas fBre.eC Ofrom as possible. The term asepsis means the absence of disease-producing microorganisms. When a person ages, normal physiological changes occur that influence susceptibility to infection.

These changes include decreased immunity, dry mucus membranes, decreased secretions, and decreased elasticity in tissues. Because of these changes, the older adult is predisposed to infections.

DIF: Cognitive Level: Apply (Application) 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 nurse maintains a sterile field when inserting a urinary catheter into the patient’s bladder.

Which term best describes the infection control practice of the nurse? a. Pathogenesis b. Bacteriostasis c. Medical asepsis d. Surgical asepsis ANS: D

Surgical asepsis is also known as sterile technique. The nurse practices surgical asepsis when inserting a urinary catheter into the patient’s bladder in order to prevent a urinary tract infection. Medical asepsis is a clean technique. The use of medical asepsis could lead to prevent a urinary tract infection because microorganisms are reduced rather than eliminated completely. Bacteriostasis is prevention of bacterial growth. Pathogenesis is the microorganism’s ability to cause disease in the host.

DIF: Cognitive Level: Apply (Application) OBJ: Describe nursing interventions designed to break each link in the infection chain.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 9. Which assessment finding indicates that the patient is at high risk for infection? a. The patient is allergic to penicillin, iodine. and watermelon. b. The patient has a urinary catheter draining clear yellow urine. c. The patient’s white blood cell count is 7500/mm3 this morning. d. The patient follows a kosher diet and refuses to eat pork or shrimp.

ANS: B

The patient’s urinary catheter places the patient at high risk for developing a urinary tract infection. The patient’s clear yellow urine indicates that a urinary tract infection is not apparent yet. Kosher diet and allergy to penicillin do not increase infection risk. The patient’s white blood cell count is within normal limits.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Assess patients at risk for acquiring an infection.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 10. Which is an appropriate goalNfoUrR thS eI diN agGnT osBis.rC isO k fMo r infection related to aspiration of fluids

into the airway? a. The patient will respond positively to IV antibiotic therapy. b. The nurse will elevate the head of the patient’s bed at mealtimes. c. The patient will remain afebrile with clear lung sounds bilaterally. d. The nurse will have suction equipment available when feeding the patient.

ANS: C

An appropriate goal for the diagnosis risk for infection related to aspiration of fluids into the airway is that the patient will remain afebrile with clear lung sounds bilaterally. Elevating the head of the bed and having suction equipment available are nursing interventions. Positive response to IV therapy indicates that the patient already has an infection.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe nursing interventions designed to break each link in the infection chain.

TOP: Nursing Process: Planning MSC: NCLEX: Safety and Infection Control 11. The nurse is caring for a patient with pneumonia with a congested cough, fever, and

wheezing. Which is the priority nursing diagnosis for the patient? a. Risk for infection related to congested cough and wheezing b. Deficient diversional activity related to boredom due to hospitalization c. Risk for imbalanced body temperature related to increased metabolic rate d. Ineffective airway clearance related to inability to clear secretions from airway ANS: D

Risk for infection and imbalanced body temperature are not appropriate as the patient is already feverish and has been diagnosed with pneumonia. Deficient diversional activity is not as important as the inability to clear secretions from the airway.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Assess patients at risk for acquiring an infection.

MSC: NCLEX: Physiological Adaptation

TOP: Nursing Process: Diagnosis

12. Which action demonstrates disinfection? a. Washing the hands with warm water and antimicrobial liquid soap b. Cleaning the patient’s mouth with a swab soaked in chlorhexidine solution c. Cleaning the stethoscope with isopropyl alcohol after each use with patients d. Using an alcohol-based hand sanitizer after performing physical assessments ANS: C

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.

Antiseptic procedures reduce microorganisms from the skin to reduce the risk of infection.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify principles of medical and surgical asepsis.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 13. Which laboratory result indicates to the nurse that antibiotic therapy is effectively treating the

NURSINGTB.COM patient’s infection? a. The patient’s urinalysis tested positive for nitrites and leukocytes. b. The patient’s wound culture showed a positive result for Candida albicans. c. The patient’s white blood cell count has increased from 12,000 to 25,000/mm3. d. The patient’s erythrocyte sedimentation rate (ESR) dropped from 56 to 33 mm/hour.

ANS: D

The drop in the patient’s erythrocyte sedimentation rate (ESR) indicates that the antibiotic therapy is effectively treating the patient’s infection. White blood cell count will rise when infection is not treated. Candida albicans is a yeast that does not respond to antibiotic therapy.

Presence of Candida albicans does not indicate that the antibiotic therapy is effectively treating the patient’s infection. Positive nitrites and leukocytes in the urine indicate an active urinary tract infection.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the normal defenses of the body against infection.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 14. Which action of the nurse demonstrates the use of standard precautions? a. The nurse uses gloves when performing oral care for the patient. b. The nurse puts on a surgical mask before entering the patient’s room. c. The patient is placed in a private room with negative-pressure airflow. d. The nurse uses sterile gloves when emptying the patient’s urinary catheter bag.

ANS: A

The nurse observes standard precautions by using gloves when performing oral care for the patient. This is because the nurse’s hands will be touching the patient’s saliva and oral mucus membranes. Surgical masks, sterile gloves, and private rooms are not required for standard precautions.

DIF: Cognitive Level: Apply (Application) OBJ: Describe strategies for Standard Precautions.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 15. Which protective apparel must the nurse wear to start an intravenous line for the patient? a. Gloves only b. Sterile gloves only c. Gloves and a mask d. Gloves and a gown ANS: A

Apply disposable gloves when there is a risk for exposing the hands to blood as in blood drawing, body fluids, mucus membranes, nonintact 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 heelsticks. 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 patient’s 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 b l o o d s a m p l e d o e s n o t u sually require more than gloves. Sterile N R I G B .C M gloves are not required for s t arU t i n gSIV Nl i n eT s. O DIF: Cognitive Level: Apply (Application) OBJ: Perform proper techniques for transmission-based precautions.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 16. The nurse is caring for a patient with the nursing diagnosis risk for latex allergy response

related to multiple food allergies. Which is the priority intervention of the nurse? a. Recommend that the patient wear a medical alert bracelet at home. b. Ensure that a medical plan is in place if an allergic response occurs. c. Lightly powder inside of the gloves before putting them on the hands. d. Provide written information about latex allergy prevention to the patient.

ANS: B

The priority action of the nurse is to ensure that a medical plan is in place if an allergic response occurs. The nurse may obtain an order for epinephrine to be administered if needed.

Prompt treatment will decrease the severity of the allergic reaction. Powdering the inside of gloves will increase the risk of latex reactions. Providing written information and instructing the patient to wear a medical alert bracelet are less important than having an emergency plan in place.

DIF: Cognitive Level: Apply (Application) OBJ: Describe nursing interventions designed to break each link in the infection chain.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential

17. The nurse disposes of gauze dressings that are saturated with drainage from a MRSA-positive

wound. Which action is appropriate? a. The gauze dressings are placed in a red medical waste disposal bag. b. The gauze dressings are placed in the wall-mounted sharps disposal box. c. The gauze dressings are left in the wastepaper basket in the patient’s room. d. The gauze dressings are flushed down the disposal system in the utility room.

ANS: A

The gauze dressings should be placed in a red medical waste disposal bag because they are saturated with drainage from an MRSA-positive wound. Biohazardous waste should not be left in the patient’s room. Only sharps like needles and lancets should be placed in the sharps container. Gauze should not be flushed down the disposal system.

DIF: Cognitive Level: Apply (Application) OBJ: Perform proper techniques for transmission-based precautions.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 18. Which is a semicritical item that requires disinfection? a. Nail file b. Safety pin c. Emesis basin d. Laryngoscope ANS: D

Semicritical items are objects that come in contact with mucus membranes or nonintact skin and present a risk. These objects must be free of all microorganisms. Semicritical items must be high-level disinfected (HLND) R or sI t e r i lGi z e dB. .

SoCmeMof these items include respiratory and U S N T O 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 mucus membranes and must be clean. Noncritical items must be disinfected.

Some of these items include bedpans, blood pressure cuffs, bedrails, linens, and stethoscopes, nail files, safety pins, and emesis basins.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe nursing interventions designed to break each link in the infection chain.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 19. Which action by the nurse demonstrates correct hand-hygiene practice? a. Letting hand sanitizer dry for a full minute before applying gloves b. Keeping hands and wrists above the level of the elbows while washing c. Scrubbing hands and nails for at least 15 seconds using plenty of soap d. Making sure that the water is hot before wetting the hands and wrists ANS: C

The nails and hands should be scrubbed for at least 15 seconds using plenty of soap. The hands and wrists should be kept below the level of the elbows while washing. Hand sanitizer should dry for at least 30 seconds before applying gloves. The water should be warm to prevent burns or chapping of the skin.

DIF:

Cognitive Level: Apply (Application)

OBJ: Perform proper procedures for hand hygiene.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 20. Which action of the nurse is appropriate after leaving the room of the patient with Clostridium

difficile? a. Wash hands thoroughly for 20 seconds with antibacterial soap and water. b. Vigorously rub a quarter-sized dollop of hand sanitizer into both hands. c. Perform a sterile scrub procedure using chlorhexidine soap solution. d. Scrub the hands for 2 minutes keeping hands above the level of the elbows.

ANS: A

The nurse should wash hands thoroughly for 20 seconds with antibacterial soap and water after leaving the patient’s room. Hand sanitizer is not recommended for hand hygiene after caring for a patient with Clostridium difficile. Chlorhexidine soap solution and sterile scrub procedure are not needed. The nurse should keep the hands below the level of the elbows and scrub the hands for 15 to 20 seconds.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Perform proper techniques for transmission-based precautions.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 21. Which precautions are appropriate for a patient with a methicillin-resistant Staphylococcus

aureus (MRSA) wound infection? a. Contact b. Airborne c. Droplet d. Standard ANS: A

NURSINGTB.COM

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 varicella zoster; pulmonary or laryngeal tuberculosis. Droplet precautions (droplets larger than 5 microns; being within 3 feet of the patient) are used for patients with diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia or scarlet fever in infants and young children, pertussis, mumps, Mycoplasma pneumoniae, meningococcal pneumonia or sepsis, or pneumonic plague. A protective environment is used to protect patients receiving allogeneic hematopoietic stem cell transplants.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Perform proper techniques for transmission-based precautions.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 22. Which item of protective apparel is removed first when the nurse leaves the room of the

patient with Clostridium difficile? a. Gown b. Mask c. Gloves

d. Eyewear ANS: B

The nurse should remove the gloves first, followed by the gown and mask. Eyewear would not be expected when caring for a patient with Clostridium difficile but it would be removed before the gown.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the steps for applying personal protective equipment.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control MULTIPLE RESPONSE 1. Which actions of the nurse cause a break in the sterile procedure? (Select all that apply.) a. Dropping a sterile instrument onto the sterile field b. Spilling sterile saline solution onto the sterile field c. Reaching over the sterile field to pick up an instrument d. Keeping the top of the table above waist level e. Placing instruments in the center of the sterile field ANS: B, C

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 package’s 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 B.C 2.5-cm (1-inch) border aroundN Ua sR tS e riIl eNG tow Tel or dMOrape 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 person’s 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. The nurse should not reach over the sterile field as microorganisms can fall and cause contamination.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify principles of medical and surgical asepsis.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 2. Which assessment findings indicate to the nurse that the patient’s incision has become

infected? (Select all that apply.) a. The incision site is red and warm to the touch. b. Thick yellow-green drainage is noted at the site. c. The patient’s white blood cell count is 5300/mm3. d. The wound edges are well approximated with sutures. e. The patient received prophylactic antibiotics before surgery.

ANS: A, B

Red, warm incision site with green purulent drainage indicates that the patient’s incision is infected. The patient’s white blood cell count is within normal limits. The well-approximated, sutured wound edges are not indicative of infection. Prophylactic antibiotics before surgery should reduce the risk of infection.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify the normal defenses of the body against infection.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

NURSINGTB.COM

Chapter 15: Vital Signs Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which vital signs are most important for a patient who is experiencing shortness of breath? a. Temperature, pulse, respirations b. Pulse, respirations, oxygen saturation c. Temperature, pulse, blood pressure d. Respirations, blood pressure, pain ANS: B

The priority vital signs for a patient experiencing shortness of breath are pulse, respirations, and oxygen saturation. Pulse oximetry can indicate decreased oxygen levels and elevated pulse can indicate compensation for such. Respiratory rate is also a key assessment tool for shortness of breath. Pain, temperature, and blood pressure are less important initial assessments for a patient presenting with shortness of breath.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 2. The nurse delegates vital signs for a patient to the nurse assistant. What is the nurse’s

responsibility regarding delegation of this task? a. The nurse assistant should not be responsible for obtaining vital signs. b. The nurse assistant should determine if the patient’s vital signs are abnormal.

N INt’s GT Mns as soon as they are done. c. The nurse should review t hU Stien e paR vB.C ital sigO d. The nurse is not responsible if the nurse assistant fails to obtain the vital signs.

ANS: C

A nurse may delegate the measurement of selected vital signs to the nurse assistant. However, it is the nurse’s responsibility to review vital sign data, interpret their significance, and critically think through decisions about interventions as soon as the vital signs are obtained.

When caring for a patient, the nurse is responsible for vital sign monitoring even if the task is delegated to the nurse assistant.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Correctly delegate vital sign measurement to nursing assistive personnel.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3. The nurse is caring for a patient with the following vital signs:

Temperature: 98.9 F Pulse: 94 Respirations: 20 Blood pressure: 144/94 Pulse oximetry: 94% What is the priority action of the nurse? a. Apply a cool washcloth to the patient’s forehead. b. Administer oxygen at 2 L/minute via nasal cannula. c. Ask the patient about his usual blood pressure results.

d. Document the findings in the patient’s medical record.

ANS: C

The nurse must know the patient’s usual range of vital signs in order to make appropriate judgments for care. A patient’s usual values sometimes differ from the standard range for that age or physical state. Use the patient’s usual values as a baseline for comparison with findings taken later. A single measurement does not adequately reflect a patient’s blood pressure.

Blood pressure trends, not individual measurements, guide nursing interventions.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 4. The nurse is caring for a patient with a temperature of 100.3° F. Why will the nurse refrain

from administering an antipyretic at this time? a. A temperature of 100.3° F is within the normal range for the patient. b. The patient’s shivering will lower the temperature more quickly than an antipyretic. c. Antipyretics should not be administered until the temperature is at over 104° F. d. The patient is diaphoretic after the temperature was 101.3° F 1 hour ago.

ANS: D

The patient’s skin is diaphoretic and the patient’s temperature is dropping so no antipyretic medication is needed at this time. Fever, or pyrexia, is an important defense mechanism.

Therefore most health care providers will not treat an adult’s fever until it is higher than 39° C (102.2° F). Shivering is counterproductive because of the heat produced by muscle activity.

DIF: Cognitive Level: AnalyzN e (ARnalyIsis)G B.C M U Sassociated N T with O OBJ: Discuss physiological changes fever.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological Therapies 5. Which technique will provide the most accurate measurement of the patient’s core

temperature? a. Orally b. Rectally c. Axillary d. Forehead ANS: B

The core temperature is the temperature of tissues deep within the body. Measurement of the rectal temperature will provide the nurse with the most accurate measurement of the patient’s core temperature. Oral, axillary, and forehead measurements do not provide accurate measurements of the temperature deep within the body tissues.

DIF: Cognitive Level: Apply (Application) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 6. The nurse is caring for an adult patient with a temperature of 101.2° F. Which statement will

the nurse make to the patient’s family member who verbalizes concern over the patient’s fever? a. “Fevers this high can cause permanent neurological damage.”

b. “Fevers under 102° F help the body’s immune system fight infections.” c. “The fever may cause the patient to have a febrile seizure.” d. “I will call the physician now to obtain an order for antibiotics.”

ANS: B

Fever serves as an important defense mechanism. Therefore most health care providers will not treat an adult’s 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 patients older than 5 years of age.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Physiological Adaptation 7. The nurse is caring for a patient who suffered a traumatic head injury. The patient’s

temperature rises to 104.5° F but there is no evidence of infection. Which statement will the nurse make to the patient’s family member who verbalizes concern over the patient’s fever? a. “The area of the brain that controls body temperature was damaged.” b. “The body is compensating for losing too much body heat in the accident.” c. “I will contact the physician now to obtain an order for antibiotics.” d. “The hospital room must be too warm so I will turn down the thermostat.”

ANS: A

The hypothalamus is the section of the brain that controls body temperature. Damage to the hypothalamus can lead to elevation of temperature as the body’s thermostat is damaged. The body is not compensating forNlosR ing I t oo Gm u cBh.bCo d yMh e a t in the accident. Antibiotics are not U S N T O indicated as the fever is due to hypothalamus damage not infection. An overly warm hospital room would not cause a fever of 104.5° F. DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss physiological changes associated with fever.

MSC: NCLEX: Physiological Adaptation

TOP: Nursing Process: Diagnosis

8. The nurse is caring for a patient whose temperature has dropped from 102.4° F to 99.4° F. The

nurse notes that the patient’s face is flushed. What is the reason for this assessment finding? a. The patient is exhausted from shivering. b. The patient’s infection has spread to the bloodstream. c. Vasodilation is working to lower the body temperature. d. The patient’s core temperature has dropped too low.

ANS: C

Vasodilation is the widening of blood vessels. It works to lower body temperature by increasing blood flow to the skin and enabling heat loss through radiation. The patient’s flushed face does not indicate that the infection has spread to the bloodstream. Exhaustion from shivering would not lead to a flushed face. Signs of hypothermia include uncontrolled shivering, loss of memory, depression, and poor judgment, not flushing of the face.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

9. The nurse is caring for a patient with a bacterial infection. After antibiotic treatment is started,

the patient develops a generalized itchy rash. What is the most likely reason for the rash? a. Vasodilation to lower the body temperature b. An allergic response to the prescribed medication c. Overloaded temperature release mechanism d. Development of infectious heat exhaustion 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. Vasodilation would lead to flushed skin rather than a rash. An overloaded temperature release mechanism or heat exhaustion would not cause a rash.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Assessment MSC: NCLEX: Pharmacological Therapies 10. The nurse is caring for a patient who has just been admitted with a fever of 102.6° F. Which

intervention will the nurse perform first for the patient? a. Administer the prescribed antibiotic. b. Administer the prescribed antipyretic. c. Draw blood cultures for laboratory testing. d. Apply a cool washcloth to the patient’s forehead.

ANS: C

Before antibiotic therapy, o b N t a i n Rb l o I o d cG ultuBre.sC wheMn ordered. Obtain blood specimens at the U S N T O 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 patient’s own thermoregulation fails or in patients with neurological damage (e.g., spinal cord injury).

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 11. The nurse is caring for a patient who came to the emergency department with confusion and

muscle cramps after working outside on a hot day. What is the priority action of the nurse? a. Place the patient in a tub of iced water. b. Take the patient’s temperature and vital signs. c. Remove fans to prevent premature chilling. d. Apply a hyperthermia blanket to lower temperature slowly.

ANS: B

Assessment includes taking the patient’s 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 body’s heat loss mechanisms. These conditions cause heatstroke, a dangerous heat emergency, defined as a body temperature of 40° C (104° F) or higher. Signs and symptoms of heatstroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. The most important sign of heatstroke is hot, dry skin. A heatstroke 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 12. The nurse is caring for an unconscious patient who was just pulled from a freezing lake. What

is the priority action of the nurse? a. Have the patient drink hot liquids. b. Wrap the patient in warmed blankets. c. Bathe the patient to promote shivering. d. Remove restrictive items of clothing.

ANS: B

NURSINGTB.COM

The priority treatment for hypothermia is to prevent a further decrease in body temperature.

Wrapping the patient in warmed blankets is a key strategic nursing intervention for hypothermia. 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. Bathing the patient will further lower the body temperature. Removing clothing may be done after the body temperature has risen to safe levels.

DIF: Cognitive Level: Apply (Application) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 13. The nurse is shown the mercury thermometer which was used to take the patient’s

temperature before coming to the hospital. What is the appropriate statement of the nurse? a. “Mercury thermometers are more accurate than electronic ones.” b. “Hospitals use mercury thermometers for patients with very high fevers” c. “Electronic thermometers are much safer than mercury thermometers” d. “Mercury thermometers can be used to take rectal or oral temperatures” ANS: C

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-in-glass thermometers at home. Patients should be taught about safer electronic temperature devices.

Mercury thermometers should be taken to a neighborhood hazardous disposal location.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Reduction of Risk Potential 14. The nurse is caring for a patient who lost consciousness and collapsed. Which site will be

used to determine if the patient has a pulse? a. Apical artery b. Radial artery c. Carotid artery d. Brachial artery ANS: C

When a patient’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 15. Which site will the nurse use to measure the patient’s pulse rate before administering the

cardiac medication digoxin? a. Apical b. Radial NURSINGTB.COM 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. DIF: Cognitive Level: Apply (Application) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Assessment MSC: NCLEX: Pharmacological Therapies 16. The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which

action will help the nurse hear the heartbeat more clearly? a. Positioning the bell very lightly over the patient’s sternum b. Placing the diaphragm firmly against the patient’s skin c. Making sure that the earpieces fit loosely in the nurse’s ear canals d. Utilizing a stethoscope with the longest possible tubing ANS: B

The nurse should always place the stethoscope directly on the skin because clothing obscures the sound. Position the diaphragm to make a tight seal against the patient’s skin. Exert enough pressure on the diaphragm to leave a temporary red ring on the patient’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 17. The nurse notes that the patient’s radial pulse is irregular. What is the most appropriate first

action of the nurse? a. Document the finding in the patient’s medical record. b. Count the patient’s apical pulse for 1 full minute. c. Assess the brachial pulse for a pulse deficit. d. Notify the health care provider immediately.

ANS: B

Irregular peripheral pulses should be compared to the patient’s apical pulse to determine if a pulse deficit is present. To assess a pulse deficit, ask another nurse to assess the radial pulse rate while you assess the apical rate. The finding should not be documented in the chart until the apical pulse is checked. The health care provider does not need to be notified immediately.

DIF: Cognitive Level: Apply (Application) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: A s s e s sN mU e nRt SINGMTSB C. : C NC OLMEX: Management of Care 18. The adult patient’s heart rate is 48 beats/minute. Which term will the nurse use when

documenting the finding in the patient’s medical record? a. Tachycardia b. Bradycardia c. Pulse deficit d. Bradypnea ANS: B

Tachycardia is an abnormally elevated heart rate, greater than 100 beats/minute in adults.

Bradycardia is a slow rate, less than 60 beats/minute in adults; 120 to 160 beats/minute is a normal heart rate for an infant. The normal heart rate for an adult is 60 to 100 beats/minute.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 19. The patient’s blood pressure is 152/92 but the primary health care provider does not diagnose

the patient with hypertension. What is the rationale for this decision? a. The patient’s primary health care provider must consult with a cardiologist in order to make a diagnosis of hypertension. b. The patient’s blood pressure must remain elevated during several separate assessments in order to make a diagnosis of hypertension.

c. The patient’s blood pressure must be at least 180/100 during a single assessment in

order for a diagnosis of hypertension to be made. d. The patient appeared extremely stressed and the health care provider decided not to

inform the patient of the diagnosis at that appointment.

ANS: B

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 (e.g., 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. Consultation with a cardiologist is not necessary to make a diagnosis of hypertension.

DIF: Cognitive Level: Apply (Application) OBJ: Describe factors that cause variations in vital signs.

MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

20. A patient’s blood pressure suddenly drops from 132/82 to 104/52. The nurse notes that the

patient’s skin is pale and the patient appears ready to faint. What is the priority action of the nurse? a. Report the findings to the health care provider immediately. b. Check the patient’s apical rate to check for a pulse deficit. c. Elevate the head of the patient’s bed to at least 45 degrees. d. Immediately check the p a t ien t f o r orthostatic hypotension.

ANS: A

N R I G B.C M U S N T O

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 patient’s health care provider. Assessing the patient for a pulse deficit is not the priority action of the nurse.

Having the patient sit and stand to check for orthostatic hypotension will further lower the blood pressure. The head of the patient’s bed should be lowered rather than raised to facilitate blood flow to the brain and prevent fainting.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 21. The nursing assistant informs the nurse that the patient’s blood pressure is 220/102 using the

electronic monitor. What is the priority action of the nurse? a. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. b. Inform the patient’s health care provider immediately to obtain an order for antihypertensive medication. c. Instruct the nursing assistant to take the patient’s blood pressure again and inform the nurse of the results immediately. d. Take the patient’s blood pressure manually with a sphygmomanometer and stethoscope.

ANS: D

Unusual or unexpected blood pressures obtained with electronic monitors should always be checked manually for accuracy. The nurse should double-check the nursing assistant’s result before taking further action. The nurse should not instruct the nursing assistant to recheck the vital signs.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 22. The nurse is caring for an adult patient with a respiratory rate of 32 breaths/minute. Which

term will the nurse use to document this finding in the patient’s chart? a. Eupnea 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. Eupnea indicates a normal respiratory rate for an adult of 12 to 20 breaths/minute.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 23. Why will the nurse draw a blood culture before giving an antipyretic medication?

R I GentB.C M UNosS a. The causative organism is m t preNvalT duriO ng a spike in temperature. b. Elevated temperatures slow metabolic rate and improve blood oxygenation. c. The antipyretic medication will inhibit bacteria growth within the culture tubes. d. Venous distention is greater because of fluid retention from hyperthermia.

ANS: A

The nurse should obtain blood specimens at the same time as a temperature spike, when the causative organism is most prevalent. Elevated temperatures increase metabolic rate and increase the body’s oxygen requirements. High fevers can cause dehydration and venous collapse. Antipyretic medications have no effect on bacterial growth within the culture tubes.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological Therapies 24. The patient calls the health care provider’s office after obtaining a reading of 170/88 with a

home wrist blood pressure monitor. What is the appropriate recommendation of the nurse? a. “Take the blood pressure again now using the other wrist.” b. “Take the blood pressure again now with the cuff on your upper arm.” c. “Take the blood pressure again tomorrow and call the office with the result.” d. “Come to the office today to have your blood pressure checked manually.”

ANS: D

The patient should be directed to come to the office for a manual blood pressure check.

Unusual or unexpected blood pressures obtained with electronic monitors should always be checked manually for accuracy. Checking the blood pressure in the other wrist, taking the blood pressure in the upper arm, or taking the blood pressure the next day are not advisable options.

DIF: Cognitive Level: Apply (Application) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 25. The nurse is unable to hear the blood pressure for a patient who is in septic shock. What is the

best option of the nurse? a. Determine the diastolic blood pressure by palpation and notify the health care provider immediately. b. Elevate the head of the patient’s bed and obtain the patient’s blood pressure with an electronic vital sign machine. c. Assess the patient’s blood pressure using a lower extremity and a thigh-sized blood pressure cuff. d. Raise the patient’s arm above the level of the heart and apply the stethoscope more firmly against the antecubital fossa.

ANS: A

The nurse may obtain the patient’s diastolic blood pressure by palpation if it is not possible to auscultate a hypotensive patient’s Korotkoff sounds. The health care provider should be informed of the result immediately. The head of the bed should be lowered for hypotensive patients to facilitate blood flow to the brain. Use of a lower extremity for blood pressure in a hypotensive patient is not recommended. Placing the stethoscope too firmly against the N R I G B.C Ma r m above the level of the heart will lead to antecubital fossa will impair h eUa r i nSg . RNa i sTi n g theO a false-low blood pressure reading.

DIF: Cognitive Level: Apply (Application) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 26. The nurse assistant is preparing to take the patient’s oral temperature with a red-tipped

electronic thermometer probe. What is the priority action of the nurse? a. Remind the nurse assistant to enter the result into the patient’s medical record. b. Give the nurse assistant a blue-tipped probe to take the patient’s oral temperature. c. Inform the patient that temperatures are most accurate when taken orally. d. Direct the nurse assistant to change the thermometer probe cover daily.

ANS: B

The red-tipped electronic thermometer probe is for rectal use. The nurse should give the assistant a blue-tipped thermometer probe to take the patient’s temperature orally. Rectal temperatures are more accurate than oral temperatures. The thermometer probe covers are single-use only and must be discarded after each use. The nurse may remind the assistant to enter the result into the patient’s medical record but that is not the priority intervention.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential

27. The nurse applies a warmed blanket to a chilled patient. Which term is used to describe the

process by which the blanket increases the patient’s temperature? a. Convection b. Radiation c. Conduction d. Emission ANS: C

Conduction is the transfer of heat from one object to another with direct contact, such as the use of a warmed blanket. Radiation is the transfer of heat between two objects without physical contact. Convection is the transfer of heat away from the body by air movement.

Fans promote heat loss through convection. Emission is not a term used to describe heat transfer.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 28. The nurse is caring for a patient who collapsed after working outside on a hot day. The patient

is disoriented with hot, dry skin and heart rate of 140 beats/minute. Which temperature will the nurse expect the patient to have? a. 99.2° F b. 100.8° F c. 102.2° F d. 104.4° F ANS: D

NURSINGTB.COM

The patient’s hot, dry skin, tachycardia, and disorientation indicate heatstroke with body temperature of 104° F or more.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 29. The nurse is to take the patient’s temperature right after the patient drank a glass of ice water.

What is the most appropriate action of the nurse? a. Wait 10 minutes before taking the temperature orally. b. Document that the patient refused the assessment. c. Take the patient’s axillary temperature instead. d. Obtain a core temperature measurement instead.

ANS: C

The most appropriate action of the nurse is to take the patient’s axillary temperature as the patient’s oral temperature will not be accurate for at least 20 minutes. Obtaining a core temperature measurement is not feasible given the information provided in the scenario. The patient did not refuse the assessment.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

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

30. The nurse applies a cooling blanket to a patient with a dangerously high fever. Which is the

most accurate method to monitor the patient’s temperature? a. Taping a digital thermometer probe to the skin of the patient’s axilla to download the temperature readings directly to the patient’s chart b. Checking the patient’s oral temperature every 15 minutes while the cooling blanket is in place until the patient is afebrile c. Applying a temperature-sensitive patch to the patient’s forehead to monitor the temperature of the patient’s skin surface d. Inserting a small rectal thermometer probe for continuous core temperature measurement ANS: D

The rectal temperature is the gold standard for measurement of core body temperature, which is the key assessment for a patient with a dangerously high fever. Small rectal thermometer probes often come with cooling blankets for this reason. Measurement of skin surface temperatures is not accurate. Continuous measurement of temperature is optimal for patients when cooling blankets are used to treat dangerously high fevers.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 31. The nurse is caring for a patient who collapsed after working outside on a hot day. The patient

is disoriented with hot, dry skin and heart rate of 140 beats/minute. What is the priority action of the nurse? a. Remove the clothes and cover the patient’s body with ice-water soaked towels. b. Insert an indwelling urinary catheter to monitor hourly urine output.

N vRentI B.COfrom M vomiting. c. Insert a nasogastric tube toU NtheGTpatient preS d. Obtain a 12-lead EKG and draw blood to check the patient’s electrolyte levels.

ANS: A

The patient presented with heatstroke and lowering the patient’s temperature is the highest priority. Removal of the patient’s clothing and covering the patient’s body with ice-water soaked towels will lower the patient’s body temperature quickly. Inserting a nasogastric tube and urinary catheter, obtaining a 12-lead EKG and drawing labs may be done after cooling methods have been implemented.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 32. The nurse is assessing a patient with shortness of breath. Which is the optimal technique to

auscultate the patient’s lung sounds? a. Place the binaurals firmly in both ears and utilize the diaphragm of the stethoscope. b. Place the earpieces loosely in both ears and utilize the bell of the stethoscope. c. Place the diaphragm of the stethoscope firmly on the skin of the patient’s chest. d. Place the bell of the stethoscope firmly on the skin of the patient’s chest.

ANS: C

The diaphragm of the stethoscope should be placed firmly onto the skin of the patient’s chest to optimally hear the high-pitched sounds of air going through the lung fields. The bell of the stethoscope is used to hear low-pitched sounds such as blood flow. The binaurals are pointed toward the face rather than inserted into the ear. The earpieces should have a snug fit within each ear.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 33. The nurse is concerned that the outside of the stethoscope is becoming dirty and unsightly.

Which is the appropriate action of the nurse? a. Obtain a soft cloth cover for the stethoscope tubing. b. Clean the stethoscope tubing throughout each shift with isopropyl alcohol. c. Send the entire stethoscope to central supply for disinfection. d. Clean the stethoscope tubing weekly with a solution of mild dish soap.

ANS: B

Stethoscopes should be cleaned after each use with patients using isopropyl alcohol or soap and water. Soft cloth covers should not be used as they will harbor microorganisms and can cause spread of infection. The stethoscope should not be sent to central supply for disinfection.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 34. The nurse is caring for a hypN otU enR siS veIpNaG tieTnB t w.hCo O s eMpe ri ph e r al pulses are very weak. Which

grade will the nurse use to document this finding? a. +1 b. +2 c. +3 d. +4 ANS: A

Diminished, barely palpable peripheral pulses are documented as +1. Easily palpable pulses are documented as +2. Increased palpable pulses are documented as +3. Bounding pulses are documented as +4.

DIF: Cognitive Level: Apply (Application) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 35. The patient has a history of orthostatic hypotension. What is the priority action of the nurse? a. Assist the patient to sit and stand slowly when getting out of bed. b. Monitor the patient’s neurological status carefully for symptoms of a stroke. c. Always take the patient’s blood pressure manually using a sphygmomanometer. d. Check the patient’s blood pressure on a lower extremity using a thigh-sized cuff.

ANS: A

The patient with orthostatic hypotension may faint when quickly getting out of bed and rising to stand so the nurse should assist the patient to do so slowly. The patient with hypertension is at high risk for a stroke. Electronic blood pressure monitors may be used to check the patient’s blood pressure with a history of orthostatic hypotension. There is no need to check the patient’s blood pressure using a lower extremity.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 36. The nurse notes that the patient is utilizing accessory and intercostal muscles to breathe. What

is the priority action of the nurse? a. Document this normal assessment finding in the patient’s medical record. b. Elevate the head of the bed and listen to the patient’s lung sounds. c. Direct the nursing assistant to obtain the patient’s temperature and blood pressure. d. Instruct the patient about the importance of smoking cessation.

ANS: B

The patient will utilize accessory and intercostal muscles to breathe when each breath requires more effort than usual. The nurse should elevate the head of the patient’s bed and begin a careful, rapid respiratory assessment by listening to the patient’s lung sounds. The use of accessory and intercostal muscles is not a normal assessment finding. The nurse should obtain the patient’s vital signs as the patient’s condition may not be stable. This is not the time to instruct the patient about smoking cessation.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: A s s e s sN mU e nRt SINGMTSB C. : C NC OLMEX: Physiological Adaptation 37. An infant born prematurely has irregular breathing patterns and short periods when breathing

stops altogether. Which device will be utilized to facilitate respiratory status assessment for this patient after discharge? a. Oxygen flowmeter b. Apnea monitor c. End-tidal CO2 monitor d. Incentive spirometer ANS: B

Apnea monitors are used to sense when the patient is having periods when breathing stops.

End-tidal carbon dioxide monitors detect the amount of CO2 exhaled with each breath and are commonly used on intubated patients on ventilators. Incentive spirometers are used to encourage deep breaths following surgery. Oxygen flowmeters regulate how much oxygen is delivered to the patient through a mask or nasal cannula.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 38. The nurse is caring for a patient who was just pulled from a freezing lake. The patient’s pulse

oximetry reads 68% although the patient is not in respiratory distress. What is the correct interpretation of these assessment findings?

a. The pulse oximeter will not give an accurate reading until the patient’s extremities

have warmed to near normal temperature. b. The pulse oximeter adhesive was left on too long and no longer stuck to the

patient’s finger adequately. c. The pulse oximeter became overheated when it was placed underneath the patient’s warming blanket. d. The pulse oximeter displayed a falsely low reading because the patient was receiving supplemental oxygen via nasal cannula.

ANS: A

Pulse oximeters will not give accurate readings unless the patient’s extremities are within normal temperature ranges. The patient was just pulled from the freezing lake so the pulse oximeter adhesive would not have been left on too long. Supplemental oxygen administration will not falsely lower pulse oximeter readings. Placing the pulse oximeter underneath the warming blanket would not cause it to overheat.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 39. Which patient should have the temperature taken orally rather than using a tympanic

thermometer? a. An unconscious, intubated patient b. A patient with bilateral middle ear infections c. A patient with gastroenteritis who is vomiting d. An agitated patient who cannot follow directions ANS: B

NURSINGTB.COM

A patient with bilateral middle ear infections should have the temperature taken orally rather than with a tympanic thermometer. Oral temperatures should not be taken on patients who are unconscious, vomiting, or unable to follow directions.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 40. The nurse is caring for a patient with a highly contagious infection. Which is the appropriate

type of blood pressure cuff to use when caring for this patient? a. A disposable vinyl blood pressure cuff b. An electronic vital signs monitor c. A soft cloth blood pressure cuff d. A Doppler ultrasound device ANS: A

The nurse should use a disposable vinyl blood pressure cuff to take the blood pressure of a patient with a highly contagious infection. An electronic vital signs monitor or soft cloth cuff should not be used as it may spread the infection to other patients. A Doppler ultrasound device would not be appropriate.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

41. The nurse is caring for a patient who is very anemic. Which assessment finding will the nurse

expect to note in the patient’s medical record? a. Irregular breaths with periods of apnea b. Tachypnea with rapid, deep breaths c. Bradypnea with shallow regular breaths d. Eupnea with even, unlabored breaths ANS: B

The patient with severe anemia will have tachypnea with rapid, deep breaths as a compensatory mechanism for the lack of hemoglobin on the red blood cells. Bradypnea, eupnea, or periods of apnea would not be expected.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse notes that the patient’s temperature varies significantly throughout the day and

night. Which are possible reasons for this variation? (Select all that apply.) a. The patient’s diagnosis of pneumonia b. The patient’s gluten-free, low sodium diet c. The patient’s history of hypertension d. The patient’s frequent trips outside to smoke e. The patient’s allergies to penicillin and shellfish ANS: A, D

NURSINGTB.COM

Infection and frequent trips outside to smoke will cause variations in the patient’s temperature measurements. A gluten-free, low sodium diet, history of hypertension or allergies to penicillin and shellfish should not impact the patient’s temperature.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 2. Which medications may be administered to reduce the patient’s fever without masking signs

of infection? (Select all that apply.) a. Acetaminophen b. Prednisone c. Ibuprofen d. Indomethacin e. Ketorolac 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 3. Which characteristics place the patient at high risk for development of hypothermia? (Select

all that apply.) a. Lack of funds to pay utility bills b. Lifelong member of Mormon Church c. History of poorly managed schizophrenia d. 25-year history of alcohol abuse e. Occasional incontinence of urine ANS: A, C, D

Lack of funds to pay utility bills leaves the patient at risk for hypothermia by living in an unheated home. Mental illness such as schizophrenia and history of alcohol abuse put the patient at risk for wandering and prolonged exposure to cold temperatures outside. Occasional urinary incontinence and membership in the Mormon Church would not increase risk of hypothermia.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. The nurse is caring for an unconscious, intubated patient in the intensive care unit. Which

methods may be used to check the patient’s temperature? (Select all that apply.) a. Axillary b. Rectal NURSINGTB.COM c. Oral d. Tympanic e. Pulmonary artery ANS: A, B, D, E

The nurse should not take the patient’s temperature orally as the patient is intubated and unconscious. The axillary, rectal, tympanic, and pulmonary artery routes would be acceptable.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 5. The nurse is caring for a patient with an elevated blood pressure. Which factors may account

for the high measurement? (Select all that apply.) a. The patient’s BMI is 42. b. The patient is in acute renal failure. c. The patient is extremely dehydrated. d. The patient refuses to take antihypertensive medications. e. The cuff was not wrapped snugly around the patient’s arm.

ANS: A, B, D, E

Common causes of elevated blood pressure readings include obesity (BMI greater than 30), renal failure, and refusal to take antihypertensive medications. Measuring the blood pressure with the cuff wrapped loosely around the patient’s arm will cause a falsely elevated measurement. Dehydration will cause the patient to be hypotensive.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 6. Which characteristics put the patient at risk for developing orthostatic hypotension? (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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 7. When getting a p ost op er at i v eNpUatRi eS ntIoNu tGoTf B be.dCfoOrM the first time, the patient immediately

feels light-headed and then faints. What are the appropriate actions of the nurse? (Select all that apply.) a. Have the patient lie down. b. Report findings to the health care provider. c. Instruct the patient not to get out of bed without assistance. d. Have the nursing assistant check the patient’s orthostatic blood pressure. e. Take the BP in each arm and use the arm with the lowest systolic reading.

ANS: A, B, C

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 light-headedness or dizziness. If orthostatic signs or symptoms such as dizziness, weakness, light-headedness, 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 cannot be delegated to nursing assistive personnel 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation

8. Which factors may lead to inaccurate pulse oximetry readings? (Select all that apply.) a. The patient drinks four to six beers every night. b. The patient has thick gel polish on the fingernails. c. The patient was admitted with heatstroke. d. The patient’s hemoglobin level is dangerously low. e. The patient has a generalized mild sunburn.

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 SpO2. An awareness of these factors allows for accurate interpretation of abnormal SpO2 measurements. Mild sunburn, alcohol intake, and heatstroke would not lead to inaccurate pulse oximetry readings.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 9. The nurse is caring for an extremely anxious patient. Which assessment findings would be

expected as a result of the patient’s emotional state? (Select all that apply.) a. Temperature 96.8 F b. Pulse 124 c. Respiratory rate 32 d. Blood pressure 188/88 e. Pulse oximetry 84% ANS: B, C, D

NURSINGTB.COM

Extreme anxiety will often lead to elevated pulse, respiratory rate, and blood pressure.

Decreased temperature and pulse oximetry would not be expected.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

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. Which term will the nurse use to document this assessment finding? a. Crackles b. Rhonchi c. Wheezes d. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Document assessment f iN n d i nR g s oI n apG propri B.atCe foMrms.

TOP: Nursing Process: AssessmU ent S N MTS C : NCOLEX: Physiological Adaptation 2. Which question is best suited for determining the patient’s chief complaint? a. “What brings you to the hospital today?” b. “How long have you been having chest pain?” c. “Did your doctor tell you to come to the hospital?” d. “Have you ever experienced this problem before?”

ANS: A

Asking what brought the patient to the hospital today is a good way for the nurse to determine the patient’s chief complaint. Asking about the duration of chest pain, doctor referral, or recurrence of the problem should be asked after the chief complaint is identified.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. The patient comes to the hospital with a variety of symptoms. Which symptom will the nurse

assess first? a. The patient experiences joint stiffness after sitting still for long periods of time. b. The patient developed an itchy rash after taking the second dose of antibiotics. c. The patient is nauseated and vomited a small amount earlier this morning. d. The patient feels short of breath and has audible expiratory wheezes.

ANS: D

The nurse needs to assess the patient’s shortness of breath before addressing the other symptoms. Oxygenation is the body’s most basic need and takes priority over other patient needs.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 4. The nurse is conducting a health history for a patient who does not speak English. What is the

best action of the nurse? a. Communicate with the patient using simple gestures and drawings. b. Arrange for a medical translator to be present during the health history interview. c. Ask an English-speaking family member to translate the nurse’s questions. d. Obtain the patient’s health history from an English-speaking family member.

ANS: B

The nurse should utilize the services of a medical translator to obtain the health history for a patient who does not speak English. Communication using simple gestures and drawings will not be sufficient to obtain an accurate health history. Family members should not be used to translate except in the case of emergency due to their lack of knowledge about medical terminology and patient confidentiality.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss how cultural awareness influences health assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5. Which intervention will facilN itateU y sic RtheSIphNG Bal.eCxam Mination of a patient with mobility issues?

T O a. Be sure that the head of the examination table may be elevated for the patient’s

comfort. b. Tune the radio to the nurse’s favorite station as a relaxation intervention for the

patient. c. Make sure that the patient has sufficient space and assistance to transfer onto the

examination table. d. Instruct the patient on the safest way to transfer onto the examination table.

ANS: C

Patients with mobility issues often have wheelchairs, walkers, or other pieces of equipment to help them move. The nurse should ensure that there is enough space for the patient to use mobility devices as needed. The nurse should eliminate other sources of noise, take precautions to prevent interruptions, and make sure the room is warm enough to maintain comfort. Playing music during the examination is distracting for the patient and the nurse.

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 table, either with a standing assisted transfer or by being lifted, as with a child or small adult.

DIF: Cognitive Level: Apply (Application) OBJ: Demonstrate preparation of a therapeutic environment before the physical examination.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control

6. Which technique will the nurse use to facilitate the history and physical examination of a

small child? a. Examine the child’s hands and feet before listening to breath sounds. b. Direct assessment questions to the child to avoid unwanted parental influence. c. Gently palpate the child’s abdomen before auscultating for bowel sounds. d. Call 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 extremities and then moves to the torso. 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, the nurse should 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.

DIF: Cognitive Level: Apply (Application) OBJ: List techniques to promote a patient’s physical and psychological comfort during an examination.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 7. Why does the nurse utilize a head-to-toe approach when performing physical examinations of

patients? 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

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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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 8. The nurse is assessing a patient with suspicious bruises. Which action is most appropriate to

facilitate an accurate account of the patient’s injuries? a. Ask the patient’s family member to wait outside 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. Provide referrals for health counseling once the assessment 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.

DIF: Cognitive Level: Apply (Application) OBJ: List techniques to promote a patient’s physical and psychological comfort during an examination.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 9. The mother of a small infant is surprised when the clinic scale indicates a 1-pound weight

gain from the scale used that morning at home. What is the appropriate response of the nurse? a. “Babies have significantly different weights throughout the day.” b. “Variations occur because of the weight of the baby’s clothing.” c. “Weight variation of 1 to 2 pounds is common for most scales.” d. “Weight measurements can vary with different scales.”

ANS: D

Different scales can give different weights for patients. To ensure accurate clinical decisions, weigh infants at the same time of day, on the same scale, and without a diaper. The scale can measure in weight increments to the nearest 0.1 pound or 0.1 kg. Weight variation of 1 to 2 pounds for a scale is unacceptable.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss normal phy si calNf iU ndRi nSg I s fN orGpT atB ien.tsCaO crM oss the life span.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 10. How can the nurse most accurately assess the skin tone for an older adult African American

patient with deeply pigmented skin? a. Utilize fluorescent lighting. b. Turn up the heat in the room. c. Utilize natural sunlight. d. Turn down the temperature in the room.

ANS: C

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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 11. The patient is brought in after collapsing outside on a very hot day. Which assessment finding

will the nurse expect to note during physical examination of the patient? a. Pallor of the patient’s extremities

b. Cyanosis of the patient’s nail beds and lips c. Dry mucus membranes and poor skin turgor d. Lower extremity edema and a generalized itchy rash ANS: C

The patient would expect to find signs of dehydration after the patient collapsed on a very hot day. These signs include dry mucus membranes and poor skin turgor. Pallor and cyanosis indicates poor blood flow and impaired oxygenation. Lower extremity edema and generalized itchy rash are not consistent with dehydration due to heat exposure.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 12. The nurse is caring for a patient who has a dangerously low platelet count. Which assessment

finding will the nurse expect to note during physical examination of the patient? a. Bright yellow jaundice in the sclera of the patient’s eyes b. Pinpoint red spots on the skin of the patient’s torso c. Dry, flaky skin with evidence of frequent scratching d. Thick indurated skin across the patient’s back ANS: B

Dangerously low platelet count leads to easy bruising and bleeding. Tiny hemorrhages in the skin layers cause pinpoint red or purple dots on the skin called petechiae. Dry flaky skin, thick, indurated skin and jaundice are not indicative of a low platelet count.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques N usedRwitI h eaGch pB h. ysC ical M assessment skill.

U S N T O TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 13. Which assessment finding will the nurse expect to note during physical examination of the

patient with a cast on the lower left leg? a. The patient’s left foot has a musty, fetid smell b. The patient’s left foot has 3+ pitting edema and pallor. c. The temperature of the left foot is the same as the right foot. d. The patient’s left foot is cool with thin, shiny skin.

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. A fetid, musty smell indicates an infection under the cast. The left foot should not have edema, pallor, shiny skin, or be cool to the touch.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 14. The nurse is caring for a dehydrated, confused patient whose breath smells like fruity bubble

gum. What is the priority action of the nurse based on these assessment findings? a. Check the patient’s pulse oximetry.

b. Check the patient’s oral mucosa for thrush. c. Check the patient’s blood sugar. d. Check the patient’s sclerae for jaundice.

ANS: C

Confusion and dehydration with fruity breath is indicative of diabetic ketoacidosis. The nurse should check the patient’s blood sugar immediately. Pulse oximetry, oral assessment for thrush, and checking for jaundice will not facilitate assessment and treatment of diabetic ketoacidosis.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 15. The nurse notes that the patient has bilateral entropion. What will the nurse plan to do as a

result of this assessment finding? a. Instruct the patient to rinse the mouth gently with warm saline solution. b. Clean the patient’s eyelids gently and apply antibiotic ointment. c. Place a wedge pillow between the patient’s legs to prevent crossing at the hip. d. Elevate the head of the patient’s bed and administer supplemental oxygen.

ANS: B

Entropion is the turning inward of eyelashes so that they irritate the conjunctiva and cornea.

The nurse should clean the patient’s eyelids gently and apply antibiotic ointment. The other interventions are not appropriate to address entropion.

DIF: Cognitive Level: Apply (Application) OBJ: Use physical assessmentNtechRniqI ues G and B sk. illC s du ring routine nursing care.

U S N MSC: T NCLEX: O M Physiological Adaptation TOP: Nursing Process: Assessment 16. The patient has red, itchy eyes with thick yellow drainage. What will the nurse plan to do as a

result of this assessment finding? a. Apply antibiotic eyedrops and use alcohol-based hand sanitizer before and after caring for the patient. b. Assess the patient’s visual fields and compare results from each of the patient’s eyes. c. Ask the patient about any history of hyperthyroid disease, hypertension, or Addison’s disease. d. Instruct the patient not to pluck or wax the eyebrows until the eye infection symptoms have resolved completely.

ANS: A

The patient’s symptoms are consistent with conjunctivitis, a highly contagious bacterial infection. The nurse should apply antibiotic eyedrops and use alcohol-based hand sanitizer before and after caring for the patient to prevent spread of the infection. None of the other interventions are indicated for treatment of conjunctivitis.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential

17. Which assessment finding will the nurse expect to note during physical examination of the

patient with a history of uncontrolled hyperthyroid disease? a. Exophthalmos b. Strabismus c. Entropion d. Diplopia ANS: A

Bulging eyes (exophthalmos) usually indicate hyperthyroidism. The crossing of eyes (strabismus) results from neuromuscular injury or inherited abnormalities. Entropion is the turning inward of eyelashes so that they irritate the conjunctiva and cornea. Strabismus refers to crossed eyes and diplopia refers to double vision.

DIF: Cognitive Level: Apply (Application) OBJ: Use physical assessment techniques and skills during routine nursing care.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 18. Which term will the nurse use to document the patient’s drooping right eyelid? a. Ectropion b. Esotropia c. Photophobia d. Ptosis 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). Esotropia refeN rs t oR Ui nSwI aNr dGTt u Br n .oOCf theMeye. Photophobia refers to light sensitivity.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Document assessment findings on appropriate forms.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 19. The patient’s pupils are the size of tiny pinpoints. Which factor could lead to this assessment

finding? a. The patient has been taking high doses of steroids. b. The patient suffered massive head trauma and is brain dead. c. The patient injected heroin intravenously 1 hour ago. d. The patient has developed acute narrow angle glaucoma.

ANS: C

Pinpoint pupils are a common sign of opioid intoxication. Brain death causes dilation of the pupils that are unresponsive to light. High doses of steroids can lead to cataracts, clouding of the lens within the eye. Acute narrow angle glaucoma will not cause tiny pinpoint pupils.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 20. Which assessment finding is expected for a patient presenting with a middle ear infection? a. The right tympanic membrane is pink and bulging.

b. The patient becomes dizzy when sitting upright. c. The pinna is red, swollen, and tender to palpation. d. The eardrum is a translucent pearly gray color.

ANS: A

The normal eardrum is translucent, shiny, and pearly gray. It is free from tears or breaks. A pink or red bulging membrane indicates inflammation consistent with middle ear infection.

Dizziness indicates an inner ear infection. Inflammation of the pinna indicates an external ear infection.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 21. The patient presents with fever for the last few days, sore throat, and enlarged lymph nodes

under the jaw. What is the appropriate response of the nurse when the patient asks about the cause of the enlarged lymph nodes? a. “Enlarged lymph nodes are associated with hypertensive heart disease.” b. “You probably have a blockage in the thoracic lymph duct.” c. “You should probably see an oncologist to rule out lymphedema.” d. “They are most likely enlarged as a result of the throat 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. The thoracic lymph duct drains lymph from the torso and extremities so a bl oNckaR tI her Cno tMcause enlargement of lymph nodes under Ug e S NeGwo T Bu.l dO the jaw. Lymphedema would be readily apparent with swelling of the affected area. There is no mention of edema and an oncologist is not needed to rule it out. Enlarged lymph nodes are not associated with hypertensive heart disease.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 22. The nurse is caring for a patient who was pulled unconscious from the pool after a near

drowning. Which lung sounds will the nurse expect to hear upon auscultation? a. Moist crackles b. Expiratory wheezes c. Friction rub d. Coarse rhonchi ANS: A

Fluid in the alveoli causes high-pitched crackles. Wheezes would be expected for a patient with asthma or an allergic reaction. Friction rub is heard with irritation of the pleura. Rhonchi is caused by the presence of thick secretions in the airways.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

23. Which technique can the nurse use to facilitate assessment of the thyroid gland? a. Have the patient tip the head back and cough twice. b. Watch the patient’s neck when sipping water from a straw. c. Have the patient slowly turn the head from side to side. d. Gently palpate from underneath the jaw to behind the ear.

ANS: B

Observing the patient’s neck during swallowing can help visualize the shape of the thyroid gland. Having the patient tip the head back or turn the head from side to side will not help visualize the shape of the thyroid gland. The thyroid gland lies just in front of the trachea so palpation behind the ear will not be helpful.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 24. The patient becomes acutely short of breath when lying flat in bed. Which term will the nurse

use to document this assessment finding? a. Orthopnea b. Atelectasis c. Emphysema d. Stridor ANS: A

Difficulty breathing while lying flat is termed orthopnea. Atalectasis is collapse of alveolar lung tissue. Emphysema is destruction of the alveoli. Stridor is a crowing sound heard as the patient struggles to breathe through swollen upper airways.

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DIF: Cognitive Level: Understand (Comprehension) OBJ: Document assessment findings on appropriate forms.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 25. The patient has been smoking 2 packs of cigarettes for the last 15 years. How will the nurse

chart the patient’s tobacco use history in pack-years? a. 7.5 pack-years b. 17 pack-years c. 30 pack-years d. 35 pack-years ANS: C

Pack-years equal the number of years smoking  number of packs per day. This patient smoked 2 packs of cigarettes for the last 15 years so the nurse would document 30 pack-years in the chart.

DIF: Cognitive Level: Apply (Application) OBJ: Identify data to collect from the nursing history before an examination.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 26. The nurse hears a distinctive swooshing sound with each heartbeat when auscultating the

patient’s heart sounds. What is the cause of this assessment finding? a. The mitral valve is leaking and some blood leaks backward with each heartbeat. b. The nurse’s stethoscope is not placed firmly enough against the patient’s skin.

c. The patient’s tricuspid valve was replaced with a mechanical prosthetic valve. d. The patient is having short runs of premature supraventricular contractions.

ANS: A

A distinctive swooshing sound with each heartbeat indicates there may be damage to the heart valves, e.g., leakage from the mitral valve. Incorrect placement of the stethoscope would limit the nurse’s ability to hear any heart sounds at all. Mechanical prosthetic valves cause clicking sounds rather than swooshing sounds. Runs of premature supraventricular contractions would cause an irregular heart rhythm not swooshing sounds.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 27. The nurse hears a blowing sound when auscultating the patient’s carotid artery. What is the

appropriate action of the nurse? a. Notify the health care provider immediately as the patient may be having a stroke. b. Gently feel over the patient’s carotid artery to check for a faint vibration. c. Massage the patient’s carotid artery to determine if the blowing sound subsides. d. Palpate the patient’s carotid pulse while the patient’s neck is hyperextended.

ANS: B

A bruit is a blowing or swooshing sound heard with the stethoscope over a blood vessel. A bruit is caused by turbulent blood flow through a vein or artery. If a bruit is heard over the carotid artery, the nurse should gently palpate the area for a thrill. A thrill is also known as a palpable bruit, a soft vibration caused by the turbulent blood flow through a vein or artery.

DIF: Cognitive Level: AnalyzN e (ARnalyIsis)G B.C M U with S N Oassessment skill.

OBJ: Describe the techniques used eachTphysical TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 28. Which assessment finding is expected for a patient who may have a lower extremity deep vein

thrombosis (DVT)? a. Deep burning pain in the extremity that worsens with walking and exercise b. Weak pedal pulses and an absence of hair on the affected extremity c. Calf pain when the knee is flexed slightly and the foot is pointed downward d. Numbness and tingling of the extremity with hyperreactive reflexes ANS: C

The nurse may perform a Homans’ test to check for the presence of a lower extremity deep vein thrombosis (DVT). The knee is flexed slightly and the foot is pointed downward. If the patient reports pain in the calf when the leg is in this position, the test is positive and the patient may have a DVT. Deep pain in the leg that increases with walking, absence of hair, and weak pedal pulses indicate arterial insufficiency. Numbness and tingling of the leg indicates a neurological problem.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 29. Which factor in the female patient’s history places her at higher risk for the development of

breast cancer?

a. b. c. d.

The patient’s first period started at age 10.

The patient has three children under the age of 12.

The patient used condoms exclusively for contraception.

The patient’s breasts are tender before each period.

ANS: A

Early menarche (first period before age 12) is a risk factor for developing breast cancer. Never having children and recent use of oral contraceptives are also risk factors. It is typical for female patients to experience breast tenderness and swelling before each menstrual cycle.

That is why it is recommended to perform self-breast examinations a few days after the period ends.

DIF: Cognitive Level: Apply (Application) OBJ: Identify data to collect from the nursing history before an examination.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 30. The nurse notes that the patient has hyperactive bowel sounds in all four quadrants of the

abdomen. Which factor from the patient’s history will account for this assessment finding? a. The patient has had gastroenteritis for the last 4 days with watery diarrhea. b. The patient takes iron supplements daily to treat chronic anemia.. c. The patient has a paralytic ileus after undergoing abdominal surgery. d. The patient takes ibuprofen 3 times daily for arthritis pain.

ANS: A

Gastroenteritis with watery diarrhea will cause hyperactive bowel sounds due to increased motility. Iron supplements and NSAIDs like ibuprofen will not cause hyperactive bowel sounds. No bowel sounds are expected when the patient has a paralytic ileus.

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DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 31. When is the best time for a male patient to perform a testicular self-assessment? a. Before getting out of bed in the morning b. After having a bowel movement c. After getting out of a hot tub d. Immediately following ejaculation ANS: C

The best time for the male patient to perform a testicular self-assessment is after getting out of a warm bath or hot tub as the scrotal sac will be relaxed. This will make it easier to carefully palpate the entire surface of each testicle. The other times are not optimal for testicular self-assessment.

DIF: Cognitive Level: Apply (Application) OBJ: Identify self-screening assessments commonly performed by patients.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 32. The nurse is caring for a patient who develops slurred speech with right-sided facial drooping.

The patient is also unable to make a fist with the right hand. What is the priority action of the nurse? a. Place a cool washcloth on the patient’s forehead and turn down the lights.

b. Obtain an order from the provider for a consultation with a speech therapist. c. Feed the patient by placing the food on the unaffected side of the mouth. d. Immediately obtain vital signs and notify the hospital’s acute stroke team.

ANS: D

Slurred speech with right-sided facial drooping and weakness on one side of the body are indicative of an acute stroke. The nurse should immediately obtain the patient’s vital signs and notify the hospital’s acute stroke team. Any delay in diagnosis or treatment can cause stroke symptoms to worsen or become permanent. Consultation with speech therapy, feeding techniques, and comfort measures can be initiated once the patient has been evaluated and cleared by the stroke team.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 33. The patient can follow directions but cannot pronounce words to express needs or thoughts.

Which term will the nurse use to document this assessment finding? a. Expressive aphasia b. Receptive aphasia c. Primary dysphagia d. Vocal dysphagia ANS: A

Expressive aphasia occurs when the patient can understand written and/or verbal speech but cannot write or speak to express needs or thoughts. Receptive aphasia occurs when the patient cannot understand written or verbal speech. Dysphagia refers to difficulty swallowing rather than communication.

NURSINGTB.COM DIF: Cognitive Level: Understand (Comprehension) OBJ: Document assessment findings on appropriate forms.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 34. Which question will the nurse ask the patient to assess abstract thinking ability? a. “Can you tell me the color of the blanket on your bed?” b. “Can you tell me what you ate for breakfast this morning?” c. “Can you tell me about what it was like to grow up in your neighborhood?” d. “What do I mean when I say that something costs an arm and a leg?”

ANS: D

Abstract thinking ability is tested by asking the patient to interpret common sayings or idioms.

Memory is tested by asking the patient what was eaten for breakfast that morning and what it was like growing up. Asking the patient to identify the color of the blanket assesses orientation and speech.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 35. Which test can the nurse use to assess the patient’s balance? a. Have the patient reach out to touch the nurse’s finger then the patient’s nose. b. Have the patient track the nurse’s finger as it moves through the field of vision.

c. Have the patient stand with feet together, arms out, and eyes closed. d. Have the patient run the heel of the foot along the shin of the other leg.

ANS: C

Having the patient stand with feet together, arms out, and eyes closed is a good test of balance. Having the patient touch or track the nurse’s finger and run the heel up and down the shin are tests for coordination and skilled movements.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 36. The patient has cloudy yellow urine with a faint odor of ammonia. Which laboratory test will

the nurse expect to note in the patient’s admission orders? a. Serum albumin and pre-albumin b. Serum calcium and magnesium levels c. Fasting blood sugar every morning d. Urine sample for culture and sensitivity ANS: D

Cloudy yellow urine with a faint odor of ammonia is a sign that the patient has a urinary tract infection. The patient’s urine should be sent for culture and sensitivity. Daily fasting blood sugars are checked for patients with diabetes or hyperglycemia. Serum calcium, magnesium, albumin, and pre-albumin do not test for the presence or a urinary tract infection.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: AssessN menR t I GMSB C:.C NCLMEX: Physiological Adaptation

U S N T

O

37. Which assessment findings lead the nurse to suspect that the patient has a history of alcohol

abuse? a. The patient has prominent tiny blood vessels running across the face. b. The patient’s skin is abnormally dry and flaky, especially on the legs. c. The patient’s nails have splinter hemorrhages along the nail bed. d. The patient’s breath smells faintly of fruity chewing gum.

ANS: A

Spider angiomas are prominent tiny blood vessels commonly running across the face and upper part of the body. They are commonly seen on patients with a long history of alcohol abuse. Dry flaky skin is commonly seen with aging. Splinter hemorrhages are seen with endocarditis. Breath that smells faintly of fruity chewing gum indicates diabetic ketoacidosis.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 38. Which technique will the nurse use to assess the patient’s olfactory nerve? a. Ask to shrug the shoulders and turn the head against the nurse’s hand. b. Ask the patient to identify the smell of peppermint oil and orange peel. c. Ask the patient to read the smallest set of letters on a Snellen eye chart. d. Ask the patient to stick out the tongue and move it side to side from midline.

ANS: B

The olfactory nerve communicates the patient’s sense of smell. Damage to the nerve will diminish the patient’s ability to smell and differentiate odors. Asking the patient to identify the smell of peppermint and orange will assess the function of the olfactory nerve. Asking the patient to read the smallest set of letters on a Snellen eye chart will assess the optic nerve.

Having the patient stick out the tongue and move it from side to side will assess the hypoglossal nerve. Checking shoulder strength tests the spinal accessory nerve.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation MULTIPLE RESPONSE 1. Which characteristics helped promote the development of the patient’s tortuous varicose veins

(Select all that apply.) a. Smoking 2 packs of cigarettes daily for the last 15 years b. Frequently sitting with the legs crossed c. Taking naproxen sodium daily for arthritis pain d. Standing for long periods of time at work e. Eating a gluten-free, low-sodium diet for the last 10 years ANS: A, B, D

Smoking, sitting with the legs crossed, and standing for long periods all contribute to the development of varicose veins. Taking NSAIDs daily and eating a gluten-free, low-sodium diet will not increase the patient’s risk of developing varicose veins.

N R I G B.C M

U (Comprehension) S N T O DIF: Cognitive Level: Understand OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 2. Which assessment findings lead the nurse to conclude that the patient has had chronic

obstructive pulmonary disease (COPD) for many years? (Select all that apply.) a. The patient’s nails have a clubbed shape. b. The patient has splinter hemorrhages under the nails. c. The patient’s chest appears rounded and bulging. d. The patient is short of breath with minimal activity. e. The patient has soft, spongy gums that bleed easily.

ANS: A, C, D

Clubbed nails are an indicator of chronic lack of oxygen and COPD. The patient with COPD has difficulty exhaling air so the chest takes on a rounded, barrel shape over time. As the airways and alveoli become damaged, the patient becomes short of breath with minimal activity. Soft, spongy gums that bleed easily indicate lack of vitamin C. Splinter hemorrhages under the nails are caused by minor trauma or endocarditis.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

3. Which positions may be used to perform a rectal examination on the patient? (Select all that

apply.) a. Sim’s b. Supine c. Lithotomy d. Lateral recumbent e. Dorsal recumbent ANS: A, C

The patient may be placed in the Sim’s or lithotomy position for a rectal examination. The supine and recumbent positions do not allow visualization of the rectal area.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Describe proper patient positioning during each phase of the examination.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 4. Which assessment findings show that the patient has a history of chronic arterial insufficiency

in the legs? (Select all that apply.) a. The nurse must use a Doppler to find the patient’s pedal pulses. b. The patient has calf pain when the knee is flexed and foot pointed downward. c. The patient’s legs are cool to the touch and show no hair growth. d. The patient has 3+ pitting pedal edema extending up to the knees. e. The patient has tortuous varicose veins from the hip to the ankle.

ANS: A, C

The patient with a history of chronic lower extremity arterial insufficiency will have weak pedal pulses. The pulses may be so weak that the nurse may have to use a Doppler to find them. The legs will be cool t oN t h eRt o uIc h G aiC s due to the poor blood flow to the area.

U S N TandBh. OrlesM Calf pain when the knee is flexed and foot pointed downward is a positive Homans’ sign that may indicate deep vein thrombosis. 3+ pitting pedal edema may be due to lymphatic blockage or congestive heart failure. Tortuous varicose veins indicate chronic venous insufficiency.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the techniques used with each physical assessment skill.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

Chapter 17: Administering Medications Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which agency determines which training is required for nurses to start intravenous lines for

patients? a. The US Food and Drug Administration (FDA) b. The MedWatch program c. Employee Assistance Program (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 institution’s employee assistance program (EAP), the State Board of Nursing, and community agencies.

DIF:

Cognitive Level: UndersN tandR(CoImpG reheB ns. ioC n) M

OBJ: Discuss legal responsibilitU ies iS n m eNdi caTti on preO scription and administration.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Management of care 2. The patient crushes extended-release pain medication tablets in order to obtain relief

immediately. Which term describes the action of this patient? 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss legal responsibilities in medication prescription and administration.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

3. The patient’s insurance company refuses to pay for the brand name formulation of a

prescribed drug. Which formulation of the drug will the patient receive instead? a. Trade b. Generic c. Chemical d. Proprietary ANS: B

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 medication’s 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 medication’s chemical name is an exact description of the medication’s 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).

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss legal responsibilities in medication prescription and administration.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 4. The nurse notes that the patient is to receive diprivan to treat the patient’s vaginal yeast

infection. What is the a p p r o pNr i U atR e aScI tioNnGoT f tB he.nCuO rsM e? a. Immediately contact the prescriber to clarify the order. b. Check with the pharmacy to confirm that the order was received. c. Ensure that the order appears on the patient’s medication sheet. d. Confirm that the dosage is appropriate for the patient’s body weight.

ANS: A

Diprivan is on the ISMP’s list of commonly confused drug names. Diprivan, a potent sedative, can be easily mistaken for Diflucan (fluconazole), a medication used to treat yeast infections.

The nurse should contact the prescriber immediately to clarify the order. Ensuring that the order appears on the patient’s medication sheet, confirming that the pharmacy received the order, and that the dosage is correct should occur after the order has been clarified.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Implement nursing actions to prevent medication errors.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 5. Which of the following drug orders will provide the fastest pain relief for the patient? a. Morphine 30 mg b. Hydromorphone 1 mg IV c. Fentanyl transdermal 25 mcg/hour d. Acetaminophen with oxycodone 10 mg/325 mg 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 mucus membranes (rectal and buccal) and respiratory airways quickly because these tissues contain many blood vessels, but the intravenous route is fastest.

DIF: Cognitive Level: Apply (Application) OBJ: Describe factors to consider when choosing routes of medication administration.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 6. How will the nurse administer a nitroglycerin sublingual tablet to the patient? a. Place the tablet under the patient’s tongue. b. Place the tablet in the patient’s mouth next to the cheek. c. Have the patient swallow the tablet with a sip of water. d. Crush the tablet and dissolve it in a teaspoon of water.

ANS: A

Sublingual medications should be placed under the patient’s tongue. They should not be swallowed, placed next to the cheek, or crushed.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

NURSINGTB.COM 7. The nurse administers enteric-coated aspirin to the patient. Where will this medication be absorbed into the body? a. In the stomach b. Through the skin c. In the small intestine d. Through the oral mucosa ANS: C

Enteric-coated medications are designed to be absorbed by the small intestine rather than by the stomach. This is usually to minimize stomach irritation. Enteric-coated medications are not absorbed through the oral mucosa or through the skin.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss factors that influence medication actions.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 8. Why does the nurse administer lorazepam intramuscularly (IM) to the patient rather than into

the subcutaneous tissue? a. The medication will be absorbed and begin to work more quickly when given IM. b. The patient does not have enough body fat to give the medication subcutaneously. c. Intramuscular injections require smaller needles than subcutaneous injections. d. Intramuscular injections are preferred for patients with high risk of bleeding.

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. The nurse would not give the patient an IM injection due to lack of body fat. IM injections require larger, longer needles than subcutaneous injections. For this reason, IM injections should be avoided in patients with high risk of bleeding.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe factors to consider when choosing routes of medication administration.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 9. The nurse is to administer a nephrotoxic medication to the patient. Which assessment finding

indicates to the nurse that the patient should receive a reduced dosage of the drug? a. The patient has a 35 pack-year history of cigarette smoking. b. The patient follows a low-carbohydrate, low-protein, high-fat diet. c. The patient has a history of hypertension and diabetic kidney disease. d. The patient is unable to exercise due to severe osteoarthritis in both hips.

ANS: C

Nephrotoxic drugs can cause severe damage to the kidneys. Patients with a history of kidney disease should receive a lowered dose as the kidneys will not be able to excrete the drug as effectively and the drug level may become toxic. Smoking, dietary preferences, and osteoarthritis do not require reduced dosages of the drug.

NURSINGTB.COM

DIF: Cognitive Level: Apply (Application) OBJ: Discuss factors that influence medication actions.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 10. The nurse notes that the patient is scratching and has hives 2 hours after receiving a dose of

antibiotic medication. The patient soon starts having difficulty breathing and his blood pressure drops. What is the correct analysis of the patient’s condition? a. The patient is having a mild reaction that can be treated easily with an antihistamine. b. The patient is experiencing a moderate allergic reaction and should improve shortly. c. These symptoms are probably due to food poisoning because very few patients have true allergic responses. d. The patient is having an anaphylactic reaction and emergency interventions should be started.

ANS: D

Patients may have very mild allergic reactions to medications and experience a rash or itching.

Other patients may have a life-threatening allergic reaction called anaphylaxis—the airways close up, the throat swells closed, and the blood pressure drops dangerously low. The patient’s symptoms are indicative of anaphylaxis—a severe, life-threatening allergic reaction. The patient may go into shock and die unless emergency interventions are initiated.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the characteristics of adverse drug events.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 11. The nurse administers a medication to the patient. Which symptoms indicate that the patient is

having an allergic reaction rather than a side effect? a. Alopecia and diaphoresis b. Nausea and constipation c. Heartburn and flatulence d. Itchy rash and difficulty breathing ANS: D

Symptoms of allergic reactions to medications typically include itchy rash and difficulty breathing. The other symptoms listed are considered to be side effects of the medication.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the characteristics of adverse drug events.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 12. Which of the following patients is most at risk for liver damage after taking acetaminophen

regularly for arthritis pain? a. Patient with a history of alcohol abuse and hepatitis C b. Patient with type 2 diabetes and end-stage renal disease c. Patient with prostate enlargement and urinary frequency d. Patient with COPD and aN20 R pacI k-yeGar hBis. toC ry oMf smoking

U S N T

O

ANS: A

Acetaminophen is metabolized and excreted by the liver. Nurses must be cautious about administering acetaminophen to patients with a history of liver disease from alcohol abuse and hepatitis C. Renal disease, diabetes, prostate enlargement, and COPD will not increase risk for liver damage with acetaminophen.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss factors to include in assessing a patient’s needs for and response to medication therapy.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 13. The patient develops constipation after taking the daily iron supplement that was prescribed

by the physician. Which term accurately describes the patient’s reaction to the supplement? 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.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the characteristics of adverse drug events.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 14. The patient’s respirations dropped from 14 breaths/minute to 8 breaths/minute after receiving

a large dose of morphine. Which term accurately describes the patient’s reaction to the morphine? a. Toxic b. Allergic c. Therapeutic d. Idiosyncratic ANS: A

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 patient’s 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 NUcau RSseIuNnpr G TB.C medication. Some medications ed i ct a M bO l e effects, such as idiosyncratic reactions, in which a patient overreacts or underreacts to a medication or has a reaction different from what is expected.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the characteristics of adverse drug events.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 15. Which statement is correct about patient tolerance to medications? a. Tolerance only develops when the patients do not take the medication as it is

prescribed. b. The patient will continually require higher doses of the drug for the same effect to

be achieved. c. The patient will require a stable dose of the medication until the drug is

discontinued. d. Tolerance occurs when the liver or kidneys are no longer able to metabolize the

drug.

ANS: B

Tolerance means that the patient will have to take higher doses of the medication in order to realize the same effects. Tolerance can develop even when patients take the medication exactly as it is prescribed. Toxicity will occur when the liver or kidneys are no longer able to metabolize the drug.

DIF: Cognitive Level: Understand (Comprehension) 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. The nurse suspects that the patient is experiencing a drug toxicity rather than a side effect.

Which question will the nurse ask to help confirm this suspicion? a. “Are you taking any other medications?” b. “Have you ever taken this medication in the past?” c. “When did you take your last dose of the medication?” d. “Have you been taking extra doses of the medication?”

ANS: D

Toxicity results when the serum drug level is too high. This may occur if the patient takes extra doses of the medication. Asking about other medications, when the last dose was taken, or use of the medication in the past will not help the nurse determine if the patient is experiencing a drug toxicity.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the characteristics of adverse drug events.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 17. The nurse is to administer the patient’s next dose of vancomycin at 9:30 a.m. What time will

the nurse draw the patient’s blood to check the trough vancomycin level? a. 8:30 a.m. b. 9:00 a.m.

NURSINGTB.COM c. 10:00 a.m. d. 10:30 a.m.

ANS: B

The patient’s trough vancomycin level should be drawn at 9:00 a.m. so that it will be 30 minutes prior to the next scheduled dose.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 18. The patient’s medication is ordered to be administered TID. Which times will be entered into

the patient’s medication schedule? a. 9:00 a.m., 1:00 p.m., 5:00 p.m. b. Before the patient’s meals and at bedtime c. 6:00 a.m., 12:00 noon, 6:00 p.m., 12:00 midnight d. 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., 2:00 a.m.

ANS: A

Medication that is ordered to be administered TID (3 times per day) should be given at 9:00 a.m., 1:00 p.m., 5:00 p.m. Medications ordered AC are to be given before meals. Medications ordered Q 6 hours should be given at 6:00 a.m., 12:00 noon, 6:00 p.m., 12:00 midnight.

Medications ordered Q 4 hours should be given at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., 2:00 a.m.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation 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 the patient’s deltoid b. Into the patient’s vastus lateralis c. Into the patient’s intravenous line d. Into the fatty tissue of the patient’s abdomen ANS: D

Subcutaneous injections are delivered into the fatty tissue just below the dermis of the skin.

Subcutaneous injection sites include the abdomen, back of the arm, and the front of the thigh.

Intramuscular injections are given into the vastus lateralis and deltoid muscles. Intravenous injections are given through IV lines.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological IN ntU egR riS tyI : PNhG arma oloCgO icM al and Parenteral Therapies TBc. 20. Which medication order is written appropriately? a. Morphine 2.5 mg PO b. Methotrexate 15.0 mg PO c. Meropenem 1.0 g IV d. Metformin .5 g PO ANS: A

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.

DIF: Cognitive Level: Apply (Application) OBJ: Implement nursing actions to prevent medication errors.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 21. The nurse is to administer 250 mg of amoxicillin PO every 6 hours.

Amoxicillin for oral suspension USP 125 mg per 5 mL

How many mL of medication will be given to the patient for each dose? a. 5 mL b. 10 mL c. 15 mL d. 20 mL ANS: B

250 mg  5 mL/125 mg = 10 mL. DIF: Cognitive Level: Apply (Application) OBJ: Calculate prescribed medication doses correctly.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 22. The patient’s medication order is for transdermal fentanyl. How will the nurse administer this

medication? a. Apply the medication patch to a clean, dry intact area of skin. b. Inject the medication into the soft tissue behind the patient’s arm. c. Carefully place the medication between the patient’s cheek and teeth. d. Have the patient swallow the medication with a small sip of water.

ANS: A

Transdermal medications are administered using a patch applied to the skin. The medication is slowly absorbed through the skin over the next few hours to days. Transdermal medications should never be injected, swallowed, or placed in the mouth.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Correctly and safely pre N pareRandIadmGinisBte. rm ications.

CedOM U S N T TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 23. The nurse is to administer 10 mg/kg of acetaminophen to a patient who weighs 70 pounds (32

kg).

Acetaminophen elixir 160 mg per 5 mL How many mL of medication will be given to the patient for each dose? a. 5 mL b. 10 mL c. 15 mL d. 20 mL ANS: B

32 kg  10 mg/kg = 320 mg 320 mg  5 mL/160 mg = 10 mL DIF: Cognitive Level: Apply (Application) OBJ: Calculate prescribed medication doses correctly.

TOP: Nursing Process: Implementation 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. b. c. d.

prn Standing One-time 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.

DIF: Cognitive Level: Apply (Application) OBJ: List the six rights of medication administration and apply them in clinical practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 25. Which medication is to be administered immediately to the patient? a. Acetaminophen 325 mg PO prn b. Insulin aspart 12 units subQ AC c. Metronidazole 500 mg PO BID d. Nitroglycerin 0.4 mg sublingual STAT ANS: D

A STAT order means that you give a single dose of a medication immediately and only once.

With standing orders, you carry out a standing order until the health care provider cancels it by another order or until a p rN es c rRi b edIn uG m b eBr .o fCd a M y s elapses. A prn order is an order in which U S N T O 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: List the six rights of medication administration and apply them in clinical practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 26. Which pain medication may be administered to the patient as needed? a. Ketorolac 10 mg IV Q 4 hours prn b. Fentanyl transdermal patch 25 mcg Q 3 days c. Acetaminophen with oxycodone 10 mg/325 mg PO Q 6 hours d. Morphine-extended release 60 mg PO Q 12 hours 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.

DIF:

Cognitive Level: Apply (Application)

OBJ: List the six rights of medication administration and apply them in clinical practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 27. Which medication order is written correctly? a. Zolpidem 10 mg PO Q HS prn insomnia b. Vitamin E 1000 IU PO QD with food c. Conjugated estrogens 300 µg daily d. Phenytoin 200 mg PO daily  4 days ANS: D

Abbreviations must be used carefully to avoid medication errors. At bedtime must be written out rather than HS. IU must be written as International Units. QD must be written out as daily or every day. The µg may be written as micrograms or mcg.

DIF: Cognitive Level: Apply (Application) OBJ: List the six rights of medication administration and apply them in clinical practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 28. The patient states “I don’t take that medication” when the nurse hands the pill to the patient.

What is the nurse’s best response? a. “It is probably the generic form of the medication you normally take.” b. “I will check your chart to see if your medication was changed.” c. “The other nurse drew up the medication so I am sure it is correct.” d. “I will chart that you refused to take the medication as it is ordered.”

ANS: B

NURSINGTB.COM

The nurse should always double-check medications when patients verbalize concerns. In this case, the nurse should check the chart to see if the medication was changed. If so, the nurse will need to educate the patient about the new medication. It is also possible that the medication order was placed in error and it must be caught before the patient takes the medication. The nurse should not assume that the generic form of the medication is being administered. Nurses should never administer medications that were drawn up by others. The patient did not refuse the medication so it should not be charted as such.

DIF: Cognitive Level: Apply (Application) OBJ: List the six rights of medication administration and apply them in clinical practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 29. A patient is to receive insulin aspart and insulin detemir. How will the nurse draw up the

insulins for administration? a. Mix the detemir and aspart in the same syringe, drawing up the aspart first. b. Mix the detemir and aspart in the same syringe, drawing up the detemir first. c. Administer the two insulins using different syringes and different sites of the body. d. Roll the bottles between the palms of the hands before drawing up the insulins.

ANS: C

Never mix insulin glargine or insulin detemir with other types of insulin. If regular and intermediate-acting insulin are ordered, prepare the regular insulin first to prevent contamination with the intermediate-acting insulin.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 30. The nurse is to administer enoxaparin 40 mg subcutaneously to the patient. Which technique

is correct? a. The nurse injects the medication into the soft tissue of the patient’s abdomen. b. The nurse aspirates immediately prior to injecting the medication. c. The nurse gently massages the injection site immediately afterward. d. The nurse draws up the medication into a 1-mL syringe with a 32-gauze needle.

ANS: A

Enoxaparin is to be administered subcutaneously into the soft tissue of the patient’s abdomen.

Enoxaparin is a low-molecular-weight heparin that comes in a prefilled syringe for administration. The nurse should not draw up enoxaparin in a separate syringe. The injection site should not be massaged as that could cause bruising at the site.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 31. The nurse is to administer heparin 5000 units to an adult patient with a BMI of 15.1. Which is

the appropriate technique for the injection? a. Pinch the skin tissue and inject at a 90-degree angle. b. Spread the skin tissue andNinjR ree a ngle.

UectSIat aNG45TBde.gC OM c. Pinch the skin tissue and inject at a 45-degree angle. d. Spread the skin tissue and inject at a 90-degree angle.

ANS: C

An adult patient with a BMI of 15.1 is severely underweight. The nurse should pinch the skin tissue and inject at a 45-degree angle to ensure that the medication is injected into the subcutaneous tissue.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 32. The nurse is to administer insulin lispro to the patient using an injection pen. Which is the

correct action of the nurse? a. The nurse primes the pen with 2 units of insulin before each injection. b. The nurse always injects into the same spot to minimize discomfort. c. The nurse uses the same pen for multiple patients with a new needle each time. d. The nurse aspirates immediately prior to injecting the medication.

ANS: A

The lispro injection pen must be primed with 2 units of insulin before each injection. Injection sites should be rotated to avoid damage to tissues. Injection pens must never be shared by patients even when new needles are used. Aspiration is never done with subcutaneous injections.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 33. The nurse is to administer 3 mL of medication intramuscularly to an adult patient. Which is

the appropriate site for the injection? a. Dorsal gluteal b. Vastus lateralis c. Deltoid d. Lateral piriformis ANS: B

The vastus lateralis muscle is thick and well developed, making it an excellent site for injections of up to 3 mL of fluid. No more than 1 mL should be injected into the deltoid muscle. The dorsal gluteal site is not recommended as damage to the sciatic nerve can occur.

No injections should ever be given into the lateral piriformis muscle.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

NURSINGTB.COM 34. Which medication may be injected into the deltoid? a. b. c. d.

Lorazepam 2 mg in 2-mL saline IM Insulin aspart 2 units subcut AC meals Lidocaine 2 mg of 2% solution ID Cyanocobalamin (vitamin B12) 500 mcg in 0.5 mL IM

ANS: D

No more than 1 mL of fluid should be injected into the deltoid muscle. Intradermal and subcutaneous injections are not administered into the deltoid.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 35. The nurse draws up a medication from a glass ampule before injection. Which technique is

correct? a. The nurse wipes the top of the ampule with an isopropyl alcohol swab after removing the metal cap. b. The nurse attaches a new needle to the syringe before administration as the needle was dulled by the rubber stopper. c. The nurse injects air into the ampule before withdrawing the medication in order to avoid creating a vacuum. d. The nurse draws up the medication from the ampule using a filter needle and

attaches an injection needle before administration.

ANS: D

Glass shards may enter the ampule when it is opened so a filter needle must be used to draw up the medication. The filter needle is replaced by an injection needle prior to administration.

Ampules do not have metal caps or rubber stoppers. The ampule top is open to air so no vacuum is created when the medication is withdrawn.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 36. Which is the priority action of the nurse immediately after administration of an intramuscular

injection? a. Engage the safety sheath over the needle. b. Ensure that there is no bleeding at the injection site. c. Assess the patient’s level of comfort. d. Inform the patient that the injection is complete.

ANS: A

The nurse must engage the safety sheath over the needle immediately after injecting the patient to prevent a needlestick injury. The needle must then be placed in the appropriate sharps container for proper disposal. Informing the patient, checking for bleeding, and assessing comfort are less important than securing the needle.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Correctly and safely pre N pareRandIadmGinisBte. rm ications.

CedM

O TOP: Nursing Process: ImplemeU ntatS i on N T MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 37. Which medication may be administered using a 3-mL syringe with a 23- gauze,

-inch

needle? a. Methotrexate 20 mg subcut b. Lorazepam 2 mg IM c. Lidocaine 2 mg of 2% solution ID d. Enoxaparin 30 mg subcut ANS: B

A 3-mL syringe with a 23-gauze, -inch needle is appropriate for administering intramuscular injections such as lorazepam 2 mg IM. A 3-mL syringe with a 23-gauze, -inch needle is not appropriate for subcutaneous or intradermal injections. Enoxaparin comes in a prefilled syringe and should not be transferred to a separate syringe.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 38. Which is an IV bolus order? a. 1 L 0.9% normal saline IV infuse over 4 hours

b. Primaxin 750 mg IVPB infuse over 30 minutes Q 12 hours c. Naloxone 300 mcg IV push over 2 minutes STAT d. 0.9% normal saline IV infusion at 125 mL/hour ANS: C

IV bolus medications inject a concentrated dose of medication directly into the IV line over a few minutes. Naloxone 300 mcg IV push over 2 minutes STAT is an example of an IV bolus order.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 39. The patient’s rheumatoid arthritis symptoms were not adequately controlled with

methotrexate so adalimumab was prescribed as well. What is the rationale for prescribing both medications? a. To obtain a synergistic effect b. To prevent an anaphylactic reaction c. To reduce medication interactions d. To avoid an iosyncratic 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 mNu s c R l e s , Ie d e G ma B of.thCe pM harynx and larynx, and severe wheezing U S N T O 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.

DIF: Cognitive Level: Apply (Application) OBJ: Compare and contrast the different types of medication effects and reactions.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 40. The nurse is to administer a clotrimazole troche to the patient. Which instruction will the

nurse give to the patient? a. “Your eyesight may be blurry for a short time after I give you the medication.” b. “Do not touch or remove the patch after I have applied it to your skin.” c. “Keep the tablet in your mouth until it dissolves completely. Do not chew it.” d. “Lay on your back so the medication will melt slowly in your vagina.”

ANS: C

Troche medications are to be held in the mouth until they fully dissolve. They should not be chewed or swallowed. Troche medications are not applied to the skin, the eyes, or the vagina.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

MULTIPLE RESPONSE 1. The nurse is to administer acetaminophen to an unconscious patient. Which medication

formulations may safely be administered to the patient? (Select all that apply.) a. Acetaminophen tablet b. Acetaminophen elixir c. Acetaminophen IV d. Acetaminophen suppository e. Acetaminophen suspension ANS: C, D

Unconscious patients are unable to swallow any oral formulations of medications so only intravenous or suppository medications are appropriate to administer. 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. Elixirs and suspensions are liquid formulations designed to be taken orally by patient who are unable to swallow pills.

DIF: Cognitive Level: Apply (Application) OBJ: List the six rights of medication administration and apply them in clinical practice.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

N R I G B.C M

N Tadministering O 2. What is wrong with this pictureUofS a nurse eyedrops to a patient? (Select all that apply.)

http://www.glaucoma.org/treatment/eyedrop-tips.php a. The tip of the eyedropper should touch the inner canthus. b. The nurse should be applying pressure to the nasolacrimal duct. c. The medication will land in the center of the patient’s cornea. d. The nurse should have gloves on when administering eyedrops. e. The patient’s eye should be closed during administration of eyedrops.

ANS: C, D

The nurse should always wear gloves when administering eyedrops. The drop should land in the lower conjunctival sac rather than on the center of the cornea. The patient’s eye must be open during administration of eyedrops. The tip of the eyedropper should not touch the patient’s eye. Pressure should not be applied to the nasolacrimal duct during administration of eyedrops.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Which of the following orders are for topical medications? (Select all that apply.) a. Methotrexate 20 mg subcutaneously once weekly on Wednesdays b. Latanoprost 0.005% one drop in left eye daily at bedtime c. Acetaminophen 650 mg suppository Q 4 hours prn mild pain d. Ofloxacin otic solution 0.3% instill drops into right ear daily e. Calcitonin nasal spray one spray daily into alternating nostrils ANS: B, C, D, E

Topical medications are applied to the skin and mucus and respiratory membranes. You can apply topical medications to mucus membranes in a variety of other ways, including the following: (1) By directly applying a liquid or ointment (e.g., eyedrops, 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., eardrops, 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe factors to consider when choosing routes of medication administration.

I T G B.C TOP: Nursing Process: Im p l emNent U Rati S o nN O M MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Which assessment finding indicates that the patient is at risk from polypharmacy? (Select all

that apply.)? a. The patient takes three different medications to treat hypertension. b. The patient’s daughter administers the patient’s eyedrops every evening. c. The patient uses four different pharmacies to fill his 16 prescriptions. d. The patient has weekly laboratory tests for warfarin dosing. e. The patient is allergic to strawberries, latex, and penicillin antibiotics.

ANS: A, C

Polypharmacy is the use of multiple medications, putting the patient at risk for drug interactions and incompatibilities. The patient is at risk from polypharmacy due to the multiple antihypertensive medications and using multiple pharmacies to fill 16 prescriptions.

Allergies, weekly laboratory testing, and assistance with eyedrops do not put the patient at risk from polypharmacy.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss factors to include in assessing a patient’s needs for and response to medication therapy.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 5. Which instructions will the nurse give to the patient prior to administering a metered-dose

inhaler? (Select all that apply).

a. b. c. d.

“Inhale deeply and then blow slowly into the inhaler while you press the canister.”

“Open your mouth wide so that the spray will reach the back of your throat.”

“Roll the inhaler gently for a few minutes between your palms before each use.”

“Hold your breath for 5 to 10 seconds immediately after you inhale the medication.” e. “Exhale fully and inhale deeply through your mouth while you press the canister.”

ANS: D, E

The patient should exhale fully and then inhale deeply through the mouth while the canister is pressed. This will allow the medication to enter the airways. The breath should be held for 5 to 10 seconds immediately after inhalation to allow the medication to absorb into the tissues of the airways. Metered-dose inhalers should be shaken 3 to 4 times before each use. The lips should be sealed tightly around the mouthpiece of the inhaler.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Correctly and safely prepare and administer medications.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies OTHER 1. Order: Cyanocobalamin 0.6 mg IM daily

Cyanocobalamin Injection USP 1000 mcg/mL For injection How many mL of medicationNw reC ceO ivMe per dose?

UiRll SthIe NpaGtiTenBt .

mL

ANS:

0.6 mL 0.6 mg  1000 mcg/1 mg = 600 mcg 600 mcg/1000 mcg  1 mL = 0.6 mL DIF: Cognitive Level: Apply (Application) OBJ: Calculate prescribed medication doses correctly.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Order: Digoxin 1 mL PO daily

Digoxin Oral solution USP 0.25 mg per 5 mL How many mcg of medication will be administered per dose?

ANS:

50 mcg 1 mL/5 mL  0.25 mg = 0.05 mg 0.05 mg  1000 mcg/1 mg = 50 mcg DIF:

Cognitive Level: Apply (Application)

mcg

OBJ: Calculate prescribed medication doses correctly.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Order: 50% Dextrose 15 g IV push STAT

50% Dextrose Injection USP 25 g per 50 mL How many mL of medication will be administered?

mL

ANS:

30 mL 15 g/25 g  50 mL = 30 mL DIF: Cognitive Level: Apply (Application) OBJ: Calculate prescribed medication doses correctly.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Order: Potassium chloride solution 9 mL PO daily

Potassium chloride Oral solution USP 10% 20 mEq per 15 mL How many mEq of medication will be administered?

ANS:

mEq

N R INGTB.COM

U S 12 mEq 9 mL/15 mL  20 mEq = 12 mEq

DIF: Cognitive Level: Apply (Application) OBJ: Calculate prescribed medication doses correctly.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 5. Order: Enalaprilat 1.25 mg IV push

Enalaprilat injection For IV use only 2.5 mg per 2 mL The agency’s safe IV push infusion rate for Enalaprilat is 625 mcg over 5 minutes.

How many minutes will it take to safely administer the dose? minutes ANS:

10 minutes 1.25 mg  1000 mcg/1 mg = 1250 mcg 1250 mcg/625 mcg  5 minutes = 10 minutes DIF: Cognitive Level: Apply (Application) OBJ: Calculate prescribed medication doses correctly.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

Chapter 18: Fluid, Electrolyte, and Acid-Base Balances Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The patient receives an infusion of albumin to pull water from the tissues into the

bloodstream. Which process is demonstrated by this treatment? a. Diffusion b. Osmosis c. Filtration d. Clarification 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. Filtration is the net effect of several forces that tend to move fluid across a membrane. Clarification is explanation of a concept in greater detail or removal of impurities.

DIF: Cognitive Level: Apply (Application) OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. Which patient should receive an IV solution of D5W? a. A trauma patient with maN ssU ivReS hI emNoG rrT haBg. e COM b. A patient being resuscitated after cardiac arrest c. A patient with CHF and acute pulmonary edema d. A patient with a serum sodium level of 162 mEq/L ANS: D

D5W solution is used to lower elevated serum sodium levels. Normal saline solution should be administered to hypovolemic patients and during resuscitation after cardiac arrest. D5W solution will worsen fluid overload with CHF and acute pulmonary edema.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. Lactated Ringer’s solution is administered to the patient during surgery. What is the purpose

of this infusion? a. Cause cells to shrink and reduce swelling. b. Expand the body’s intravascular fluid volume. c. Move fluid from intravascular space into cells. d. Pull fluid from cells into the intravascular space.

ANS: B

Fluids that have the same osmolality as normal blood are called isotonic. Isotonic solutions such as Lactated Ringer’s expand the body’s 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe purpose and procedures for initiation and maintenance of intravenous therapy.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. What causes the patient to feel thirsty and drink more water? a. Colloid osmotic pressure b. Osmoreceptor stimulation c. Increased oncotic pressure d. Decreased hydrostatic pressure ANS: B

Thirst, a conscious desire for water, regulates fluid intake when plasma osmolality increases (osmoreceptor-mediated thirst) or the blood volume decreases (baroreceptor-mediated thirst and angiotensin II–mediated 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 out war d-p ush i ng force.

N R I G B.C M U S N T O

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient with metabolic acidosis due to severe hyperglycemia. Which

assessment finding indicates to the nurse that the patient’s body is attempting to compensate for the acidosis? a. The patient’s breathing is very deep and rapid. b. The patient’s temperature has been rising steadily. c. The patient’s skin is flushed and warm to the touch. d. The patient is urinating large amounts of light colored urine.

ANS: A

The patient’s deep breathing is an attempt by the body to blow off additional carbon dioxide which converts to carbonic acid. Reduction of carbonic acid in the body will raise the pH and compensate for the acidosis. Elevated temperature, flushed skin, and increased urine output will not compensate for the acidosis.

DIF: Cognitive Level: Apply (Application) OBJ: Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. The nurse is caring for a patient who is very malnourished and laboratory results show that the

patient’s albumin level is extremely low. Which finding would the nurse expect to observe during the patient’s physical assessment? a. The patient has generalized edema. b. The patient is confused and irritable. c. The patient has an irregular heartbeat. d. The patient’s eyes are red, irritated, and itchy.

ANS: A

Albumin is responsible for keeping water within the bloodstream using oncotic pressure. Low albumin levels allow water to seep from the bloodstream into the tissues causing generalized edema. Confusion, irregular pulse, and irritated eyes are not expected with low albumin levels.

DIF: Cognitive Level: Apply (Application) OBJ: Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a patient with a serum potassium level of 7.1 mEq/L. Which is the

highest priority nursing diagnosis for this patient? a. Risk for spiritual distress related to chronic illness despair b. Powerlessness related to illness-related physical limitations c. Impaired social interaction related to limited physical activity d. Risk for decreased cardiac output related to altered heart rhythm ANS: D

NURSINGTB.COM

The patient’s potassium level is dangerously high, which can cause ventricular fibrillation.

For this reason the highest priority diagnosis for the patient is risk for decreased cardiac output related to altered heart rhythm. Risk for spiritual distress, powerlessness, and impaired social interaction are not the priority.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss risk factors for fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a patient who has been vomiting. The patient’s sodium level is 124

mEq/L. Which laboratory result will the nurse also expect to see in the patient’s chart? a. Chloride 81 mEq/L b. Calcium 11.1 mg/dL c. Phosphate 5.1 mg/dL d. Magnesium 2.3 mEq/L ANS: A

Chloride levels are closely associated with sodium levels. When the serum sodium level is low, the chloride level will drop as well. The normal sodium level is 135 to 145 mEq/L so the patient’s 124 mEq/L level indicates hyponatremia. The nurse will expect to find the patient’s chloride level to be 81, below the 95 to 105 normal range. Hypercalcemia, normal magnesium level, and hyperphosphatemia are not expected with hyponatremia due to vomiting.

DIF:

Cognitive Level: Understand (Comprehension)

OBJ: Describe fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 9. The nurse is caring for a patient with a poorly controlled hypoparathyroid condition. Which is

the highest priority nursing diagnosis for this patient? a. Risk for injury/fracture related to bone fragility b. Disturbed energy field related to chronic illness c. Deficient knowledge related to importance of exercise d. Disturbed body image related to hormonal changes ANS: A

Hypoparathyroid disease can lead to low serum calcium levels and osteoporosis, putting the patient at risk for developing a pathological fracture. Risk for fracture is the highest priority diagnosis for this patient. Disturbed energy field, deficient knowledge, and disturbed body image are not as important as the risk for fracture.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss risk factors for fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 10. The patient reports muscle weakness after taking prescribed furosemide daily. Which

laboratory finding will the nurse expect to see in the patient’s chart? a. Chloride 84 mEq/L b. Sodium 124 mEq/L c. Calcium 12.6 mg/dL d. Potassium 2.8 mEq/L ANS: D

NURSINGTB.COM

Loop diuretics cause hypokalemia. The nurse will expect to find the patient’s potassium level to be 2.8 mEq/L as a result. The patient would not have hyponatremia (sodium 124 mEq/L), hypercalcemia (calcium 12.6 mg/dL), or hypochloremia (chloride 84 mEq/L) as a result of taking loop diuretics.

DIF: Cognitive Level: Apply (Application) OBJ: Describe fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11. The nurse is caring for a dyspneic patient with a long history of smoking. The blood gas

report shows a pH of 7.33, PaCO2 of 47, PaO2 of 78, and HCO3- of 26. What is the patient’s acid-base status? 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 PaCO2 and an increased hydrogen ion concentration (pH below 7.35) that reflect the excess carbonic acid (H2CO3) 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 PaCO2 and increased pH (above 7.45) that reflect the deficit of carbonic acid (H2CO3) 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.

DIF: Cognitive Level: Apply (Application) OBJ: Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a patient with bulimia. The patient vomits after eating and is

experiencing tingling of the fingers and toes and muscle cramps. What is the patient’s expected acid-base status? 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 B.C MOns that reduce alveolar ventilation results from respiratory diseaseN Us oRrSoIt hNeGr cT ondit io (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.

DIF: Cognitive Level: Apply (Application) OBJ: Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 13. The nurse is caring for a diabetic patient with a blood sugar of 879 mg/dL, and notes the

patient has fruity breath, and Kussmaul respirations. Which acid-base imbalance should the nurse expect? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: A

Diabetic ketoacidosis is a common cause of metabolic acidosis that occurs in patients with dangerously high blood sugars. Kussmaul respirations are a compensatory mechanism of the body during metabolic acidosis to raise the serum pH by blowing off additional carbon dioxide.

DIF: Cognitive Level: Apply (Application) OBJ: Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. Which patient has the greatest risk for extracellular fluid volume (ECV) deficit? a. A female with Crohn’s disease b. A male with peptic ulcer disease c. An infant with fever and vomiting d. An adolescent with acute appendicitis ANS: C

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 for 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 Crohn’s 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.

DIF: Cognitive Level: Apply N (AU pR pliS caI tiN onG ) TB.COM OBJ: Discuss risk factors for fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15. Which is the best method for measuring the patient’s daily weight? a. Weigh the patient daily using different scales for comparison. b. Teach that daily weights are done in hospitals, but not at home. c. Monitor daily weight, comparing with the previous day’s weight. d. Weigh the patient at different times of the day to determine trends.

ANS: C

Daily weights are an important indicator of fluid status. Each kilogram (2.2 pounds) 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity 16. Which intake and output measurement can the nurse delegate to the nursing assistant? a. Oral fluid intake b. Nasogastric tube intake c. Wound drainage output d. Intravenous fluid intake ANS: A

You can delegate portions of intake and output measurement to nursing assistants. In many agencies nursing assistants can record oral intake but not intake through tubes or IVs. Nursing assistants can record urine, diarrhea, and vomitus output, but not drainage through wound drainage tubes.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse is teaching a patient with vomiting and diarrhea about appropriate dietary fluids.

Which option chosen by the patient would indicate further teaching is needed? a. Ice chips b. Tap water c. Black coffee d. Chicken broth ANS: C

Coffee should be avoided by Na p aRt i e nIt wG i t h vBo. mC itinM g and diarrhea as caffeine is a diuretic that U S N T O can worsen dehydration. The patient should consume fluids high in Na+ (e.g., electrolyte oral solution, chicken broth). Strategies to encourage fluid intake include offering small sips of fluid frequently, popsicles, and ice chips.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse is caring for a patient with a sodium level of 156 mEq/L due to diabetes insipidus.

Which is the highest priority nursing diagnosis for this patient? a. Activity intolerance related to fatigue from chronic illness b. Imbalanced nutrition related to excessive carbohydrate intake c. Excess fluid volume related to increased isotonic fluid retention d. Risk for ineffective airway clearance related to secretions during seizure ANS: D

Diabetes insipidus is caused by a lack of antidiuretic hormone (ADH). Excessive urination causes dehydration and hypernatremia. The patient’s sodium level of 156 mEq/L puts the patient at risk for seizures and risk for ineffective airway clearance related to secretions during seizure. Diabetes insipidus is not related to blood sugar levels unlike diabetes mellitus so imbalanced nutrition related to excessive carbohydrate intake is not appropriate for the patient. Excess fluid volume related to increased isotonic fluid retention is appropriate for a patient with SIADH rather than diabetes insipidus. Activity intolerance is not as important as risk for ineffective airway clearance.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss risk factors for fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 19. 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 D5W IV fluid infusing. Which is the priority action of the nurse? a. Check the patient’s potassium level before hanging the new IV solution. b. Administer 20 mEq KCl diluted in 5 mL of fluid by IV push in 5 minutes. c. Give the KCl undiluted by IV push in 5 minutes for the most rapid action. d. Estimate the amount of fluid in the IV bag and add KCl to equal 20 mEq/L. ANS: A

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 hos pita ls, n u r s e s do not a d d KCl to IV bags. Usually a pharmacist N R I G B.C M U S N T O prepares the solution.

DIF: Cognitive Level: Apply (Application) OBJ: Describe how to change intravenous solutions, tubing, and dressings.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 20. The nurse is to administer 40 mEq of IV KCl to the patient with severe hypokalemia. Why did

the pharmacy send up four 100 mL IV bags with 10 mEq of KCl in each bag? a. To prevent the patient from receiving too much IV fluid. b. The four smaller bags are less expensive than one large one. c. To prevent accidentally infusing the 40 mEq of KCl too quickly. d. The doctor may change his mind and lower the prescribed KCl dose.

ANS: C

Rapid infusion of KCl can cause life-threatening cardiac dysrhythmias. The pharmacy sent up four separate IV bags containing 10 mEq KCl in each to prevent accidentally infusing the 40 mEq of KCL too quickly. Four smaller bags are not necessarily less expensive than one large bag but the cost is less important than patient safety. The small amount of extra fluid is negligible. The infusion may be stopped if the physician lowers the ordered dose of KCl. DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe purpose and procedures for initiation and maintenance of intravenous therapy.

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

21. Approximately 30 minutes into the transfusion of this blood product, the patient becomes

short of breath with wheezing, low BP, and hives. Which medication must be administered to the patient immediately? a. 500 mL 0.9 NS IV fluid bolus b. Epinephrine 0.4 mg IM c. Diphenhydramine 50 mg IV d. Methylprednisolone 40 mg IV ANS: B

The patient is experiencing an anaphylactic reaction to the transfusion and requires epinephrine immediately to prevent the development of shock. Methylprednisolone, normal saline IV, and diphenhydramine may be given after epinephrine.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the procedure for initiating a blood transfusion and complications of blood therapy.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 22. Which is the priority assessment to be documented prior to administering a blood product to a

patient? a. Strength of peripheral pulses b. Vital signs and pulse oximetry c. Presence/absence of bowel sounds d. Height, weight, and body mass index (BMI) ANS: B

Vital signs and pulse oximetry must be documented before administering a blood product to the patient. This will allow the nurse to compare subsequent findings after the transfusion has started. Peripheral pulses, b o N w e l Rs o uI U Sn dNs G, and T Bh.eC OightM/weight are not as important as vital signs and pulse oximetry prior to starting a transfusion.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the procedure for initiating a blood transfusion and complications of blood therapy.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 23. The patient is receiving an intravenous infusion of 40 mEq of potassium chloride in a 1000

mL solution of 0.9% saline. The patient states that the area around the IV site burns. What intervention does the nurse perform first? a. Notify the physician. b. Stop the IV infusion. c. Document the finding. d. Increase the IV drip rate.

ANS: B

The nurse’s first action should be to stop the IV infusion and assess the IV site carefully. The physician does not need to be notified. The IV drip rate should not be increased as it will increase tissue damage and phlebitis risk. The finding should be documented after the patient’s IV line has been taken care of.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss complications of intravenous therapy and what to do if they occur.

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

24. Which complication is suspected when the patient’s IV site is swollen, cool, and pale with no

blood return? 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss complications of intravenous therapy and what to do if they occur.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 25. Which is the appropriate action of the nurse when selecting a vein for IV placement? a. Select a vein that appears to be well dilated. b. Elevate the extremity to visualize the vein. c. Tap and rub the vein vigo rously with fri ct io n.

N R I G B.C M

d. Stroke from proximal to di U s tal S a b oN v e tT h e site. O 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 patient’s activities of daily living (ADLs).

DIF: Cognitive Level: Apply (Application) OBJ: Describe purpose and procedures for initiation and maintenance of intravenous therapy.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 26. Which is the highest priority of the nurse immediately after withdrawing the needle from the

IV catheter after venipuncture? a. Engage the safety device to cover the needle. b. Check for blood return in the flashback chamber. c. Stabilize the catheter with the nondominant hand. d. Align the catheter on the top of vein at a 15-degree angle.

ANS: A

The nurse’s highest priority after withdrawing the needle from the IV catheter after venipuncture is to engage the safety device and cover the needle. It is absolutely essential for this to be done in order to prevent needlestick injury. The nurse will check for blood return in the flashback chamber prior to withdrawing the needle. Stabilizing the catheter with the nondominant hand is less important than engaging the safety device. The catheter is aligned on top of the vein prior to venipuncture.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the purpose and procedures for initiation and maintenance of intravenous therapy.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 27. The patient is scheduled for hip replacement surgery and significant blood loss is expected.

What is the best possible action of the patient to reduce the risk of transfusion complications? a. Arrange for an autologous blood donation. b. Take an iron supplement daily prior to the surgery. c. Expect transfusions will come from a directed donor. d. Request that donated blood be screened twice by the blood bank.

ANS: A

The patient should be advised to arrange for an autologous blood donation. This way the patient will receive his/her own blood rather than from a donor. Iron supplementation will not be sufficient to compensate for the blood loss expected with hip replacement surgery. Patients cannot request extra screening precautions for transfusions. The patient should not be instructed to expect that transfusions will come from a directed donor.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the procedure for initiating a blood transfusion and complications of blood therapy.

NeUntR TOP: Nursing Process: Implem atS ionINGMTSB C. : C NC OLMEX: Physiological Integrity

28. Which assessment findings indicate that the patient has developed fluid overload as a result of

transfusing two units of packed red blood cells? a. Hypotension and thirst b. Dyspnea and tachycardia c. Shivering and high fever d. Hypotension and urticaria ANS: B

Dyspnea and tachycardia are signs of pulmonary edema and fluid overload after transfusion.

Hypotension and urticaria indicate anaphylactic shock. Shivering and high fever are signs of a transfusion reaction rather than fluid overload. Hypotension and thirst indicate fluid deficit.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the procedure for initiating a blood transfusion and complications of blood therapy.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Which assessment findings prevent the nurse from starting an IV in the patient’s right arm?

(Select all that apply.) a. The patient is right-handed. b. The IV pole will be on the left side of the bed.

c. The patient has a dialysis fistula in the right arm. d. The patient has right-sided paralysis after a stroke. e. The patient had a right mastectomy 6 years ago.

ANS: C, D, E

Dialysis fistula, history of mastectomy, and paralysis all prevent the nurse from starting the patient’s IV in the right arm. The patient’s preferences for the right hand and IV pole position have no bearing on where to start the IV. DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe purpose and procedures for initiation and maintenance of intravenous therapy.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient whose pituitary secretes excessive amounts of antidiuretic

hormone (ADH). Which findings will the nurse expect to see during assessment of the patient? (Select all that apply.) a. The patient’s serum sodium level is 122 mEq/L. b. The patient’s serum chloride level is 116 mEq/L. c. The patient is voiding large amounts of watery urine. d. The patient’s mucus membranes are dry and cracked. e. The patient has gained 5 pounds and has swollen feet.

ANS: A, E

Excessive amounts of ADH (SIADH) will lead to hyponatremia with a serum sodium level of 122 mEq/L. Fluid retention from excess ADH will cause weight gain and swollen feet.

Diabetes insipidus (DI) causes hyperchloremia, dry mucus membranes, and excessive urination due to a shortage of ADH.

NURSINGTB.COM

DIF: Cognitive Level: Apply (Application) OBJ: Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. A patient reports chills, dizziness, and feeling hot during a blood transfusion. What are the

appropriate actions of the nurse? (Select all that apply.) a. Slow the rate of infusion. b. Stop the blood transfusion. c. Check the patient’s vital signs. d. Notify the physician and blood bank. e. Restart the patient’s IV at a different site.

ANS: B, C, 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. The patient’s IV should not be restarted at a different site.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the procedure for initiating a blood transfusion and complications of blood therapy.

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

4. The nurse is caring for a patient who has just been found in respiratory arrest. Which

laboratory values will the RN expect to find in the patient’s chart? (Select all that apply.) a. pH 7.28 b. PaO2 65 mm Hg c. PaCO2 58 mm Hg d. HCO3- 15 mEq/L ANS: A, B, C

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 PaCO2 and an increased hydrogen ion concentration (pH below 7.35) that reflect the excess carbonic acid (H2CO3) in the blood.

Hypoventilation produces respiratory acidosis. The elevated PaCO2 level is a result of the patient not breathing (normal range is 35 to 45 mm Hg). The low PaO2 is also a result of not breathing (normal range is 80 to 100 mm Hg). The low HCO3- is not expected as a result of respiratory arrest (normal range is 22 to 26 mEq/L).

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. Which patients can receive a unit of A+ blood? (Select all that apply.) a. Type A+ b. Type Ac. Type B+ d. Type Be. Type AB+ NURSINGTB.COM f. Type ABANS: A, E

Patients with type A+ and AB+ blood may receive a unit of A+ blood. Type A-, B+, B-, ABpatients would not be compatible with A+ blood.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the procedure for initiating a blood transfusion and complications of blood therapy.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity SHORT ANSWER 1. Order: IV 500 mL 0.9% NS to infuse over 10 hours

IV tubing: 10 drops/mL What will the infusion pump rate be set at—how many mL/hour?

ANS:

50 mL/hour 500 mL/10 hours = 50 mL/hour DIF: Cognitive Level: Apply (Application) OBJ: Calculate an intravenous flow rate. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

2. Order: IV 1000 mL 0.9% NS to infuse over 5 hours

IV tubing: 10 drops/mL No infusion pump is used. What is the flow rate in drops/minute?

ANS:

33 drops/minute 1000 mL/5 hours = 200 mL/hour 200 mL/60 minutes  10 drops/mL = 33 drops/minute DIF: Cognitive Level: Apply (Application) OBJ: Calculate an intravenous flow rate. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. Order: Merrem 500 mg in 100 mL D5W IVPB infuse over 30 minutes

IV tubing: 10 drops/mL What will the infusion pump rate be set at—how many mL/hour?

ANS:

200 mL/hour 100 mL/30 minutes  60 minutes/1 hour = 200 mL/hour DIF: Cognitive Level: Apply (Application) OBJ: Calculate an intravenous flow rate. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. Order: 500 mL D5W to infuse at 100 mL/hour

IV tubing: 10 drops/mL N R I G B.C M The IV bag was hung at 12:00 Un o oSn . N T O What time will the IV bag be completed?

ANS:

5:00 p.m. or 1700 500 mL  1 hour/100 mL = 5 hours infusion time 12:00 start time + 5:00 run time 1700 finish time DIF: Cognitive Level: Apply (Application) OBJ: Calculate an intravenous flow rate. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 5. Order: 500 mL D5W to infuse at 50 mL/hour

IV tubing: 10 drops/mL How many mL will infuse over the nurse’s 12 hour shift?

ANS:

12 hours  50 mL/hour = 600 mL DIF: Cognitive Level: Apply (Application) OBJ: Calculate an intravenous flow rate. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Chapter 19: Complementary and Alternative Therapies Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which is an example of allopathic treatment? a. Prescription of antibiotic medication for a bacterial infection b. Use of tai chi exercises to relieve chronic back pain c. Manipulation of the spine to relieve migraine headaches d. Burning dried herbs to relieve chronic abdominal pain and diarrhea ANS: A

Allopathic medicine is also known as biomedicine or conventional western medicine. An example of allopathic medicine is prescription of antibiotic medication for a bacterial infection. Tai chi and burning herbs are both examples of complementary medicine.

Manipulation of the spine to relieve migraine headaches is an example of chiropractic treatment, also considered to be a form of complementary medicine.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe complementary, alternative, and integrative therapies.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 2. Which action by the nurse best demonstrates the concept of integrative nursing? a. The nurse evaluates the patient’s medications to determine if the patient is at a

high risk for falls or drug interactions.

b. The nurse educates the p a t i e n t about perineal c a r e and fluid intake to help prevent

urinary tract infections. N URS IN GT B.CO M c. The nurse regularly assesses the patient’s pain level and administers analgesic medication as needed. d. The nurse is authentically present when providing care to the patient while accepting the patient as an individual.

ANS: D

Integrative nursing focuses on the development of a caring-healing relationship between the patient and nurse. The nurse best demonstrates this concept by being authentically present for the patient and accepting the patient as an individual. Educating about UTI prevention, administering pain medication, and reducing fall risks are nursing interventions but do not embody the concept of integrative nursing.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe complementary, alternative, and integrative therapies.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 3. Which assessment finding indicates to the nurse that the patient has begun to master the

cognitive skill of receptivity? a. The patient readily accepts feedback from the nurse about how to perform dressing changes. b. The patient calmly accepts the physician’s recommendation for surgery without a request for a second opinion. c. The patient chooses not to inform family members about the complications and

risks of upcoming surgery. d. The patient uses guided imagery techniques to minimize anxiety and push negative

thoughts out of the mind.

ANS: A

Receptivity is the ability to accept and tolerate differing views or unfamiliar circumstances.

The patient demonstrates receptivity by accepting feedback from the nurse about how to perform the dressing changes. Accepting recommendations without question or comment demonstrates passivity. Choosing not to inform family members is maintaining privacy.

Guided imagery to minimize anxiety demonstrates focusing.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the relaxation response and its effect on somatic ailments.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 4. Which patient would be a candidate for biofeedback therapy? a. A patient with a history of heart failure and hypotension b. A diabetic patient with difficulty managing blood sugar levels c. A patient with an anxiety disorder after a traumatic experience d. A forgetful, anxious patient with a history of senile dementia ANS: C

Biofeedback therapy is very helpful for anxiety disorders. Biofeedback is not recommended for patients with unstable endocrine disorders, hypotension, bradycardia, or dementia.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the purpose and principles of biofeedback.

TOP: Nursing Process: AssessN menR t I GMSB C:.C NCLMEX: Physiological Adaptation

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5. Which nursing diagnosis is a priority for a patient using tai chi to relieve arthritis pain? a. Risk for falls b. Sleep deprivation c. Risk for contamination d. Ineffective individual coping ANS: A

Tai chi is a form of exercise with gentle, flowing movements, inner serenity, and deep breathing. Patients are at risk for falls if balance is lost during the movements. Tai chi will not cause insomnia, contamination, or ineffective coping.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe complementary, alternative, and integrative therapies.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Reduction of Risk Potential 6. The patient prefers to take an herbal supplement rather than the prescription medication

ordered by the physician. Which is the most appropriate response of the nurse? a. “It is very convenient to take herbal supplements because they can be obtained without a prescription.” b. “Herbal supplements are significantly less expensive than prescription medications.” c. “Herbal supplements are not held to the same high-quality standards as prescription medications.”

d. “Herbal supplements are made from plant materials so they are organic and

nontoxic.”

ANS: C

The US Food and Drug Administration closely monitors the production of prescription medications but not herbal supplements. Even though it is convenient for patients to obtain herbal supplements without a prescription, it is more important for the nurse to inform the patient that herbal supplements are not held to the same high-quality standards as prescription medications. Herbal supplements may or may not be more expensive than prescription medications. Some plant materials may be toxic or even poisonous.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe safe and unsafe herbal therapies.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Reduction of Risk Potential 7. The nurse is caring for a patient who is taking ephedra for weight loss. Which assessment

finding puts the patient at high risk for an adverse reaction? a. The patient takes three different antihypertensive medications. b. The patient has been unemployed for the last 8 months. c. The patient is deaf and communicates through sign language. d. The patient has a strong family history of breast cancer.

ANS: A

Ephedra is a central nervous system stimulant and will elevate blood pressure. The patient has a history of hypertension and use of ephedra can raise the blood pressure to dangerous levels.

Unemployment, deafness, and a history of breast cancer will not put the patient at high risk of adverse reaction from ephedrN a. R I G B.C M

U S N T

O

DIF: Cognitive Level: Apply (Application) OBJ: Describe safe and unsafe herbal therapies.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 8. The patient reports taking valerian root capsules regularly. What is the patient’s rationale for

taking the supplement? a. Relief of constipation b. Relief of nausea and vomiting c. Relief of arthritis pain d. Inability to fall asleep at night ANS: D

Valerian root is a central nervous system depressant commonly used to help patients fall asleep at night and relieve mild anxiety. Valerian root will not relieve constipation, nausea, or arthritis pain.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe safe and unsafe herbal therapies.

TOP: Nursing Process: Assessment MSC: NCLEX: Pharmacological and Parenteral Therapies 9. The nurse is caring for a patient who is taking garlic for high cholesterol. Which assessment

finding puts the patient at high risk for an adverse reaction?

a. b. c. d.

The patient is training for a marathon.

The patient is severely allergic to beestings.

The patient takes enoxaparin daily.

The patient has a history of hypothyroid disease.

ANS: C

Garlic will inhibit platelet function and clotting so it should not be taken with blood thinners such as enoxaparin. Marathon training, bee sting allergies, and hypothyroid disease will not put the patient at high risk of adverse reaction from garlic.

DIF: Cognitive Level: Apply (Application) OBJ: Describe safe and unsafe herbal therapies.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 10. Which supplement will help minimize the discomfort of seasickness for a patient going on a

sailing cruise? a. Garlic b. Ginger c. Ginseng d. Gingko biloba ANS: B

Ginger is used to relieve nausea and vomiting including from seasickness. Garlic is used to lower high cholesterol. Ginseng is used to increase endurance and immune function. Gingko biloba is used to improve memory.

DIF: Cognitive Level: Apply (Application) OBJ: Describe safe and unsafeNherR bal I t he r G apieB s . .C M U S N T O TOP: Nursing Process: Assessment MSC: NCLEX: Pharmacological and Parenteral Therapies 11. The patient reports using chaparral to ease breathing. Which assessment finding leads the

nurse to advise stopping the supplement immediately? a. The patient has a history of hepatitis C. b. The patient is morbidly obese. c. The patient requires supplemental oxygen. d. The patient has frequent sinus infections.

ANS: A

Chaparral has been found to cause severe liver damage and should not be taken by patients with preexisting liver diseases including hepatitis C. The patient should be advised to stop taking chaparral immediately for that reason. Obesity, supplemental oxygen, and sinus infections are not reasons for the patient to stop taking chaparral immediately.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe safe and unsafe herbal therapies.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 12. Which patient would be a candidate for animal-assisted therapy? a. An elderly patient with Clostridium difficile diarrhea b. A patient who has just undergone bone marrow transplantation c. A young patient with an acute asthma exacerbation and dyspnea

d. A forgetful, irritable patient with a history of Alzheimer’s disease ANS: D

Patients with Alzheimer’s disease are often excellent candidates for animal-assisted therapy.

The animals help to calm and reorient the patients, improving cognitive functions.

Clostridium difficile is a highly contagious bacterial infection that could be spread by the therapy animals. Patients who have just undergone bone marrow transplantation are severely immunocompromised and should not be exposed to animals. Animal fur or dander may worsen asthma and dyspnea.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the principles and effectiveness of imagery, meditation, breathwork and animal-assisted therapy.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 13. Which assessment finding indicates that the patient is not a candidate for acupuncture

therapy? a. The patient has several herniated lumbar disks. b. The patient follows a lactose-free diet. c. The patient is allergic to latex and strawberries. d. The patient has a history of thrombocytopenia.

ANS: D

Patients with bleeding disorders such as thrombocytopenia are not candidates for acupuncture therapy. Herniated lumbar disks would be an indication for acupuncture therapy. Lactose-free diet and allergies to latex and strawberries are not contraindications for acupuncture therapy.

DIF: Cognitive Level: Apply N ( A pR p l i c aIt i o nG) B.C M U S N and T integrative O therapies.

OBJ: Describe complementary, alternative, TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 14. Which herbal supplement is likely to worsen symptoms for a patient with rheumatoid

arthritis? a. Echinacea b. Ginger c. Turmeric d. Valerian ANS: A

Echinacea is an immune system stimulant and can cause exacerbation of symptoms in patients with autoimmune diseases. Ginger relieves nausea and is not known to affect the immune system. Valerian is a mild herbal sedative. Turmeric is an antiinflammatory supplement which may help relieve the pain and stiffness of arthritis.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe safe and unsafe herbal therapies.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential MULTIPLE RESPONSE

1. Which assessment findings indicate to the nurse that the patient is experiencing a stress

response? (Select all that apply.) a. The patient’s pupils are dilated. b. The patient’s blood sugar is 36 mg/dL. c. The patient’s blood pressure is 104/56. d. The patient’s pulse is 132 beats/minute. e. The patient is unable to sleep at night.

ANS: A, D, E

Dilated pupils, tachycardia, and insomnia are common indicators of stress. Elevated blood sugar and blood pressure would also be expected.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss the relaxation response and its effect on somatic ailments.

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

Chapter 20: Caring in Nursing Practice Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which statement about caring for patients is true? a. Basically all patients are the same. b. Each patient has a unique background. c. Caring for patients requires very little experience. d. Standard solutions exist for most patient’s 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 nurse’s ability to know a patient, allowing the nurse to recognize a patient’s problems, and to find and implement individualized solutions.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the commonalities among theories of caring.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Caring

2. Which statement is part of Leininger’s Transcultural View of Caring? a. Caring and curing are basically synonymous. b. Caring acts are independent of p at i e n t values.

NUpro RSach I NforGTallBpatie .COnts.

M c. Care uses a standardized ap d. Care is tailored to meet the needs of the individual patient.

ANS: D

Caring is very personal and tailored to meet the needs of the individual patient. 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the commonalities among theories of caring.

MSC: NCLEX: Psychosocial Integrity 3. Which activity best demonstrates the caring role of a nurse? a. Assessing the patient’s entire health history b. Administering antibiotic medications on time c. Inserting a urinary catheter using aseptic technique d. Maintaining privacy when conversing with the patient ANS: D

TOP: Nursing Process: Caring

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. The patient will not feel comfortable sharing with the nurse if the conversation can be easily overheard. Administering medications, 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role that caring plays in building nurse-patient relationships.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 4. Which nursing goal is consistent with Watson’s Transpersonal Theory of Caring? a. The nurse will develop a therapeutic relationship with the patient. b. The nurse will tell the patient what needs to be done to resolve health problems. c. The nurse will be viewed as the authority when it comes to health care issues. d. The nurse will exclude the family from health discussions to protect privacy.

ANS: A

Watson’s Transpersonal Theory of Caring states that caring is at the very core of nursing practice. The nurse’s development of a therapeutic relationship with the patient is a goal that is consistent with Watson’s Transpersonal Theory of Caring. Viewing the nurse as a prescriptive authority will not demonstrate caring according to Watson’s theory. The nurse should allow the patient to decide how and when to include family members in health discussions.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role that caring plays in building nurse-patient relationships.

TOP: Nursing Process: C ar i n gN U R S I N GMTSB C. : C NC OLMEX: Psychosocial Integrity 5. The nurse helps the patient set small, achievable goals and celebrates with the patient when

the goals are met. Which caring behavior is demonstrated by the nurse? a. Human respect b. Encouraging manner c. Healing environment d. Affiliation needs ANS: B

An encouraging manner helps the patient retain hope and manage negative feelings. The nurse demonstrates an encouraging manner by helping the patient set small, achievable goals and celebrating with the patient when the goals are met. Setting small achievable goals does not demonstrate affiliation needs, healing environment, or human respect.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the therapeutic benefit of listening to patients.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Caring

6. Which action by the nurse facilitates mutual problem solving? a. The nurse refers the newly widowed patient to a local bereavement support group. b. The nurse elevates the head of the bed and administers oxygen when the patient

becomes short of breath. c. The nurse asks the patient which high-fiber foods are preferred to prevent

constipation. d. The nurse assesses the patient’s oral mucus membranes for ulcerations, bleeding,

or dryness.

ANS: C

Mutual problem solving is facilitated when patients are encouraged to help create goals and interventions. The nurse demonstrates this by asking the patient which high-fiber foods are preferred to prevent constipation rather than making the selections independent of the patient’s preferences. Assessment of mucus membranes, administering oxygen, and referring patients to support groups do not facilitate mutual problem solving.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the therapeutic benefit of listening to patients.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Caring

7. Which action by the nurse demonstrates attentive reassurance? a. The nurse provides gentle oral care to a patient with a nasogastric tube. b. The nurse spends time with the patient to provide empathy and inspire hope. c. The nurse assesses the patient for cultural influences that affect body image. d. The nurse encourages the patient to wear hearing aids to facilitate communication.

ANS: B

Attentive reassurance is demonstrated by spending time with the patient, providing empathy and inspiring hope. Assessment for cultural influences, facilitating communication, and providing oral care do not demonstrate attentive reassurance.

DIF: Cognitive Level: Apply (Application) OBJ: Describe ways to expresN s ca R ring I throG ughBp . resCencM e and touch.

U S N T O TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 8. The nurse ensures that the patient’s room is cool, quiet, and dark so that the patient can rest

and sleep. Which caring behavior is demonstrated by the nurse? a. Fulfilling affiliation needs b. Providing a sense of presence c. Creating a healing environment d. Demonstrating an encouraging manner ANS: C

Creation of a healing environment is demonstrated by ensuring that the patient’s room is cool, quiet, and dark so that the patient can rest and sleep. Affiliation needs, sense of presence, and encouraging manner do not create a healing environment for patients.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the evidence about patients’ perceptions of caring.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 9. The nurse teaches the patient’s family members how to assist with colostomy care. Which

caring behavior is demonstrated by the nurse? a. Providing presence b. Meeting affiliation needs c. Meeting basic human needs d. Appreciating unique meanings

ANS: B

The nurse is meeting the patient’s need for affiliation by teaching the family members to assist with colostomy care. This helps minimize the sense of loneliness that the patient may experience as a result of changed health status. Teaching the family members does not provide presence, meet basic human needs, or appreciate unique meanings.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain the relationship between knowing a patient and clinical decision making.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 10. The nurse gently repositions the patient every 2 hours and applies a rich moisturizer to dry

skin areas. Which caring behavior is demonstrated by the nurse? a. Meeting affiliation needs b. Mutual problem solving c. Meeting basic human needs d. Using an encouraging manner ANS: C

The nurse is meeting the basic human needs of the patient by preventing skin breakdown.

Repositioning the patient and moisturizing skin does not meet affiliation needs, facilitate mutual problem solving, or demonstrate an encouraging manner.

DIF: Cognitive Level: Apply (Application) OBJ: Describe ways to express caring through presence and touch.

TOP: Nursing Process: Caring MSC: NCLEX: Basic Care and Comfort 11. What is the goal of the nurse wh en l i s t e n i n g t o t h e p atient’s story about the meaning of the

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U S N T O illness? a. Provide the patient with hope for full recovery. b. Maintain the patient’s sense of confidentiality. c. Determine the extent of the patient’s recuperation. d. Allow the patient to express frustrations about the illness.

ANS: D

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 express frustration and break the distress of the illness. Listening to the patient’s story will not maintain the patient’s sense of confidentiality, provide the patient with hope for full recovery, or determine the extent of the patient’s recuperation.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the therapeutic benefit of listening to patients.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Caring

12. The nurse respects the patient’s cultural standard to have the father of the baby wait outside

the delivery room when the baby is born. Which caring behavior is demonstrated by the nurse? a. Meeting basic human needs b. Appreciating unique meanings c. Offering attentive reassurance d. Providing an encouraging manner

ANS: B

The nurse respects the patient’s cultural standards and demonstrates appreciation of unique meanings by having the father outside of the delivery room for the baby’s birth. The nurse does not meet basic human needs, offer attentive reassurance, or provide an encouraging manner by respecting the patient’s cultural standards.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the relationship between knowing a patient and clinical decision making.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 13. Which action of the nurse demonstrates Florence Nightingale’s beliefs about caring? a. The nurse hangs the patient’s get well cards on the wall for the patient to enjoy. b. The nurse uses active listening skills to communicate effectively with the patient. c. The nurse teaches the family member how to care for the patient’s tracheostomy. d. The nurse develops a toileting schedule for a patient with functional incontinence.

ANS: A

Florence Nightingale believed that nurses must provide a healing environment for patients to recover. The nurse can do this by hanging the patient’s get well cards on the wall for the patient to enjoy. Active listening skills, teaching family members, and developing toileting schedules do not create a therapeutic healing environment.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the commonalities among theories of caring.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Caring

14. The hospice nurse is caring for a terminally ill patient who is preparing for a peaceful death at

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home after spending quality t i mUe wSi t h Nl o v T e d onesO . Which nursing diagnosis is most appropriate for this patient? a. Situational low self-esteem related to negative perception of self-worth b. Ineffective therapeutic regimen management related to decisional conflicts c. Impaired religiosity related to inability to participate in faith-based services d. Readiness for enhanced comfort related to desire for peace and companionship ANS: D

The hospice patient demonstrated readiness for enhanced comfort related to desire for peace and companionship. The patient in the scenario does not show any signs of decisional conflicts, inability to participate in faith-based services, or negative perception of self-worth.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain the relationship between knowing a patient and clinical decision making.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. The nurse is caring for a patient with hemiplegia following a right-sided stroke. Which actions

of the nurse demonstrate caring behaviors? (Select all that apply.) a. The nurse fosters the patient’s denial of need for long-term rehabilitation. b. The nurse uses warmed blankets and gentle soaps when bathing the patient. c. The nurse assists the patient to make choices from the menu for mealtimes.

d. The nurse requires the patient to stay in the wheelchair for an hour after eating. e. The nurse acknowledges the patient’s frustration and anger about the disability.

ANS: B, C, E

Caring behaviors include being honest, advocating for the patient’s 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 patient’s back, reading patients passages from religious texts, a favorite book, cards or e-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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe ways to express caring through presence and touch.

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

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Chapter 21: Cultural Awareness Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The patients with health insurance receive higher dosages of pain medications than patients

who are uninsured. Which term best describes this problem? a. Health disparity b. Intersectionality c. Cultural dissonance d. Linguistic incompetence ANS: A

Health disparity occurs when a population is treated differently as a result of a cultural, financial, or ethnic characteristic. Administration of lower pain medication dosages to uninsured patients is an example of a health disparity. Intersectionality is the coming together of a person’s cultural, political, financial, educational, and ethnic contexts. Culturally congruent care is tailored to meet the ethnic, cultural, and linguistic needs of the individual.

Dissonance is an incompatibility between a person’s beliefs and actions. Linguistic competence is the ability to effectively communicate with individuals or groups from other cultural or ethnic backgrounds.

DIF: Cognitive Level: Apply (Application) OBJ: Describe health disparity and the social determinants that affect it.

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

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2. The emergency room staff insiU sts tS hat N a feT male MO uslim patient disrobe completely and put on

a hospital gown before being treated by the physician. Which nursing diagnosis is most applicable in this situation? a. Risk for compromised human dignity related to cultural attire requirements b. Ineffective role performance related to inadequate direction and preparation c. Noncompliance related to expected behavior of patients in the emergency room d. Impaired environmental interpretation syndrome related to busy emergency room ANS: A

Many female Muslim patients believe in covering the entire body at all times except for the face, hands, and feet. If the emergency room staff insists that the patient disrobe completely for the physician, the patient’s human dignity may be put at risk. The patient has not demonstrated any noncompliance behaviors and has not shown any difficulty interpreting the emergency room environment. The ineffective role performance diagnosis does not apply to the patient.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain the concepts of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire in the cultural competence model.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. Which action of the nurse demonstrates culturally competent care? a. Helping a Hindu patient to eat meatloaf and gravy for dinner b. Cutting up ham and vegetables for an orthodox Jewish patient

c. Bringing a grieving Mormon family a tray of coffee and snacks d. Adding fruit to a Buddhist patient’s bowl of oatmeal for breakfast ANS: D

Buddhist patients are often vegetarian so oatmeal and fruit would be an appropriate meal.

Mormon families do not believe in consumption of alcohol or caffeine. Orthodox Jewish patients do not eat pork. Hindu patients are often vegetarian.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the concepts of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire in the cultural competence model.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 4. Which statement indicates the patient’s world view? a. “My religion prohibits me from eating meat or drinking alcohol.” b. “My family has a strong history of hypertension and type 2 diabetes.” c. “A doctoral degree will allow me to advance my professional career.” d. “The government is not interested in caring for immigrants to the United States” ANS: D

The patient’s world view includes how others are perceived and their beliefs about life around them including opinions about the federal government. Personal religious beliefs, family medical history, and educational plans for career advancement are not examples of world views.

DIF: Cognitive Level: Apply (Application) OBJ: Describe social and cultural influences in health and illness.

TOP: Nursing Process: AssessN menR t I GMSB C:.C NCLMEX: Psychosocial Integrity

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5. A Muslim patient has requested to have only female nursing staff provide personal care.

Which is the appropriate response of the nurse? a. “I know that it may be difficult to understand but both male and female nurses are employed at this hospital.” b. “I will make sure that the charge nurse is notified about your request so that it can be accommodated.” c. “It will be difficult for people like you to adjust to our ways, but there are limitations for all of us.” d. “You may be perceived as a ‘difficult patient’ if you insist on limiting which nurses can take care of you.”

ANS: B

Nurses who provide culturally competent care bridge cultural gaps to provide meaningful and supportive care for all patients. The Muslim patient’s request to have female nursing staff members provide personal care should be accommodated. The patient should not be threatened with a perception of being labeled as difficult. Even though both male and female nurses are employed at the hospital, female nurses can be assigned to provide personal care for the Muslim patient.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the role communication plays in developing cultural competence.

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

6. Which intervention is most appropriate for the patient with the nursing diagnosis

Noncompliance related to the patient’s preference for cultural therapies rather than prescription medications? a. Create a clearly written medication schedule and instruction list with dosages and side effects. b. Describe the negative health outcomes that will be experienced if the cultural therapies are continued. c. Attempt to coordinate the patient’s cultural therapies with the prescribed treatments. d. Inform the patient that the hospital will not be able to continue providing care if the noncompliant behavior continues.

ANS: C

The best option for the nurse is to attempt to coordinate the patient’s cultural therapies with the prescribed treatments. The nurse needs to start with the patient’s own beliefs and then try to coordinate prescribed treatments so that they will be congruent. Threatening discontinuation of care and negative health outcomes will alienate the patient and worsen noncompliance. Creating a medication schedule will not increase compliance as it does not address the patient’s cultural beliefs.

DIF: Cognitive Level: Apply (Application) OBJ: Describe social and cultural influences in health and illness.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 7. Which technique is most appropriate when performing a physical assessment for a male

Muslim patient? a. Use short, simple sentenc es a n d complete the ph ysical assessment as quickly as N R I G B.C M U S N T O possible. b. Have a male nurse perform the assessment and expose only the body part being examined. c. Stand close to the patient, speak clearly, and be careful not to exaggerate lip movements or facial expressions. d. Use therapeutic touch to reassure the patient and convey the nurse’s sense of concern.

ANS: B

The male Muslim patient must not expose himself to women other than his wife. It is important for a male nurse to perform the assessment. Modesty is also extremely important so the body should remain covered except for the part being examined. There is no need to complete the assessment quickly or limit facial expressions. Therapeutic touch is not the priority assessment technique and should be used sparingly with patients from other cultures.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the approaches to use in conducting a cultural nursing history and physical assessment.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 8. The nurse has just completed discharge teaching about self-injection of insulin to a patient

who speaks little English. How can the nurse best determine that the teaching has been successful? a. Ask the patient if there are any questions about the procedure. b. Provide written instructions in the patient’s preferred language.

c. Have the patient watch a video about how to self-inject insulin. d. Watch the patient self-administer the next scheduled dose of insulin.

ANS: D

The best way for the nurse to determine that the teaching has been successful is to watch the patient self-administer the next scheduled dose of insulin. This way the nurse can observe for any difficulties and provide feedback immediately. Asking the patient if there are any questions is not recommended due to the patient’s language difficulty. Written instructions and videos will not determine if the patient is able to self-administer insulin correctly.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe how teach-back helps a patient with limited health literacy TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Which situations demonstrate oppression in health care? (Select all that apply.) a. A pediatrician who refuses to treat children of parents in same-sex marriages b. A medical practice refuses to interpret for patients who do not speak English c. An emergency room physician refuses to administer opiates for minor pain d. A pediatrician who refuses to treat children whose parents refuse vaccinations e. A social services agency refuses to allow any Asian couples to adopt children ANS: A, B, E

Oppression in health care occurs when providers treat patients unfairly on the basis of ethnic, cultural, financial, or other characteristics. Refusing to treat children of same-sex parents, refusing to interpret for patients, and refusing Asian couples to adopt children are examples of Nr a R oppression. It is appropriate f o U n Se I mN eG rg eB.C Tn c y r oMoOm physician to refuse to administer opiates for minor pain. Pediatricians may refuse to treat children whose parents refuse vaccinations as they can endanger the health of the other patients in the practice.

DIF: Cognitive Level: Apply (Application) OBJ: Describe health disparity and the social determinants that affect it.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 2. Which assessment findings are social determinants of health? (Select all that apply.) a. Living in a house containing lead paint b. Genetic predisposition to spinal osteoarthritis c. Growing up in a neighborhood without grocery stores d. Annual income 125% above the federal poverty level e. Completed high school and 1 year of community college ANS: A, C, D, E

Genetic makeup is not a social determinant of health. Living conditions, neighborhood, annual income, and educational level are all social determinants of health.

DIF: Cognitive Level: Apply (Application) OBJ: Describe social and cultural influences in health and illness.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. Which patient populations are at risk for being marginalized? (Select all that apply.)

a. b. c. d. e.

Recent immigrants to the United States Individuals with type AB positive blood Professionals with a master’s or doctoral degree Individuals who speak at least three different languages Individuals who have undergone sexual reassignment surgery

ANS: A, E

Recent immigrants and transgender individuals are considered to be marginalized and at risk for having poor health outcomes. Blood type, advanced education, and fluency in multiple languages are not criteria for marginalization.

DIF: Cognitive Level: Apply (Application) OBJ: Describe health disparity and the social determinants that affect it.

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

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Chapter 22: Spiritual Health Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse feels a deep sense of altruism and wonderment after successfully resuscitating a

young athlete who suddenly collapsed in cardiac arrest. Which term best describes the sensation experienced by the nurse? a. Holy conviction b. Spiritual distress c. Divine expectation d. Self-transcendence ANS: D

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. Spiritual distress is suffering due to lack of connectedness with a faith system. The nurse did not experience holy conviction or divine expectation.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the relationship among faith, hope, and spiritual well-being.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 2. Which term is used to describe a person who does not believe in the existence of a higher

NUl lR B.C MOng to the lives of others? power but has had a meaningfu i fSeIbyNGcoT ntributi a. Deist b. Atheist c. Fatalist d. Humanist ANS: B

An atheist is a person who does not believe in the existence of a higher power or Supreme Being. Atheists search for meaning in life through their work and relationships with others. A humanist is devoted to the study of human nature and human welfare. A fatalist believes that all events were predetermined. A deist believes that God created the world but does not control how it functions.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the relationship among faith, hope, and spiritual well-being.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 3. The nurse is caring for a patient who expresses anger about being abandoned and unloved by

God since becoming ill. Which nursing diagnosis is appropriate for this patient? a. Spiritual distress related to perceived alienation from God b. Risk for loneliness related to social and physical isolation c. Acute confusion related to hallucinations and misperceptions d. Impaired memory related to inability to remember familiar prayers

ANS: A

The nursing diagnosis spiritual distress related to perceived alienation from God is appropriate for this patient due to feelings of alienation from God since becoming ill. The patient scenario does not indicate social or physical isolation, impaired memory, or hallucinations. Feeling abandoned by God is not a hallucination.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the relationship among faith, hope, and spiritual well-being.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 4. Which assessment finding leads the nurse to include hopelessness as a nursing diagnosis in

the patient’s plan of care? a. The patient does not wish to attend any type of religious services. b. The patient does not believe in a higher power, spirit guide, or God. c. The patient has a source of structure and guidance for difficult times. d. The patient has no motivation or resources to achieve any life goals.

ANS: D

Hope is energizing, giving individuals a motivation to achieve and the resources to use toward that achievement. The patient experiences hopelessness when there is no motivation or resources to achieve any life goals. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the relationship among faith, hope, and spiritual well-being.

TOP: Nursing Process: A s s e s sN mU e nRt SINGMTSB C. : C NC OLMEX: Psychosocial Integrity 5. The patient is distressed because hospitalization has prevented participation in church services

and adherence to important prayer rituals. Which nursing diagnosis is most appropriate for this patient? a. Impaired religiosity related to inability to participate in religious services b. Noncompliance related to failure to adhere to prescribed treatment regimens c. Disturbed thought processes related to delirium and altered level of consciousness d. Ineffective role performance related to discrimination and inadequate coping ANS: A

Impaired religiosity is an appropriate diagnosis for this patient because hospitalization has prevented participation in the patient’s religious services. Nothing in the scenario indicates that the patient is noncompliant, has experienced discrimination, or is delirious.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Compare and contrast the concepts of religion and spirituality.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 6. A patient who survived a near-death experience tells the nurse about feeling a deep sense of

peace, light, and unconditional love while watching the health care providers perform resuscitation procedures. Which is the best response of the nurse? a. “Your experiences were probably due to side effects of the medications.” b. “I will ask the doctor for a psychiatric evaluation since you are hallucinating.”

c. “It sounds like you are fearful of suffering associated with the dying process.” d. “Your experience is similar to others who have survived near-death experiences.”

ANS: D

Patients who survive near-death experiences relate comparable experiences during resuscitation efforts. The nurse should reassure the patient that similar to those reported by others who have survived near-death experiences. The patient’s experiences were not hallucinations or due to side effects of medications. The patient does not show any evidence of fearing suffering associated with the dying process.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the relationship of spirituality to an individual’s total being.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 7. A nurse is caring for a patient who survived cardiopulmonary resuscitation after almost

drowning. How can the nurse best help the patient to deal with the aftereffects of the experience? a. Recommend that the patient avoid discussing the experience with family. b. Assume that the near-death experience was a positive experience for the patient. c. Be nonjudgmental and help the patient to work through the near-death experience. d. Explain that people who have not had a near-death experience will not understand.

ANS: C

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. Fur t hNerm t allBN.DO CEs Ma r e positive experiences. However, URore S I, Nn o G T individuals experiencing an NDE who discuss it openly with family or caregivers find acceptance and meaning from this powerful experience.

DIF: Cognitive Level: Apply (Application) OBJ: Establish presence with patients.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 8. Which action by the nurse is appropriate for a family with a terminally ill newborn? a. Call the rabbi to come to the bedside. b. Arrange for the infant to be baptized immediately. c. Call the hospital chaplain to pray with the family. d. Ask the family how their spiritual needs can be supported.

ANS: D

Nurses need to differentiate their personal spiritual beliefs from those of the patients and their families. The nurse’s role is not to solve the spiritual problems of patients, but to provide an environment for your patients to express their spirituality. Having the baby baptized or calling the rabbi indicates that the nurse is applying personal spiritual values on the patient and family. Calling the chaplain assumes that the patient and family value a religious denomination.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss nursing interventions designed to promote spiritual health.

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

9. A patient refuses to remove a religious headscarf when being bathed. Which is appropriate

action of the nurse? a. Remove the headscarf because its presence hinders hygiene. b. Respect the patient’s wishes and work around the headscarf. c. Explain to the patient that the headscarf has no real spiritual value. d. Identify the refusal to remove the headscarf 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 patient’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss nursing interventions designed to promote spiritual health.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 10. The nurse is caring for a patient with the nursing diagnosis impaired religiosity related to

inability to participate in religious services while hospitalized. Which nursing intervention is most appropriate for this patient? a. Call the patient’s religious leader to coordinate bedside services for the patient. b. Help the patient to make a list of important values and ideals in the patient’s life. c. Use therapeutic touch and authentic presence to support the patient spiritually.

N RonIpNhys G TB.C M d. Encourage the patient to foU cus S i cal heaOling before meeting spiritual needs.

ANS: A

The patient is distressed because of the inability to participate in religious services while hospitalized. The best way for the nurse to address the religious need of the patient is to call the patient’s religious leader to coordinate bedside services for the patient. This will facilitate meeting the patient’s religious needs. Helping the patient to list values and using therapeutic touch will not meet the patient’s religious needs. Encouraging the patient to focus on physical healing before meeting spiritual needs minimizes the patient’s priorities and may be seen as condescending.

DIF: Cognitive Level: Apply (Application) OBJ: Compare and contrast the concepts of religion and spirituality.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Which nursing interventions are appropriate for a terminally ill patient who is a devout Jew?

(Select all that apply.) a. Arrange for a minister to provide the sacrament of anointing of the sick. b. Facilitate bedside Sabbath services for the patient and the family members. c. Allow the patient’s family to maintain a vigil throughout the day and night. d. Provide snacks and meals for the patient and family only from sunset until dawn. e. Respect the decision of the patient and family not to put the patient on life support.

ANS: B, C, E

Sabbath services are very important for people of Jewish faith so the nurse should attempt to facilitate bedside Sabbath services for the patient and the family members. Constant vigil at the bedside is also very important so the nurse should allow the patient’s family to maintain a vigil throughout the day and night. Life support is often discouraged within the Jewish faith and the nurse must respect the wishes of the patient and family. It would only be appropriate for the nurse to arrange for a minister to provide the sacrament of anointing of the sick when the patient is Catholic and requests to receive the sacrament. Muslims do not eat anything from dawn until sunset during the month of Ramadan. Providing snacks and meals for the patient and family only from sunset until dawn would be inappropriate for a Jewish patient and family.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss nursing interventions designed to promote spiritual health.

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

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Chapter 23: Growth and Development Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which nursing diagnosis is most appropriate for a toddler who is not walking by the age of 24

months? a. Delayed growth and development related to failure to achieve age-appropriate motor skills b. Impaired walking related to inability to maintain a steady gait along uneven surfaces c. Sedentary lifestyle related to preferred lifestyle that requires minimal physical activity d. Impaired parenting related to unrealistic expectations for age-appropriate motor skills ANS: A

If a child does not walk by the age of 20 months, there is delayed gross-motor ability.

Therefore delayed growth and development related to failure to achieve age-appropriate motor skills is the appropriate nursing diagnosis. Delayed development has nothing to do with sedentary lifestyle or unrealistic parenting expectations. Impaired walking is not the appropriate nursing diagnosis for a developmentally delayed toddler.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the growth and development changes that occur in individuals from conception through old age.

TOP: N ursin g P roce ss: Diagnosis N R I G B.C M MSC: NCLEX: Health PromotioU n a nS d MN ainteTnance O 2. Loud wails erupt whenever the nurse tries to pick up the infant from the mother. Which

developmental stage is the infant experiencing? a. Affiliation and love b. Production and care c. Trust versus mistrust d. Autonomy versus doubt ANS: C

The infant is at the first stage of Erikson’s psychosocial development, trust versus mistrust.

The infant trusts the mother and must learn to trust others. The infant is not able to address more advanced developmental needs such as autonomy, affiliation, and production.

DIF: Cognitive Level: Apply (Application) OBJ: Compare the frameworks for growth and development as described by major developmental theorists.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. A young adult is balancing the need to live and work independently with the desire to have a

girlfriend for companionship and love. Which developmental stage is the young adult experiencing? a. Intimacy versus isolation b. Obedience and orientation

c. Self-control and independence d. Generosity versus self-absorption ANS: A

The young adult is at the intimacy versus isolation stage of Erikson’s theory of psychosocial development. The young adult is balancing the need for independence and personal growth with the desire to form intimate relationships with others. Generativity versus self-absorption is experienced during the middle adult years. Obedience and orientation is experienced during the early childhood/toddler years. Self-control and independence is also experienced during the early childhood/toddler years.

DIF: Cognitive Level: Apply (Application) OBJ: Compare the frameworks for growth and development as described by major developmental theorists.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. Which action demonstrates Piaget’s formal operations period of development? a. Touching everything and putting everything into the mouth to learn about the

surroundings b. Learning not to touch a hot radiator cover again after suffering a mild burn the first

time c. Taking insulin as prescribed because otherwise dangerous complications of

diabetes will develop d. Understanding that a family vacation is in the future and asking daily if vacation

will be “today.”

ANS: C

The formal operations stage oNf d R e v e lIo p mGe n tBi s.tC y p i cMa l l y achieved during adolescence through U S N T O adulthood. The individual is able to understand abstract concepts and realize the consequences of actions. Touching everything demonstrates the sensorimotor stage experienced by infants.

Memory about events is achieved during the preoperational stage when the child learns not to touch a hot item after previously suffering a burn. Preoperational stage is also demonstrated by knowing that something will happen in the future but not being able to fully understand when it will occur.

DIF: Cognitive Level: Apply (Application) OBJ: Compare the frameworks for growth and development as described by major developmental theorists.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. Which is the highest priority nursing diagnosis for a toddler who is at the autonomy versus

doubt stage of development? a. Toileting self-care deficit related to readiness for transition from diapers b. Impaired verbal communication related to stage of cognitive development c. Readiness for enhanced sleep related to desire to sleep in a big kids’ bed d. Risk for poisoning related to unawareness of environmental risks within reach ANS: D

Toddlers cannot understand the risks of their environment and want to put everything in their mouths. This presents a very significant risk of poisoning as toddlers are not aware when substances may be toxic or poisonous. Impaired verbal communication is expected for toddlers as they struggle to learn to speak clearly. Toddlers are ready to transition from a crib to a big kids’ bed and to stop using diapers. Communication, toileting, and sleep are less of a priority than protection from poisoning.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Apply developmental theories when planning intervention in the care if patients across the life span. TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 6. The nurse is caring for an elderly patient with the nursing diagnosis loneliness related to

recent loss of spouse and limited contact with significant others. Which stage of Maslow’s hierarchy of needs is addressed with this diagnosis? a. Belonging b. Self-esteem c. Self-actualization d. Safety and security ANS: A

The nursing diagnosis risk for loneliness relates to Maslow’s need for belongingness and love.

Self-esteem relates to feelings of accomplishment. Self-actualization is about achieving one’s full potential. Safety and security include protection from cold, illness, or injury.

DIF: Cognitive Level: Apply (Application) OBJ: Apply developmental theories when planning intervention in the care if patients across the life R span. TOP: Nursing PNrocU e ss: e ssm ntC SIAss NG T Be. O M MSC: NCLEX: Health Promotion and Maintenance 7. Which technique is best to calm a preschooler’s fears before auscultating bowel sounds? a. Reassure the child that listening to bowel sounds will not hurt in the least. b. Allow the child to use the stethoscope to listen to a teddy bear’s abdomen. c. Explain how a stethoscope is used to listen to the functioning of the bowel. d. Seat the child in the parent’s lap and have the parent hold the child’s hands.

ANS: B

The preschooler should be allowed to use the stethoscope to listen to the teddy bear’s abdomen. This will enable the child to understand how the stethoscope works and reassure the child that the procedure will cause no discomfort. A preschooler should never be restrained when other options are available. Touching the stethoscope will be more effective for reducing fears than explanations and reassurance.

DIF: Cognitive Level: Apply (Application) OBJ: Identify specific nursing interventions for the health promotion of patients across the life span.

TOP: Nursing Process: Caring MSC: NCLEX: Health Promotion and Maintenance 8. A young child learns how to use scissors and catch a ball. Which term best describes these

developments? a. Puberty b. Growth

c. Adolescence d. Development ANS: D

Development is the gradual increase in cognitive and motor abilities over time, such as the ability to use scissors or catch a ball. Growth is an increase in the individual’s physical size.

Puberty is the developmental point when reproduction is possible. Adolescence is the time period that occurs between puberty and adulthood.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the difference between growth and development TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. Which technique is used to assess fine-motor skills in a middle-school child? a. Observe the child drawing a picture on a piece of paper. b. Watch the child sit on the floor and rise to a standing position. c. Ask the child to walk a straight line in a heel-toe (tandem) gait. d. Ask the child to stand on one leg and hop in place several times.

ANS: A

Fine-motor skills can be assessed by watching the child draw a picture on a piece of paper.

This allows the nurse to see how the pencil is held, check for tremors, and observe hand muscle strength. Rising to a standing position assesses muscle strength. Walking heel-toe and standing on one leg assesses balance.

DIF: Cognitive Level: Apply (Application) OBJ: Identify specific nursing interventions for the health promotion of patients across the life span.

TOP: Nursing Process: AssessN menR t I GMSB C:.C NCLMEX: Health Promotion and Maintenance

U S N T

O

10. The mother of a healthy toddler reports that the child is eating less than a few months ago but

the child has not lost any weight. Which is the most appropriate response of the nurse? a. “You need to make him eat more every day. 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 doesn’t mean much.” c. “Toddlers have periods when they aren’t growing as fast and they don’t need to eat as much.” d. “Make him eat with a spoon and don’t 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 child’s pattern of growth with standard growth charts is reassuring to parents concerned about their toddler’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Specify the physical and psychosocial health concerns of infants, children, adolescents, and adults. TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Health Promotion and Maintenance

11. The adolescent with a BMI of 18.5 feels overweight after seeing excessively slender actresses

on TV and in the movies. Which nursing diagnosis is appropriate for this adolescent? a. Decisional conflict related to how much weight should be lost to look pretty b. Defensive coping related to denial of imbalanced weight to height proportion c. Powerlessness related to perception that weight loss is needed to gain friends d. Disturbed body image related to cultural perception of ideal body proportions ANS: D

The adolescent with a BMI of 18.5 is at a healthy weight for height. The adolescent’s feelings of overweight are due to a disturbed body image brought on by seeing the excessively slender actresses. The adolescent’s weight is appropriate for height so there is no denial or defensive coping. The adolescent does not need to lose weight to gain friends and there is no decisional conflict about how much weight should be lost.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Specify the physical and psychosocial health concerns of infants, children, adolescents, and adults. TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 12. The mother of a school-age child asks the nurse why the child’s blood pressure is measured at

a routine physical examination appointment. What is the best answer of the nurse? a. “Insurance companies require blood pressure checks of children as well as adults to calculate premium rates.” b. “The state health department requires blood pressure checks before immunizations can be administered.” c. “Sometimes children develop high blood pressure that can lead to health problems in adulthood.”

N R I G B.C M d. “Blood pressure checks areUstaS rtedNin cThi ldho oOd so that adults will not be afraid of them later on.”

ANS: C

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 child’s blood pressure is elevated and needs further medical attention. Childhood obesity is a prominent health problem, which increases the child’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Identify specific nursing interventions for the health promotion of patients across the life span.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Health Promotion and Maintenance 13. Which is an example of a primary sexual characteristic? a. Enlarged larynx and deeper voice b. Enlargement of female breast tissue c. Growth of hair on the face and chest d. Development of the penis and testicles ANS: D

Primary sexual characteristics include the presence of a penis and testicles rather than a clitoris and vagina. Enlarged larynx, facial hair, and enlargement of female breast tissue are all secondary sexual characteristics.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Describe the growth and development changes that occur in individuals from conception through old age.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. Which is the highest priority goal for the young adult patient with the nursing diagnosis risk

for suicide related to depression and inability to make friends? a. The patient will express feelings and maintain self-control. b. The patient will not cause any sort of harm or injury to self. c. The patient will develop a therapeutic relationship with the nurse. d. The patient will verbalize less anxiety and fear around other people.

ANS: B

The highest priority goal is that the patient will not cause any harm or injury to self.

Expressing feelings, developing relationships, and verbalizing less anxiety are all less important than maintaining safety of the patient.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Use knowledge of growth and development to enhance use of the nursing process for individuals across the life span.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 15. The nurse is caring for a middle-aged adult who verbalizes a desire to start jogging and has a

goal to run a half marathon. W ch iI s thG t aCpprM N hiR U S Ne mo TBs. O op ri at e action of the nurse? a. Tell the patient that exercising during middle age could lead to injury. b. Recommend that the patient have a complete physical examination first. c. Inform the patient that it is unwise to take up new sports during middle age. d. Explain that the disability from normal aging prevents taking up new sports.

ANS: B

Taking up new sports and activities during middle age is acceptable but the patient should have a physical examination first to ensure that there are no significant health impairments.

Taking up a new sport during middle age could lead to injury but that should not prevent the patient from taking on new activities. The normal aging process does not necessarily prevent taking up new sports.

DIF: Cognitive Level: Apply (Application) OBJ: Use critical judgment to determine appropriate teaching topics for individual patients across the life span.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. The nurse is caring for an elderly patient who has become withdrawn and refuses to eat after

being admitted to a long-term nursing facility. Which is the highest priority goal for the patient? a. The patient will participate in social activities with other residents. b. The patient will ask questions about the prescribed care and treatment. c. The patient will develop meaningful relationships with the nursing staff. d. The patient will maintain usual weight and show no signs of dehydration.

ANS: D

The highest priority goal for this patient is maintenance of weight and prevention of dehydration. When this goal is met, the nurse can help the patient to participate in activities with other residents, ask questions about care, and develop relationships with the staff.

DIF: Cognitive Level: Apply (Application) OBJ: Specify the physical and psychosocial health concerns of infants, children, adolescents, and adults. TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 17. The middle-aged patient is overwhelmed by the stresses of caring for aging parents as well as

young children living at home. Which nursing diagnosis is most appropriate for this patient? a. Disturbed body image related to developmental changes associated with middle age b. Deficient diversional activity related to desire to enhance relaxation and contentment c. Caregiver role strain related to amount of attention and care needed by both parents and children d. Readiness for enhanced power related to desire for freedom from family responsibilities ANS: C

The patient feels overwhelmed by the care required by young children and aging parents so caregiver role strain is the appropriate diagnosis. The patient is not ready for enhanced power and does not need additional diversional activities. The patient does not demonstrate any sign of disturbed body image.

N R I G B.C M

S N T O DIF: Cognitive Level: Analyze U (Analysis) OBJ: Identify factors that promote or interfere with normal growth and development of individuals at each stage of life.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 18. The nurse is caring for an elderly patient who has just been diagnosed with a bladder

infection. The normally alert and appropriate patient thinks that she is going to bake cookies with her mother when she gets home after school this afternoon. Which term best describes the patient’s mental status? a. Delirious b. Dejected c. Depressed d. Demented ANS: A

The patient is delirious due to the urinary tract infection. The patient is normally alert and appropriate so the patient is not demented. Alzheimer’s disease and other forms of dementia cause long-term mental status changes. The patient is not depressed or dejected as there is no sadness evident in her plan to bake cookies with her mother.

DIF: Cognitive Level: Understand (Comprehension) 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

19. Which assessment finding indicates that the patient is at risk for developing polypharmacy? a. The patient stores medications in the kitchen cabinet. b. The patient takes four different medications for congestive heart failure. c. The patient requires financial assistance to pay for prescriptions. d. The patient obtains all prescription medications from a mail-order pharmacy.

ANS: B

Polypharmacy is the use of multiple prescription medications, putting the patient at risk for developing harmful drug interactions. The four different medications for congestive heart failure put the patient at risk of developing polypharmacy. Financial assistance, storage location, and use of mail-order pharmacy do not increase the risk of polypharmacy.

DIF: Cognitive Level: Understand (Comprehension) 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: Health Promotion and Maintenance 20. Which is the most appropriate goal for an elderly adult with the nursing diagnosis of

sedentary lifestyle related to deconditioning and lack of physical exercise? a. The patient will participate in social activities with others. b. The patient will increase walking to at least 5000 steps per day. c. The patient will identify ways to conserve energy and prevent fatigue. d. The patient will develop meaningful relationships with the nursing staff.

ANS: B

The most appropriate goal for the sedentary lifestyle diagnosis is to increase activity. The patient can achieve this by wN a l k iR Gas t 5B0.00 U nSg aI Nt l eT OCsteMps each day. Participation in social activities does not necessarily require physical movement or walking. Conserving energy and developing relationships are not goals for the sedentary lifestyle diagnosis.

DIF: Cognitive Level: Apply (Application) OBJ: Identify specific nursing interventions for the health promotion of patients across the life span.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 21. Which assessment finding leads the nurse to include the risk for delayed development nursing

diagnosis in the care plan for an infant? a. The baby’s father works from home b. The baby has three older sisters at home c. The baby was born at only 30 weeks’ gestation d. The baby cannot tolerate formula that contains lactose ANS: C

Preterm birth is an important risk factor for delayed development in infants. The father’s employment, older siblings, and need for lactose-free formula are not risk factors for delayed development.

DIF: Cognitive Level: Apply (Application) 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: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. Which abilities are required for moral development of the child? (Select all that apply.) a. Accept social responsibility. b. Perform repetitive motion responses. c. Respect the integrity and rights of others. d. Integrate principles of justice and fairness. e. Use symbols and objects for abstract thinking.

ANS: A, C, D

Moral development depends on the child’s ability to accept social responsibility and integrate personal principles of justice and fairness. In addition, the child’s 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. Piaget’s theory, not Kohlberg’s, 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 child’s point of view, to logical thinking, and finally to abstract thinking.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Compare the frameworks for growth and development as described by major developmental theorists.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. The nurse is caring for an adolescent with a BMI of 22 and the nursing diagnosis imbalanced

nutrition, more than body requirements related to caloric intake greater than metabolic needs.

Which nursing interventionsNw i l lRt h eIn u rGs e uBs. e tC o h e l p the adolescent achieve a balanced diet?

U S N T O M (Select all that apply.) a. Use sugary treats as a reward for getting good grades in school. b. Encourage the adolescent to gradually increase physical activity. c. Recommend intake of at least 2 to 3 L of water each day. d. Remind the adolescent of how body image affects relationships. e. Encourage the adolescent to eat breakfast every day before school.

ANS: B, C, E

Gradually increasing physical activity, drinking 2 to 3 L of water daily, and eating breakfast daily will help the adolescent balance the diet and manage weight. Using sugary treats as a reward will worsen the adolescent’s imbalanced diet. The adolescent does not need to be reminded about how body image affects relationships.

DIF: Cognitive Level: Apply (Application) OBJ: Specify the physical and psychosocial health concerns of infants, children, adolescents, and adults. TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. Which are expected physical assessments finding for a middle-aged adult? (Select all that

apply.) a. Difficulty hearing female voices b. Diminished breath sounds bilaterally c. Gradual loss of senses of taste and smell d. Need for reading glasses to see small print

e. Decreased ability to solve practical problems ANS: A, B, 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. Cranial nerves are unaffected so senses of taste and smell remain intact.

Middle-aged patients often report difficulty hearing female voices as they are higher in pitch than male voices.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the growth and development changes that occur in individuals from conception through old age.

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

NURSINGTB.COM

Chapter 24: Self-Concept and Sexuality Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse is caring for an adult patient who must quit working due to complications from

hypertension. Which self-concept is likely to be put at risk for this patient? a. Identity b. Self-esteem c. Body image d. Role performance ANS: D

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 the role of wage earner. 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 individual’s overall sense of personal worth or value. Identity involves the sense of individuality and being distinct and separate from others.

DIF: Cognitive Level: Apply (Application) 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 2. The nurse is caring for an adolescent patient who dips snuff because all of his friends do it.

Which self-concept need l e d Nt hUe R paStiI enNt G toTdB o. thC isO ?M a. Body image b. Sexual identity c. Cultural identity d. Role performance ANS: C

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 one’s 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. Sexual identity refers to the patient’s preference for sexual partners (i.e., homosexual, heterosexual).

DIF: Cognitive Level: Apply (Application) 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. The nurse is caring for an adolescent who feels overweight with a BMI of 16. Which nursing

diagnosis is most appropriate for this patient? a. Risk-prone health behavior related to inadequate self-efficacy b. Noncompliance related to failure to adhere to healthy dietary plan

c. Disturbed body image related to distorted view of ideal body weight d. Self-mutilation related to depersonalization and self-destructive behaviors ANS: C

The patient has a distorted view of ideal body weight so disturbed body image is the most appropriate nursing diagnosis. There is no information to indicate risk-prone health behaviors, self-mutilation, or noncompliance.

DIF: Cognitive Level: Apply (Application) 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. The nurse is caring for a patient who has lost all sexual desire due to severe chronic illness.

Which term will the nurse use to chart this assessment finding? a. Fluid b. Queer c. Binary d. Aromantic ANS: D

The nurse will use the term aromantic to chart the patient’s lack of sexual or romantic desire.

The term fluid is used to indicate sexual desires that fluctuate between heterosexual, homosexual, and trans-sexual. Queer is a term used to describe individuals who have sexual desires outside of the usual heterosexual preferences. The term binary is used to describe a set of only two options rather than a wide range of options.

DIF: Cognitive Level: UndersN tandR(CoImpG rehe ns ioC n) M Uself-concept, S N TB .

O OBJ: Identify stressors that affect self-esteem, and sexuality.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5. The nurse is caring for a patient who no longer feels like a real woman after hysterectomy

surgery. Which nursing diagnosis is most appropriate for this patient? a. Situational low self-esteem related to negative perception of self after removal of reproductive organs b. Risk for self-directed violence related to emotional distress and hormonal fluctuations c. Anticipatory anxiety related to concerns about feelings of inadequacy during recovery from surgery d. Deficient diversional activity related to boredom from hospitalization and need for increased rest after surgery ANS: A

Situational low self-esteem is a negative perception of a person’s self-worth in response to a particular situation or event. In this case, the patient has a low self-esteem after removal of her reproductive organs. The patient does not demonstrate any risk for self-directed violence, anticipatory anxiety, or deficient diversional activity.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify stressors that affect self-concept, self-esteem, and sexuality.

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

6. The nurse is caring for a patient who feels useless after chronic illness has left the patient

unable to work. Which intervention will be most beneficial for this patient? a. Tell the patient that a fulfilling life is about more than just a career. b. Encourage the patient to participate in activities that support and help others. c. Use reminiscence therapy to help the patient remember enjoyable activities. d. Help the patient to start a daily journal to record and express emotions.

ANS: B

The patient needs to feel useful again in order to relieve feelings of uselessness. The patient can do this by participating in activities that support and help others. The patient can use skills and abilities that remain after chronic illness. Remembering enjoyable activities and recording emotions will not help the patient to feel useful. Telling the patient that a fulfilling life is about more than just a career is condescending and not helpful.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss factors that influence the following components of self-concept: identity, body image, and role performance.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 7. An elderly patient with Alzheimer’s disease tells the nurse that she will be baking cookies

with her mommy when she gets home from school later that afternoon. Which nursing diagnosis is most appropriate for this patient? a. Disturbed personal identity related to delusional description of self b. Readiness for enhanced power related to desire for freedom of choices c. Risk for loneliness related to hospitalization and separation from family d. Chronic low self-esteem related to negative feelings about self-capabilities ANS: A

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Disturbed personal identity reflects the patient’s inability to distinguish between self and non-self. The patient believes that she is a young girl rather than an elderly woman so the diagnosis of disturbed personal identity is appropriate. The patient does not demonstrate a desire for freedom of choices, risk for loneliness or negative feelings about self-capabilities.

DIF: Cognitive Level: Analyze (Analysis) 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 8. Which educational topic is the highest priority for a patient who has received a new

prescription for sildenafil? a. Condoms must be used to prevent spread of STIs even though contraception is not needed. b. The sildenafil tablet may be split into two pieces if the patient has difficulty swallowing the tablet whole. c. Sildenafil is most effective when the tablet is taken approximately 1 hour before sexual activity. d. Eating a high-fat meal before taking sildenafil may reduce effectiveness of the medication.

ANS: A

Sexual activity due to medications like sildenafil has caused an increase in sexually transmitted infections in the elderly. Condoms must be used to prevent spread of STIs even though contraception is not needed. Teaching about splitting the pill, timing of the dosage, and dietary considerations are not as important as STI prevention.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss your role in maintaining or enhancing a patient’s sexual health.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9. The patient tells the nurse that the spouse is only interested in sexual activity when inflicting

physical pain on the patient. Which is the priority nursing diagnosis for the patient? a. Activity intolerance related to inability to fulfill spouse’s sexual needs b. Ineffective sexuality pattern related to differing sexual activity expectations c. Risk for injury related to physical abuse from spouse during sexual activity d. Risk for compromised human dignity related to spouse’s demeaning actions ANS: C

The highest priority nursing diagnosis is risk for injury as the patient may be physically hurt during sexual activity. The couple should be referred to therapy only after the patient’s physical safety is ensured. Activity intolerance does not relate to the patient’s inability to fulfill spouse’s sexual needs. Ineffective sexuality pattern and risk for compromised human dignity should be addressed only after the patient’s physical safety is ensured.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Apply the nursing process to promote a patient’s self-concept and sexual health.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 10. The nurse is caring for a p a t i N e nUt R whSoI seNhGuT sbB an.dCisOiM mpotent following prostate surgery. Which

is the priority intervention of the nurse? a. Stress the importance of condom use to prevent the spread of infection. b. Encourage the patient to exercise in order to be more sexually attractive. c. Educate the patient and spouse about normal sexual anatomy and functioning. d. Present alternative options for sexual expression and mutual sexual gratification.

ANS: D

Patients who are unable to participate in sexual intercourse due to physical limitations should be encouraged to find alternative options for sexual expression and mutual sexual gratification. Condom use is not relevant as the patient’s spouse is impotent. Encouraging the patient to become more sexually attractive does not resolve the spouse’s impotence.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Apply the nursing process to promote a patient’s self-concept and sexual health.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 11. Which is the priority nursing intervention for a patient who presents to the emergency

department after a sexual assault? a. Assist the patient to take a long hot shower to relax and feel clean again. b. Discuss the possibility of pregnancy and sexually transmitted infections. c. Provide personal hygiene items such as shampoo and soap for the patient. d. Stay with the patient and contact the sexual assault response (SART) team.

ANS: D

The priority action of the nurse is to stay with the patient and contact the sexual assault response (SART) team. The SART team will perform physical examination, provide counseling, and initiate investigation into the incident. Showering or bathing will remove evidence such as hair, semen, or DNA that may be used for prosecution by law enforcement.

Providing personal hygiene products is not as important as contacting the SART team. The SART team sexual assault nurse examiner is trained to discuss the possibility of pregnancy and STI with the patient.

DIF: Cognitive Level: Apply (Application) OBJ: Apply the nursing process to promote a patient’s self-concept and sexual health.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 12. Which is the priority intervention for an elderly patient with the nursing diagnosis ineffective

sexuality pattern related to vaginal dryness? a. Help the patient to communicate the need for privacy for sexual activity. b. Encourage the patient to utilize a water-based vaginal lubricant for comfort. c. Let the patient know that vaginal dryness is a normal finding in older women. d. Instruct the patient to void immediately after intercourse to prevent irritation.

ANS: B

The patient should be encouraged to use a water-based vaginal lubricant for comfort as vaginal dryness is the cause of the sexual difficulty. Ensuring privacy and voiding after intercourse will not reduce vaginal dryness. Letting the patient know that vaginal dryness is a normal finding in older women does not help to solve the problem.

DIF: Cognitive Level: Apply (Application) OBJ: Apply the nursing process to promote a patient’s self-concept and sexual health.

NeUntR TOP: Nursing Process: Implem atS ionINGMTSB C. : C NC OLMEX: Physiological Adaptation

13. The nurse is caring for a young adult patient who frequently participates in sexual activities

after abusing alcohol. Which is the priority nursing diagnosis for this patient? a. Risk for sexually transmitted infection related to participation in unprotected sexual activity b. Risk for compromised human dignity related to exposure on social media c. Ineffective sexuality patterns related to alcohol-induced promiscuous behavior d. Impaired social interaction related to inability to maintain satisfying relationships ANS: A

Risk for sexually transmitted infection (STI) is the highest priority nursing diagnosis for this patient. Risk for compromised human dignity, ineffective sexuality patterns, and impaired social interaction are all less important than the development of a potentially fatal infection.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Apply the nursing process to promote a patient’s self-concept and sexual health.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 14. Which sexual education concept is appropriate for a 3-year-old child? a. Little boys have a penis while little girls do not. b. Sometimes white liquid comes out of the penis. c. The penis gets bigger when it is ready to make a baby. d. The penis goes into the woman’s body to make a baby.

ANS: A

The 3-year-old child is just beginning to identify with a gender and realize that boys are different from girls. The 3-year-old child will be satisfied with a simple explanation that little boys have a penis while little girls do not. The 3-year-old child is not ready to learn how the penis is used to make a baby or that white liquid sometimes comes out of the penis.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the components of self-concept as each relates to Erikson’s developmental stages.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Psychosocial Integrity 15. Which is the priority nursing diagnosis for an adolescent who is being bullied by peers? a. Powerlessness related to inability to stop bullying from peers b. Social isolation related to dysfunctional relationships with peers c. Risk for self-directed violence related to feelings of worthlessness d. Risk for loneliness related to inability to make supportive friendships ANS: C

Adolescents who are being bullied are at risk for violence toward themselves or toward others as they attempt to cope. Risk for self-directed violence is the highest priority nursing diagnosis as it can lead to significant injury or death. Powerlessness, social isolation, and risk for loneliness may be addressed once the potential for violence has been resolved.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Apply the nursing process to promote a patient’s self-concept and sexual health.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE

NURSINGTB.COM

1. The nurse is caring for a patient with the nursing diagnosis self-mutilation related to inability

to cope with ongoing sexual abuse. Which interventions will the nurse include in the patient’s plan of care? (Select all that apply.) a. Teach the patient appropriate alternative outlets for anger and pain. b. Assess and treat injuries using careful aseptic technique for wounds. c. Report the patient’s situation to the state protective services department. d. Encourage the patient to forgive and forget in order to move on with life. e. Perform a physical examination to check for sexually transmitted infection.

ANS: A, B, C, E

The patient’s injuries must be carefully treated and the patient’s situation must be reported to the appropriate state agency. A physical examination must be done to check for sexually transmitted infection. The nurse should teach the patient about appropriate alternative outlets for anger and pain instead of self-mutilation. The nurse should not encourage the patient to forgive and forget as that will not help the patient to cope with the pain of the abuse. The patient is not at a point of forgiveness if self-mutilation is needed to help cope with the pain.

DIF: Cognitive Level: Apply (Application) OBJ: Apply the nursing process to promote a patient’s self-concept and sexual health.

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

Chapter 25: Family Dynamics Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which example best demonstrates family durability? a. Four generations of family have lived at the same address. b. Two of the couple’s children were adopted because of infertility. c. The grandparents watch the children while the parents are at work. d. The mother works full time while the father stays home with the children.

ANS: C

Family durability refers to support offered by extended family such as grandparents providing child care while the parents are at work. Adoption of children, living in the same home for many years, and parental roles do not demonstrate family durability.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss common family forms and associated health implications.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 2. Which example best demonstrates family resiliency? a. The grandmother uses native healing herbs to treat illnesses. b. The family consists of two fathers and their three adopted children. c. The adult children take turns providing care for their dying mother. d. The children spend summers and weekends with their divorced father.

ANS: C

NURSINGTB.COM

Family resiliency is the ability of the family to effectively deal with stressors and challenges.

This is best demonstrated by the adult children taking turns to care for their dying mother.

Family diversity is demonstrated by a family with two fathers and their three adopted children. Shared custody arrangements and alternative medicine do not demonstrate family resiliency.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss common family forms and associated health implications.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. The nurse includes decisional conflict related to adoption versus abortion in the care plan for

a pregnant adolescent. Which is the priority outcome for the patient? a. The patient will express satisfaction with the decision once it is made. b. The patient will communicate life goals, values, and beliefs to the nurse. c. The patient will utilize support from social worker when making the decision. d. The patient will make an informed choice in accordance with beliefs and morals.

ANS: D

The appropriate outcome is that the patient will make an informed choice in accordance with beliefs and morals. The decision to abort or adopt is a difficult personal choice to be made by the teen. Communication of life goals to the nurse and utilizing support of the social worker are helpful tools for decision making. Satisfaction with the decision is not the priority outcome.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Use the nursing process to provide for the health care needs of a family.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 4. The nurse includes ineffective role performance related to inability to work following stroke to

the patient’s care plan. Which is the priority outcome for the patient? a. The patient will make a list of strengths that can be used to fulfill new role. b. The patient will demonstrate ways to fulfill responsibilities of new family role. c. The patient will identify ways to compensate for physical and mental disabilities. d. The patient will participate in support group activities to facilitate role adjustment.

ANS: B

The priority outcome for the patient is to demonstrate ways to fulfill responsibilities of new family role. The patient will not be able to continue in the role of wage earner and so must find ways to fill a new role within the family unit. Making a list of strengths, identifying ways to compensate, and participating in support group activities are all interventions rather than goals.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain how the relationship between family structure and patterns of functioning affects the health of individuals within a family and the family as a whole. TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 5. Which is the priority nursing diagnosis for a family without health insurance? a. Ineffective health maintenance related to lack of access to medical care b. Risk-prone health behavior related to nonacceptance of health status c. Readiness for enhanced immunization status related to annual flu shots d. Health-seeking behavior N CeOrgMency room for medical care reU laR teS dI toNuG seToBf . em ANS: A

Families without health insurance have difficulty obtaining routine health care as the emergency room is often the only option for medical care. Therefore ineffective health maintenance related to lack of access to medical care is the priority nursing diagnosis. There is nothing to demonstrate that the family is unable to accept health status. Readiness for enhanced immunization status is not appropriate as the family has difficulty obtaining routine health care. The use of the emergency room for medical care does not demonstrate health-seeking behaviors.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Examine current trends in the American family.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Diagnosis

6. Which is the priority nursing diagnosis for a homeless family? a. Risk for trauma related to lack of protection from crime and weather b. Caregiver role strain related to meeting needs of children without a home c. Unilateral neglect related to failure to maintain a safe home for the family d. Powerlessness related to dependence on charitable organizations for shelter ANS: A

Risk for trauma related to lack of protection from crime and weather is the highest priority nursing diagnosis for the family as their safety is in peril. Caregiver role strain and powerlessness are lower priority diagnoses. Unilateral neglect refers to unawareness of a body part following a stroke.

DIF: Cognitive Level: Apply (Application) OBJ: Examine current trends in the American family.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Diagnosis

7. Which assessment finding leads the nurse to include caregiver role strain related to

overwhelming responsibilities in the patient’s care plan? a. The patient refuses to take any of his prescribed blood pressure medications. b. The patient’s spouse switched to a part-time job to spend more time at home. c. The patient’s spouse cannot sleep and has lost 10 pounds in the last 2 months. d. The patient can feed himself using adaptive utensils and cups with large handles.

ANS: C

The spouse’s insomnia and weight loss indicate that the responsibilities of caregiving are overwhelming. Switching to a part-time position at work should reduce the spouse’s responsibilities. The patient’s need for assistance at mealtimes and refusal to take medications do not demonstrate caregiver role strain.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role of families and family members as caregivers.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 8. Which outcome is most important for the family with the nursing diagnosis interrupted family

processes related to terminalN lyUilRl fS aI thN erG ? TB.COM a. Family members will verbalize their feelings when sharing the evening meal. b. Family members will feel fulfilled when meeting the dying wishes of the father. c. Family members will cooperate to support the father’s needs during his last days. d. Family members will find spiritual meaning and peace through the dying process.

ANS: C

The most important outcome for the family is that the members will cooperate to support the father’s needs during his last days. Finding spiritual meaning and feeling fulfilled are not measurable outcomes. Verbalization of feelings at mealtimes is less important than meeting the father’s needs during his last days.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Compare and contrast nursing care that views family as context, family as patient, and family as system, and explain how these different perspectives influence nursing practice.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9. Which example demonstrates hardiness of the family unit? a. Three of the children in the family were born with fetal alcohol syndrome due to

alcohol abuse during pregnancy. b. The mother and two of her four children were born with congenital cardiac defects

that required open-heart surgery. c. The children clean the house and make dinner every night so that the mother can

care for the terminally ill father.

d. The mother has primary custody so that the children see their father every other

weekend and during the summer.

ANS: C

Family hardiness is the internal strengths and durability of the family unit through times of difficulty. Family hardiness is demonstrated by the children’s assistance with household duties so that the mother can care for the father. Congenital disease, fetal alcohol syndrome, and custody arrangements do not demonstrate family hardiness.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss common family forms and associated health implications.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 10. The nurse is caring for a terminally ill patient whose spouse and children will not

acknowledge or speak about his impending death. Which nursing diagnosis is most appropriate? a. Readiness for enhanced knowledge related to signs and symptoms of impending death b. Impaired social interaction related to communication barriers and disturbed thought processes c. Ineffective individual coping related to patient’s frustration with other family members d. Compromised family coping related to inability to accept and discuss impending death ANS: D

Compromised family coping related to inability to accept and discuss impending death is the appropriate nursing diagnosisNU as R the is . un S I NfamTGily B OCablMe to cope with the patient’s impending death. The family is not demonstrating ineffective individual coping, impaired thought processes, or readiness for enhanced knowledge.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Compare and contrast nursing care that views family as context, family as patient, and family as system, and explain how these different perspectives influence nursing practice.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 11. Which is the highest priority intervention for a family with the nursing diagnosis risk for

other-directed violence related to drug and alcohol abuse? a. Teach the family about the use of relaxation techniques to release frustration. b. Assess the family members’ ability to protect themselves from injury or harm. c. Help family members to pray for continued abstinence from drugs and alcohol. d. Use therapeutic massage and calming music to help decrease agitation and anxiety.

ANS: B

The highest priority intervention is for the nurse to assess the family members’ ability to protect themselves from injury or harm. Protection from harm must be the highest priority for care. Relaxation techniques, calming music, and prayer are less important interventions.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain how the relationship between family structure and patterns of functioning affects the health of individuals within a family and the family as a whole. TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

12. Which is the appropriate action of the nurse when the patient’s daughter offers to assist with

the morning bath? a. Accept the daughter’s offer if the patient agrees. b. Accept the daughter’s offer and encourage her to assist. c. Politely decline the daughter’s offer of assistance. d. Decline the daughter’s offer as it will not be needed.

ANS: A

The most appropriate action is to accept the daughter’s offer if the patient agrees. The offer should not be accepted or declined without input from the patient. The daughter’s assistance may make the bath more comfortable for the patient so it should not be declined outright.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role of families and family members as caregivers.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 13. The nurse is caring for a patient who will require assistance with colostomy care after

discharge. Which is the initial action of the nurse? a. Plan to teach the patient’s spouse about colostomy care during her next visit. b. Begin preparations to transfer the patient to an inpatient rehabilitation agency. c. Inform the patient that discharge is not possible until colostomy care is taught. d. Determine if a member of the patient’s family will be able to assist the patient.

ANS: D

The initial action of the nurse is to determine if a member of the patient’s family will be able to assist the patient with colostomy care. Nothing else can be done until this is assessed. An inpatient rehabilitation agencN y wR i l l nIo t bG e neBe. deCd ifMa family member can assist with care. The U S N T O patient need not be informed that discharge is not possible until colostomy care is taught as it will only increase the patient’s anxiety. The nurse should not assume that the spouse will be able to assist with colostomy care.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role of families and family members as caregivers.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 14. Every time the nurse asks the patient a question, the patient’s spouse interrupts and answers

instead. Which nursing diagnosis is most appropriate for this patient? a. Impaired social interaction related to patient’s refusal to answer questions b. Interrupted family processes related to situational crisis and patient illness c. Impaired verbal communication related to spouse’s answers to all questions d. Readiness for enhanced communication related to interpretation of nonverbal cues ANS: C

The diagnosis impaired verbal communication related to spouse’s answers to all questions is appropriate because the spouse will not allow the patient to answer. The patient is not refusing to answer questions and the nurse is not effectively interpreting nonverbal cues. There is no evidence to demonstrate interrupted family process due to the patient’s illness.

DIF: Cognitive Level: Apply (Application) OBJ: Use the nursing process to provide for the health care needs of a family.

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

15. Which is an example of a blended family? a. Three generations of family live together under the same roof. b. A divorced couple share custody of their three small children. c. Grandparents babysit the children while the parents are at work. d. A widower with two children marries a widow with three children.

ANS: D

A blended family is formed when unrelated children are brought into the family through marriage, foster care, or adoption. An example of a blended family is a widower with two children who marries a widow with three children. Three generations of family living together under the same roof is an example of extended family. Shared custody and grandparents as babysitters do not demonstrate a blended family.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Examine current trends in the American family.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 16. Which is an example of a skip generation family? a. A military family moves frequently from state to state due to deployments. b. A couple provides foster care for infants while their mothers are incarcerated. c. A divorced mother moves far away from the child’s father to prevent visitation. d. Grandparents raise the grandchildren after their parents are jailed for drug abuse.

ANS: D

A skip generation occurs when grandparents raise the grandchildren, skipping the parental generation. Relocation, foster care, and prevention of visitation do not demonstrate a skip generation.

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DIF: Cognitive Level: Understand (Comprehension) OBJ: Examine current trends in the American family.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 17. Which nursing diagnosis is most appropriate for an adult patient who is raising young children

while caring for elderly parents? a. Risk for unilateral neglect related to inability to care for both generations b. Ineffective protection related to inability to constantly supervise elderly parents c. Risk for caregiver role strain related to responsibilities for parents and children d. Readiness for enhanced parenting related to realistic expectations of development ANS: C

The patient is at risk for caregiver role strain related to responsibilities for parents and children. Unilateral neglect occurs after a stroke when the patient is unaware of a paralyzed body part. Ineffective protection does not relate to constant supervision. Readiness for enhanced parenting is less appropriate for this situation as the parent is struggling to meet the needs of both children and aging parents.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role of families and family members as caregivers.

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

MULTIPLE RESPONSE 1. Which interventions are appropriate for the nursing diagnosis risk for caregiver role strain

related to inadequate support for caregiver? (Select all that apply.) a. Monitor the caregiver for signs of physical and/or emotional fatigue. b. Observe both the patient and caregiver for any signs of neglect or abuse. c. Encourage placement of the patient in a residential skilled nursing facility. d. Help the caregiver to schedule time to meet needs for rest and personal care. e. Identify resources for the caregiver in the family, church, and local community.

ANS: A, B, D, E

The nurse should help the caregiver to identify resources for support to reduce role strain.

Scheduling time for the caregiver to meet personal needs will maintain the caregiver’s physical and emotional health. The nurse should monitor the caregiver for signs of physical and/or emotional fatigue so that additional support can be provided. The nurse should observe both the patient and caregiver for any signs of neglect or abuse so that intervention can be initiated immediately. The strains of caregiving can lead to abuse, especially when constant care is required. The nurse should not encourage placement of the patient in a residential skilled nursing facility unless the caregiver is unable to meet the needs of the patient and no other options are available.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Use the nursing process to provide for the health care needs of a family.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 2. Which family members are considered to be part of the nuclear family? (Select all that apply.) a. Mother and father NURSINGTB.COM b. Grandparents c. Adopted children d. Aunts and uncles e. Nieces and nephews ANS: A, C

The nuclear family consists of parents and their children. Grandparents, aunts and uncles, nieces and nephews are all part of the extended family.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Examine current trends in the American family.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. Which questions should the nurse ask to assess family patterns? (Select all that apply.) a. “How does your family cope?” b. “How does your family make day-to-day decisions?” c. “Which family members work outside the home?” d. “Does your family have any goals for childrearing?” e. “How does your family divide household cleaning chores?”

ANS: B, C, E

How the family makes day-to-day decisions, which family members work outside the home, and how cleaning chores are divided indicate family patterns. Coping of the family refers to family resources, not family patterns. Short- and long-term goals refer to family function, not family patterns.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Use the nursing process to provide for the health care needs of a family.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 4. Which assessments are appropriate when caring for a stroke patient living with a spouse and

two children using the family as context? (Select all that apply.) a. Assess the stroke patient for self-care abilities. b. Assess the ability of the spouse and two children to help feed and bathe the patient. c. Assess communication processes among family members. d. Assess the spouse’s ability to emotionally comfort the patient. e. Assess how the spouse is dealing with parenting issues of the two children.

ANS: A, B, D

When you view the family as context, your primary focus is on the health and development of an individual member existing within a specific family environment. Although you focus the nursing process on an individual, you also assess the extent to which a family helps the individual meet basic needs. You also need to consider a family caregiver’s ability to help a patient meet psychological needs as well. Assessing communication processes among family members and assessing how the spouse is dealing with parenting issues is caring for the family as patient, not family as context.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Compare and contrast nursing care that views family as context, family as patient, and family as system, and explain how these different perspectives influence nursing practice.

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

NURSINGTB.COM

Chapter 26: Stress and Coping Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which assessment finding is expected for a patient who was just chased by an attacker? a. Blood sugar 45 mg/dL b. Blood pressure 180/94 c. Pulse rate 55 beats/minute d. Hyperactive bowel sounds 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the three stages of the general adaptation syndrome.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. The young child cries and tries to run away when after being told that a flu shot is to be

administered. Which term best describes the psychological reaction of the child? a. Primary appraisal b. Ineffective denial c. Adventitious crisis NURSINGTB.COM d. Developmental crisis 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. Ineffective denial is not indicated as the child realized the injection would be administered shortly and became upset. An adventitious crisis is a major disaster such as an earthquake or fire. A developmental crisis is when new coping strategies are needed to deal with stages of maturation such as getting married or having a child.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the three stages of the general adaptation syndrome.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. The patient is severely injured in an accident but does not feel the pain until several hours

afterward. Which type of hormone reduced the patient’s sense of pain as part of the stress response? a. Endorphins b. Mineralocorticoids c. Prostaglandins d. Bradykinins ANS: A

Endorphins are hormones that interact with the opiate receptors in the brain to reduce the perception of pain and produce a sense of well-being. Mineralocorticoids control salt and water balance within the body. Prostaglandins cause vasodilation and inhibit platelet function.

Bradykinins play a role in inflammation causing vasodilation and pain.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the three stages of the general adaptation syndrome.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 4. Which hormone is the most important factor for the physiological response to stress? a. Cortisol b. Glucagon c. Histamine d. Vasopressin ANS: A

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 brain’s 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. Glucagon raises blood sugar levels.

Histamine causes allergic reactions.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the three stages of the general adaptation syndrome.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 5. The new mother exp eri en ces Ni nUs oRmSnIi aN , iG rrT itaBb. iliC tyO ,M a n d lack of appetite after several weeks in

the neonatal care unit with her critically ill infant. Which stage of the general adaptation syndrome (GAS) is the new mother experiencing? a. Alarm b. Resistance c. Adaptation d. Exhaustion ANS: D

If the stressor remains and adaptation does not happen, the person enters the third stage of the GAS, 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.

During the alarm reaction, rising hormone levels result in increased blood volume, blood glucose levels, heart rate, blood flow to muscles, and mental alertness. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the three stages of the general adaptation syndrome.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 6. The new mother experiences insomnia, irritability, and lack of appetite after several weeks in

the neonatal care unit with her critically ill infant. Which nursing diagnosis is most appropriate for the new mother?

a. b. c. d.

Stress overload related to ongoing stress and worry about her critically ill infant Chronic low self-esteem related to lack of success at beginning of motherhood Disturbed sensory perception related to change in problem-solving abilities Disturbed personal identity related to inability to distinguish day shift from night

ANS: A

Stress overload related to ongoing stress and worry about her critically ill infant is the appropriate nursing diagnosis for the new mother. The new mother is at the exhaustion stage of the GAS due to the excessive demands of caring for her critically ill infant. The new mother does not demonstrate chronic low self-esteem, disturbed sensory perceptions, or disturbed personal identity.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Develop a care plan for a patient experiencing stress.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Diagnosis

7. The nurse manager is overwhelmed as the unit prepares for an accreditation inspection. Which

type of factor is causing the stress for the nurse manager? a. Situational b. Maturational c. Sociocultural d. Conventional 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 andNst U afRf.SCIN o p iT atC egieM s vary with the individual and the Gn g sBtrO . situation. Maturational factors involve stressors and coping strategies that vary with life stage.

Sociocultural factors include prolonged poverty, physical handicap, and chronic illness.

Conventional factors are not a cause of stress.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss how stress in the workplace affects nurses.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Diagnosis

8. Which situation demonstrates an allostatic stress load? a. The nursing student uses meditation to cope with mild test anxiety. b. The patient develops anaphylactic shock after being stung by a bee. c. The nurse develops hypertension after working too many double shifts. d. The patient’s heart rate returns to normal after a painful procedure is completed.

ANS: C

An allostatic load is the negative physiological effect of long-term extreme stress on the body.

An allostatic load is demonstrated by the nurse’s development of hypertension after working too many double shifts. Mild test anxiety, recovery after a stressful experience, and anaphylactic shock are not examples of allostatic stress.

DIF: Cognitive Level: Apply (Application) OBJ: Identify how stress and coping relate to health.

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

9. The patient is frustrated after being treated poorly by providers due to lack of health

insurance. Which type of factor is causing the stress for the patient? a. Rational b. Situational c. Maturational d. Sociocultural ANS: D

Sociocultural factors include prolonged poverty, physical handicap, and chronic illness.

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. Rational factors are not a cause of stress.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the integration of stress theory with nursing theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 10. Which position is best suited for a nurse who preferred to study until the early hours of the

morning during nursing school? 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 nuN rse R w h oIt y pGi c a lBl y.t C U S N T Oh i n kMs 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss how stress in the workplace affects nurses.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 11. The patient is overwhelmed by the stresses of being a spouse, new parent, and full-time

employee. The nurse encourages the patient to use a housekeeper, babysitter, friends, or relatives to help reduce personal responsibilities and obligations. Which stress-relieving technique was recommended for the patient? a. Assertiveness training b. Engaging support systems c. Mindfulness stress reduction d. Progressive muscle relaxation ANS: B

The nurse encourages engagement of support systems to relieve the patient’s overwhelming duties. The patient will be better able to cope if a support system can assist with some of the patient’s personal responsibilities and obligations. 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. Mindfulness stress reduction is a form of meditation to reduce symptoms of stress.

DIF: Cognitive Level: Apply (Application) OBJ: Develop a care plan for a patient experiencing stress.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 12. The patient’s spouse is overwhelmed and exhausted trying to provide the ongoing care

required by the patient. Which nursing diagnosis is most appropriate for the patient’s spouse? a. Activity intolerance related to fatigue and generalized weakness b. Readiness for enhanced comfort related to change in personal health status c. Caregiver role strain related to amount and complexity of patient health needs d. Risk for compromised human dignity related to loss of control of bodily functions ANS: C

The patient’s spouse is demonstrating caregiver role strain by feeling overwhelmed and exhausted trying to meet the patient’s needs. The patient’s spouse is not experiencing activity intolerance and is not at risk for compromised human dignity. The patient’s spouse is exhausted and overwhelmed so readiness for enhanced comfort is not appropriate.

DIF: Cognitive Level: AnalyzN eU (ARnS a lyIsN i s)GTB.COM OBJ: Develop a care plan for a patient experiencing stress.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Diagnosis

13. Which intervention is appropriate for the nurse to reduce compassion fatigue? a. Increase nursing responsibilities at work. b. Hang out with co-workers when not at work. c. Strengthen relationships outside of the hospital. d. Take control over new areas at work to reduce stress.

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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss how stress in the workplace affects nurses.

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. Define the problem at hand and ensure that the patient is safe. b. Take control of the situation and tell the patient what needs to be done. 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: A

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.

DIF: Cognitive Level: Apply (Application) OBJ: Develop a care plan for a patient experiencing stress.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 15. The patient refuses to believe the physician’s diagnosis and insists on a second opinion from a

specialist. Which ego-defense mechanism is used by the patient? a. Denial b. Dissociation c. Deterioration d. Displacement ANS: A

NURSINGTB.COM

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. Dissociation is experiencing a subjective sense of numbing and a reduced awareness of one’s surroundings. Deterioration is the worsening of a situation or patient condition.

DIF: Cognitive Level: Apply (Application) OBJ: Identify stress-management techniques used in coping with stress.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 16. The patient develops an inability to swallow after many years of emotional abuse. The

physicians can find no medical reason for the patient’s dysphagia. Which ego-defense mechanism is used by the patient? a. Displacement b. Dissociation c. Compensation d. Conversion ANS: D

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. Dissociation is experiencing a subjective sense of numbing and a reduced awareness of one’s surroundings. Displacement is the practice of taking out stressful feelings on someone or something else than the cause.

DIF: Cognitive Level: Apply (Application) OBJ: Identify stress-management techniques used in coping with stress.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 17. A young child begins wetting the bed again after the parents bring home a new baby sister.

Which ego-defense mechanism is used by the child? a. Regression b. Conversion c. Identification d. Compensation ANS: A

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). Identification is the adoption of another person’s behaviors or mannerisms.

DIF: Cognitive Level: Apply (Application) OBJ: Identify stress-managemN enUt R tecShI niN quG esTuB se. dC i nOc oMp i n g with stress.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 18. The patient concentrates on the mind-numbing details of the spouse’s funeral to delay dealing

with the overwhelming pain of the loss. Which ego-defense mechanism is used by the patient? a. Conversion b. Dissociation c. Compensation d. Reimbursement ANS: B

Dissociation is experiencing a subjective sense of numbing and a reduced awareness of one’s surroundings. The patient is demonstrating dissociation by immersion in the mind-numbing details of funeral planning. 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. Reimbursement is not an ego-defense mechanism.

DIF: Cognitive Level: Apply (Application) OBJ: Identify stress-management techniques used in coping with stress.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE

1. The nurse is caring for a patient who has just been diagnosed with amyotrophic lateral

sclerosis (ALS). Which assessment findings justify the diagnosis of ineffective denial related to fear of loss of body function and death for the patient? (Select all that apply.) a. The patient attempts to hide shortness of breath from the nurse. b. The patient has fallen twice after insisting that a walker is not needed. c. The patient uses a gastrostomy tube for nutrition when unable to swallow. d. The patient attends support group meetings for families and patients with ALS. e. The patient insists that an uneven sidewalk caused a fall rather than leg weakness.

ANS: A, B, E

Ineffective denial occurs when the patient continues to deny the presence of an illness to the point where the patient’s health is endangered. The patient demonstrates ineffective denial by trying to hide shortness of breath, refusing to use a walker, and insisting an uneven sidewalk caused a fall. Use of the gastrostomy tube and attendance at support group meetings do not demonstrate ineffective denial.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify how stress and coping relate to health.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 2. Which interventions are appropriate to assist the patient who is exhausted and depressed from

providing care to the spouse with advanced dementia? (Select all that apply.) a. Assist the patient to identify and utilize support systems. b. Teach the patient how to maintain a sleep and activity log. c. Arrange for intervals of respite care for the patient’s spouse. d. Help the patient to find personal time to rest and recuperate.

N nced R I B.CaOMnd living will options. e. Educate the patient about aU dvaS NdirGTective ANS: A, C, D

The nurse should assist the patient to identify and utilize support systems for assistance with caring for the spouse. This will reduce feelings of abandonment and loneliness when caring for the spouse. Helping the patient to find personal time to rest and recuperate will allow self-care and increase patient coping skills. Arranging for intervals of respite care for the spouse will provide breaks from the constant caregiving duties of the patient. Maintaining a sleep/activity log and learning about advanced directives will not reduce caregiver role strain.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Develop a care plan for a patient experiencing stress.

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

Chapter 27: Loss and Grief Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The patient grieves the security of a solid supportive marriage after the spouse has an affair.

Which type of loss was experienced by the patient? a. Actual b. Perceived c. Situational d. Maturational ANS: B

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 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss five categories oN f loR ss. I GT OB P :.C N u r sMi n g Process: Assessment O MSC: NCLEX: Psychosocial Int U e gritS yN T 2. The patient leaves behind nightly dinners with the family, babysitting assistance from friends,

and the warmth of the local church community when moving across the country. Which type of loss was experienced by the patient? a. Conditional b. Perceived c. Situational d. Maturational ANS: C

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. 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. There is no such thing as a conditional loss.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss five categories of loss.

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

3. The patient concentrates on the mind-numbing details of the spouse’s funeral to delay dealing

with the overwhelming pain of the loss. Which stage of grief is currently being experienced by the patient? a. Anger b. Denial c. Bargaining d. Acceptance e. Depression ANS: B

Individuals in the denial stage cannot believe or understand that a loss has occurred and shut down their feelings until they are able to process the grief a little at a time. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 4. Which action demonstrates that the patient is experiencing the disorganization and despair

stage of mourning? a. The patient puts the parent’s estate and financial matters in order.

N R GeTks B.C Mthe loss of the parent. b. The patient cannot eat or s lU eep SfoI r Nwe afterO c. The patient sues the hospital for malpractice for not saving the parent’s life. d. The patient falls sobbing to the floor when learning that the parent just died.

ANS: C

Expressing anger at the hospital for not saving the parent’s life is an example of the disorganization and despair stage. Expressions of anger and hostility at an individual or institution responsible for the loss are seen with the disorganization and despair stage. The person may also take long periods to reflect on how and why the loss occurred. Falling sobbing to the floor and inability to eat or sleep demonstrate the yearning and searching stage.

Putting the parent’s financial estate in order demonstrates completion of a necessary monetary task after death.

DIF: Cognitive Level: Apply (Application) OBJ: Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5. Which action demonstrates that the patient is experiencing the reorganization stage of

mourning after having a stillborn baby? a. The patient volunteers at a local infant loss support group. b. The patient sits for hours and hours just looking at the empty crib. c. The patient has panic attack with shortness of breath and chest pain. d. The patient turns to alcohol to numb the overwhelming pain of the loss.

ANS: A

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.

DIF: Cognitive Level: Apply (Application) OBJ: Review grief and loss theories.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 6. Which nursing diagnosis is most appropriate for a patient who is having difficulty with

accepting the reality of a lung cancer diagnosis by attempting to hide periods of shortness of breath from the nurse? a. Ineffective denial related to threat of unpleasant reality of lung cancer b. Noncompliance related to failure to adhere to prescribed treatment plan c. Effective therapeutic regimen management related to illness symptom reduction d. Readiness for enhanced decision making related to realignment of personal values ANS: A

The patient is experiencing ineffective denial related to threat of unpleasant reality of lung cancer by hiding episodes of shortness of breath. The patient is not displaying noncompliance with the treatment plan, effec tive the rap euti c regimen management, or readiness for enhanced N R I G B .C M decision making.

U S N T O DIF: Cognitive Level: Analyze (Analysis) OBJ: Develop a care plan for a patient, family caregivers, and family members experiencing loss and grief. TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 7. Which nursing diagnosis is most appropriate for a patient whose friends and family have

grown distant after the death of the patient’s spouse? a. Impaired verbal communication related to alteration in sensory perception b. Risk for loneliness related to insufficient interactions with friends and family c. Health-seeking behavior related to desire for increased control of personal health d. Readiness for enhanced spiritual well-being related to expressed desire for prayer ANS: B

The patient is at risk for loneliness because the patient’s friends and family have grown distant after the death of the patient’s spouse. The patient does not demonstrate any sensory perception, desire for increased control, or expressed desire for prayer based on the information presented.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss variables that influence a person’s response to grief.

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

8. Which action by the patient demonstrates reminiscence of a lost parent? a. The patient obtains a copy of the parent’s will and inventories all assets. b. The patient returns to school to start a new career in business administration. c. The patient sues the hospital for malpractice after reviewing the medical record. d. The patient creates a scrapbook to remember special times spent with the parent.

ANS: D

The patient demonstrates reminiscence by taking the time to remember the lost loved one through creation of a scrapbook. Suing the hospital for malpractice does not remember individual characteristics of the loved one or shared experiences. Returning to school indicates that the patient has reached the acceptance stage of grief and is moving on to new activities.

Obtaining the will and completing inventory of assets demonstrates completion of necessary monetary tasks after death.

DIF: Cognitive Level: Apply (Application) OBJ: Identify nursing interventions for helping patients cope with loss, death, and grief.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 9. The patient is the caregiver to the spouse with advanced dementia. The patient mourns the

loss of the spouse’s mind and personality even though the body is still physically functioning.

Which type of grief is being experienced by the patient? a. Normal b. Anticipatory c. Complicated d. Disenfranchised ANS: B

Anticipatory grief is the p ai nNfel tU he B ph.yO Rb efSIore Cs i caMl death of the loved one occurs. Normal or N GtT 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 person’s loss as insignificant or invalid.

DIF: Cognitive Level: Apply (Application) OBJ: Compare and contrast types of grief.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 10. Which behavior supports inclusion of the nursing diagnosis complicated grieving related to

sudden death of a sibling in the patient’s care plan? a. The patient donates the sibling’s clothes to a local charity. b. The patient withdraws from relationships with friends and family. c. The patient adopts the sibling’s dog and arranges for veterinary care. d. The patient arranges for the gravestone to be placed at the sibling’s burial site.

ANS: B

Withdrawing from relationships with friends and family is an unhealthy coping behavior and demonstrates complicated grieving. Adopting the dog, arranging for a gravestone, and donating clothes are all tasks to be completed after a death and indicate normal grieving.

DIF:

Cognitive Level: Apply (Application)

OBJ: Identify assessment parameters in a patient experiencing loss and grief.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 11. The female patient grieves the loss of her child to adoption and finds it difficult to cope

because the pregnancy was kept a secret from the family and community. Which type of grief is being experienced by the patient? a. Delayed b. Complicated c. Anticipatory d. Disenfranchised ANS: D

Disenfranchised grief occurs in situations in which others view a person’s loss as insignificant or invalid or when the patient’s friends and family are unaware of the loss. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Compare and contrast types of grief.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 12. The chart lists the patient’s daughter as having medical durable power of attorney for the

patient. How does this impact the patient’s care? a. The daughter is an attornN eyUaR ndSpIlaNnG sT toBsu.eCtoOtM he nursing staff and hospital for malpractice after the patient’s death. b. The daughter can provide consent for medical procedures if the patient becomes unresponsive or disoriented. c. The patient’s daughter must be consulted before asking the patient to consent to medical procedures. d. The patient’s daughter will translate medical terminology used by health care providers when communicating with the patient.

ANS: B

Medical durable power of attorney allows the patient’s daughter to make medical decisions for the patient in the event that the patient is unable to do so. Medical durable power of attorney does not indicate a plan to sue for malpractice or require consultation before obtaining consent for procedures. Medical translation is not part of medical durable power of attorney.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss the role of the nurse when caring for patients at the end of life.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 13. Which attitude of the nurse will facilitate effective care for hospice patients? a. The patient needs the nurse’s presence and personal connection. b. Remaining silent signifies a noncaring attitude toward the patient. c. Reminiscing with the patient only makes a difficult situation worse.

d. The patient does not recognize the impact of the loss if no tears are shed.

ANS: A

Patients need the presence and personal connection of the nurse as they progress through the dying process. 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss the role of the nurse when caring for patients at the end of life.

TOP: Nursing Process: Caring MSC: NCLEX: Psychosocial Integrity 14. Which treatment would be refused by a patient who has requested palliative care? a. Therapeutic touch b. Supplemental oxygen c. Narcotic pain medications 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. Knee-replacement surgery would not be appropriate for an end-of-life patient.

DIF: Cognitive Level: Apply N (ApR tionG U p lica SandIN T) B.C OM OBJ: Discuss principles of palliative hospice care.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Caring

15. Which assistance is provided to the patient and family by the hospice care providers? a. Education about resuscitation techniques if the patient stops breathing b. Options for ending the patient’s life when the pain becomes too severe c. Financial support for funeral and burial services after the patient’s death d. Volunteers to stay with the patient to give the family a break from caregiving ANS: D

Hospice care provides supportive services for patients who are at the end of life. This includes volunteers who can provide respite care to give the family a break from caregiving. Hospice care does not provide financial support for burial, assistance for ending the patient’s life, or education about resuscitation.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss principles of palliative and hospice care.

MSC: NCLEX: Psychosocial Integrity

TOP: Integrated Process: Caring

16. Which of the following is true for a patient to receive home hospice care? a. Caregiver support is available during normal business hours. b. A primary caregiver must be living in the home with the patient. 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: B

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, but does not provide actual patient care.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss principles of palliative and hospice care.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Caring

17. Which intervention is appropriate for the nursing diagnosis hopelessness related to disease

progression? a. Withhold negative information about the patient’s disease processes. b. Help the patient set realistic goals and then help the patient achieve them. c. Impress on the family the importance of limiting visiting hours to provide rest. d. Assure the patient that he will be well cared for and does not need to do anything.

ANS: B

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 people 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 patient’s perceptions.

DIF: Cognitive Level: Apply N (ApR plicaItionG ) B.C M U S N T O cope with loss, death, and grief.

OBJ: Identify nursing interventions for helping patients TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 18. The nurse is caring for a patient who generally copes well after losing a child many years ago

but becomes despondent each year on the anniversary of the death. Which is the best statement by the nurse? 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. “What happens to you is understandable and common in people who have lost loved ones.” c. “I 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 psychological 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss variables that influence a person’s response to grief.

TOP: Integrated Process: Caring

MSC: NCLEX: Psychosocial Integrity

19. The patient is on a ventilator and has a heartbeat, but is brain dead. What should the nurse do? a. Explain that as long as the heart is beating, the patient is still alive. b. Provide a private area for the family to discuss organ donation options. 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: B

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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the role of the nurse when caring for patients at the end of life.

TOP: Nursing Process: Caring MSC: NCLEX: Physiological Integrity 20. A nurse is caring for a patient who is depressed because her children have gone away to

college. Which type of loss is experienced by the patient? a. Perceived b. Situational c. Conditional d. Maturational ANS: D

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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. 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. There is no such thing as a conditional loss.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss five categories of loss.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 21. The nurse is caring for a patient who has just passed away. Which is the priority action of the

nurse? a. Ask the family to leave the room so that postmortem care can be provided. b. Have the patient’s family members sign consent forms for organ donation. c. Remove all drainage tubes and IV lines in case an autopsy is to be performed. d. Provide postmortem care in a manner consistent with religious or cultural beliefs.

ANS: D

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 patient’s religious or cultural beliefs. 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 patient’s body, except in the case of autopsy. In that case all medical devices should be left in place.

DIF: Cognitive Level: Apply (Application) OBJ: List the steps in caring for a body after death.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Which behaviors support inclusion of the nursing diagnosis compromised family coping

related to loss of home in a fire in the care plan? (Select all that apply.) a. The children missed school and the parents missed work during the first few days after the fire. b. All of the family members were able to stay at the home of a neighbor for the first week after the fire. c. The parents have not been able to speak to each other without screaming in anger for the last 2 weeks. d. The children still have occasional nightmares about the fire and the damage to the family home. e. The parents are so preoccupied with insurance frustration that they have not noticed that the oldest ch i l d is fa iling sch o ol .

ANS: C, E

N URSIN GT B. C OM

Inability to speak to each other without screaming and not noticing the needs of other family members demonstrate the appropriateness of compromised family coping as a nursing diagnosis. It is expected that the family members would miss work and school for the first few days after the fire. The family is fortunate that they were able to stay with a neighbor.

Occasional nightmares are to be expected following a house fire and do not demonstrate compromised family coping skills.

DIF: Cognitive Level: Apply (Application) OBJ: Identify assessment parameters in a patient experiencing loss and grief.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 2. Which assessment findings lead the nurse to inform the family that the patient’s death is

imminent? (Select all that apply.) a. The patient’s pupils are fixed and dilated bilaterally. b. The patient is lethargic, drifting in and out of consciousness. c. The patient’s breathing is harsh and congested with periods of apnea. d. The patient had only 40 mL in the urinary catheter bag for the last 8 hours. e. The patient’s temperature is 102.6° F (39.2° C) but the hands and feet are cool and mottled.

ANS: B, C, D, E

Lethargy, harsh breathing, low urine output, fever, and mottled skin are all signs of imminent death. Fixed, dilated pupils indicate that death has already occurred.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify ways to educate and involve family caregivers in providing palliative care.

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

NURSINGTB.COM

Chapter 28: Exercise and Activity Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. How does the nurse maintain a low center of gravity while transferring the patient from the

bed to the chair? a. The nurse ties the gait belt loosely around the patient’s waist. b. The nurse stands with the knees slightly bent and legs spread apart. c. The nurse bends at the waist when setting the patient’s feet on the floor. d. The nurse leans backward slightly when helping the patient to stand.

ANS: B

The nurse maintains a low center of gravity by bending the knees and standing with the legs apart. This will help maintain a stable base of support. The gait belt should be tied securely around the patient’s waist. The nurse should bend the knees to set the patient’s feet on the floor. The nurse should not lean backward when helping the patient to stand as it will increase the risk of fall or injury.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the role of the musculoskeletal and nervous systems in the regulation of activity and exercise.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 2. Which instruction directs the patient to perform an isometric exercise? a. “Use the trapeze to lift your upper body off the bed.” b. “Tighten and hold your sN toU mR acS hI mN uG scT leB s f. oC r 1O5Mseconds.” c. “Close your fists and squeeze them tightly, release and repeat.” d. “Lift your buttocks off the bed by pushing against the mattress.”

ANS: B

Isometric exercise involves tightening or tensing muscles without moving body parts.

Tightening and holding abdominal muscles is an example of isometric exercise. Isotonic exercises cause muscle contraction and shortening of muscle length. Isotonic exercises include lifting the body off the bed, closing fists, and lifting the buttocks off the mattress.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the role of the musculoskeletal and nervous systems in the regulation of activity and exercise.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. The nurse is caring for a patient with a traumatic injury to the cerebellum. Which assessment

finding will be expected as a result? a. The patient sways from side to side when walking. b. The patient’s ligaments are weak and easily ruptured. c. The patient has fine tremors with purposeful movement. d. The patient’s joints are reddened, swollen, and warm to touch.

ANS: A

Essentials for Nursing Practice 9th Edition Potter Test Bank The cerebellum works to control balance through the nervous system. Damage to the cerebellum will impair the patient’s balance and a swaying movement when walking may be seen. Damage to the cerebellum infection will not cause weak ligaments, red joints, or fine tremors.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the role of the musculoskeletal and nervous systems in the regulation of activity and exercise.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 4. What is the priority nursing diagnosis for a patient with osteoporosis? a. Risk for injury (fracture) related to fragile bone tissue b. Activity intolerance related to pain and joint stiffness c. Impaired tissue integrity related to red, swollen, painful joints d. Fatigue related to chronic inflammatory destruction of tissues ANS: A

Osteoporosis is a reduction of bone density due to insufficient calcium and vitamin D. Patients with osteoporosis can suffer bone fractures as a result of even minor injury so prevention of injury and fracture is the highest priority diagnosis. Osteoporosis is not due to inflammation and does not cause red, swollen joints or joint stiffness.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 5. Which assessment finding is expected for a patient who suffered a left-sided thrombotic

stroke?

NURSINGTB.COM a. Bilateral footdrop b. Fine tremors of the hands c. Curvature of the lumbar spine d. Weakness of the right arm and leg ANS: D

A patient who has suffered a left-sided thrombotic stroke would have weakness of the right arm and leg. A left-sided thrombotic stroke would not be expected to cause curvature of the lumbar spine, fine hand tremors, or bilateral footdrop.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the role of the musculoskeletal and nervous systems in the regulation of activity and exercise.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 6. The nurse is caring for a patient with right-sided hemiplegia after a stroke. Which is the

appropriate goal for the diagnosis impaired transfer ability related to insufficient muscle strength? a. The patient will safely transfer from bed to chair with the assistance of one person. b. The patient will verbalize feelings about physical limitations due to immobility. c. The nurse will reposition the patient every 2 hours and pad bony prominences. d. The nurse will utilize a gait belt around the patient’s low back for all transfers.

ANS: A

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Essentials for Nursing Practice 9th Edition Potter Test Bank An appropriate goal for the diagnosis impaired transfer ability related to insufficient muscle strength is that the patient will safely transfer from bed to chair with the assistance of one person. Verbalization of feelings about immobility is not an appropriate goal for the diagnosis of impaired transfer ability. Goals are achieved by the patient rather than the nurse.

Repositioning the patient and utilizing a gait belt are examples of interventions.

DIF: Cognitive Level: Apply (Application) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Planning MSC: NCLEX: Basic Care and Comfort 7. The nurse is caring for a patient with arthritis who wants to exercise but finds it difficult due

to joint pain and stiffness. Which nursing diagnosis is appropriate for this patient? a. Activity intolerance related to exertional discomfort b. Noncompliance related to lack of motivation to exercise c. Unilateral neglect related to health beliefs about chronic illness d. Powerlessness related to expressions of uncertainty about benefits of exercise ANS: A

Activity intolerance is the appropriate nursing diagnosis for this patient as joint pain and stiffness is preventing the patient from participating in exercises as desired. The patient desires to exercise so noncompliance related to lack of motivation is not appropriate.

Unilateral neglect is a lack of attention to a body part after stroke. The patient has not expressed any uncertainty about the benefits of exercise so powerlessness is not a suitable diagnosis either.

DIF: Cognitive Level: Apply (Application) OBJ: Formulate nursing diagnoses for patients experiencing alterations with activity and exercise.

TOP: Nursing Process: D i a g n oNs iU s RSINGMTSB C. : C NC OLMEX: Health Promotion and Maintenance

8. Which is the priority intervention for a patient with the nursing diagnosis of impaired physical

mobility related to muscle weakness and neuromuscular impairment? a. Allow the patient to decide when and how far to ambulate each day. b. Utilize a walker, gait belt, and two nursing staff members for ambulation. c. Suggest a variety of physical activities to encourage patient engagement. d. Encourage the patient to use positive self-talk to gradually increase strength.

ANS: B

The highest priority for impaired physical mobility is the prevention of injury or falls. In this case, the patient should be ambulated with a walker, gait belt, and two staff members.

Allowing the patient to decide when and how far to ambulate, suggesting various activities, and encouraging positive self-talk are not as important as preventing injury.

DIF: Cognitive Level: Apply (Application) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. Which is an appropriate goal for a patient with the nursing diagnosis of sedentary lifestyle

related to generalized weakness and fatigue? a. The patient will identify barriers that limit social interactions. b. The patient will increase physical activity to 3500 steps daily. c. The patient will use a pain rating scale to identify levels of discomfort.

NURSINGTB.COM

Essentials for Nursing Practice 9th Edition Potter Test Bank d. The patient will verbalize the risks of continuing noncompliance with treatment.

ANS: B

Increased physical activity is the goal for the nursing diagnosis of sedentary lifestyle, such as gradually increasing the number of steps taken daily. Increasing social interactions and rating pain do not address the need for increased physical activity. Nothing in the scenario indicates that the patient is noncompliant with the treatment regimen.

DIF: Cognitive Level: Apply (Application) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 10. Which exercises are appropriate for a quadriplegic patient? 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 weight-bearing exercises are incorrect responses for this patient.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

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

N R I G B.C M

11. Which action by the nurse demU onsS trateNs coTrrect uO se of a gait belt? a. The patient holds on to the gait belt during transfer to the chair. b. The gait belt is used to lift the patient whose legs are too weak to stand. c. The gait belt is tied loosely around the patient’s waist just above the hips. d. The nurse follows behind the patient holding onto the gait belt during ambulation.

ANS: D

The gait belt should be tied securely around the patient’s waist just above the hips. It should not be used to lift a patient who is unable to stand independently. The nurse holds on to the back of the gait belt when following the patient during ambulation. This will help the nurse ease the patient gently to the floor if the patient falls or loses consciousness.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 12. Which action demonstrates correct use of a cane by a patient following a left leg injury? a. The patient holds the cane securely in the left hand. b. The patient uses the cane when stepping forward with the right leg. c. The patient’s left leg and cane move forward together when walking. d. The patient leans slightly to the left when advancing the cane forward.

ANS: C

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Essentials for Nursing Practice 9th Edition Potter Test Bank The cane should be held securely in the right hand following a left leg injury. The patient’s left leg and cane move forward together with each step when walking. The patient should lean slightly to the right into the cane if needed when advancing the cane forward.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 13. Which action demonstrates correct use of crutches by a patient following a left leg injury? a. The handgrips are set so that the axillae fully support the patient’s body weight. b. The patient looks down at the floor when taking each step with the crutches. c. The patient moves the crutches approximately 12 inches forward with each step. d. The patient’s elbows are flexed at a 45-degree angle when holding the handgrips.

ANS: C

The crutches should be moved forward approximately 12 inches with each step to allow for a steady gait. The patient’s axillae should not bear the weight of the body as nerve damage can result. The grips should be set so that the weight of the body is borne by the hands. The patient should look forward when walking with crutches. The elbows should be flexed at a 20to 25-degree angle when holding the handgrips.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 14. Which is the safest method for a patient with a left leg injury to navigate up a set of stairs? a. Sit down on the stairs and use the right leg to lift the body up each step. b. Use a gait belt, the left haN nU drR aiS l, I anNdGaT crB u. tchCuOnM der the right arm. c. Securely place both crutches on the next step and swing the body upward. d. Bend the knee of the right leg when lifting the left leg up to the next step.

ANS: A

The safest method for a patient with a left leg injury to navigate up a set of stairs is to sit on the stairs and use the right leg to lift the torso up to the next step. The left leg is held out so that it does not bear any weight. Crutches should be avoided on the stairs whenever possible due to the high risk of falls.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 15. Which task may be delegated to the nursing assistant? a. Determine the patient’s need for a low-air-loss mattress overlay. b. Assess the patient’s legs for the presence of thromboembolism. c. Teach the patient about the contractures and the benefits of resting hand splints. d. Reposition the patient at least every 2 hours using pillows and foam wedges.

ANS: D

The skill of moving and positioning patients in bed can be delegated to nursing assistive personnel. Assessing for thromboembolism, teaching the patient, and determining the need for a specialty air mattress are the nurse’s responsibilities.

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Essentials for Nursing Practice 9th Edition Potter Test Bank DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16. Which action by the nurse demonstrates correct technique for repositioning the patient in bed? a. The nurse’s knees are kept stiff to enhance lifting strength potential. b. The nurse’s abdominal muscles are relaxed to prevent back injury. c. The nurse’s pelvis is tucked inward to maintain balance during the procedure. d. The nurse’s torso twists with the patient to facilitate upper extremity muscle use.

ANS: C

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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss physiological and pathological influences on body alignment and joint mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 17. The nurse has just completed teaching the patient about how to use crutches safely. Which

statement by the nurse will help determine that the teaching was effective? a. “Now I want to see you walk using the crutches correctly.” b. “Here are written instructions in case you forget my directions.” c. “I will make a note in the chart that you were taught how to use crutches.” d. “Please let me know if you have any questions about how to use crutches.”

ANS: A

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The best way for the nurse to determine that the teaching was effective is to have the patient demonstrate the use of crutches correctly. The other statements will not ensure that the teaching was effective.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Basic Care and Comfort 18. Which exercise program should be avoided by a patient with osteoporosis? a. Yoga b. Tai chi c. Tennis d. Water aerobics ANS: C

High impact sports like tennis or jogging should be avoided by patients with osteoporosis due to the risk of fracture. Low impact activities such as yoga, tai chi, and water aerobics will all help to strengthen bones and prevent fractures.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss physiological and pathological influences on body alignment and joint mobility.

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

NURSINGTB.COM

Essentials for Nursing Practice 9th Edition Potter Test Bank

19. Which term best describes the relationship between the hamstring and quadriceps muscles? a. Synergistic b. Ergonomic c. Antigravity d. Antagonistic ANS: D

The hamstring and quadriceps muscles cause movement of the leg joint in different directions.

This means that the two muscles are antagonistic. Synergistic muscles work together to cause the joint to move in the same direction. Antigravity muscles help maintain posture and stabilize the joint against gravity. Ergonomic refers to efficiency and comfort in the working environment.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the role of the musculoskeletal and nervous systems in the regulation of activity and exercise.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 20. Which action is appropriate for transferring a hemiplegic patient from the bed to the

wheelchair? a. The nurse ensures that the wheelchair brakes are locked before helping the patient to stand. b. The patient’s arms are placed around the nurse’s neck before the patient is helped to stand. c. The nurse secures the gait belt under the patient’s arms and uses it to lift the patient to a standing position. d. The nurse’s legs are keptN stU raR igS htIaN ndGcTloBs. eC toO geM ther to avoid tripping the patient during the transfer.

ANS: A

The wheelchair brakes must be locked before helping the patient to stand. If the wheelchair is not locked, it may move backward as the patient sits causing injury. The patient’s arms should never be placed around the nurse’s neck as it may cause injury to the nurse and patient. The gait belt is secured around the patient’s waist to prevent damage to the nerves under the arms.

The nurse’s legs should be bent slightly and spread apart to maintain balance.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 21. Which action by the patient indicates appropriate use of the walker? a. The patient leans over the walker when rising to a standing position. b. The patient’s elbows are bent at a 45-degree angle when holding onto the walker. c. The patient ensures that the walker is locked in the open position before using it. d. The patient looks down at the walker when walking to keep from kicking it.

ANS: C

NURSINGTB.COM

Essentials for Nursing Practice 9th Edition Potter Test Bank Most walkers fold for easy storage. Patients should ensure that the walker is locked in the open position before using it. Failure to do so could cause the patient to fall. The patient should not lean over the walker when rising to stand as that could also lead to a fall. The patient’s elbows should be bent at a 20- to 30-degree angle to prevent hunched posture. The patient should always look forward when walking with a walker.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 22. Which equipment should the nurse utilize when ambulating a patient with a history of severe

COPD? a. Penlight b. Stethoscope c. Pulse oximeter d. Doppler ultrasound ANS: C

The nurse should monitor the patient’s pulse oximetry during ambulation to monitor for hypoxemia. The patient’s oxygen needs will increase with exertion and the nurse must know if additional oxygen is required. A stethoscope, pulse oximeter, or Doppler ultrasounds is not needed.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss physiological and pathological influences on body alignment and joint mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 23. The nurse is caring for a pat i N enUt R wiS thIrN igG htT -sB i d. edChOeM m i pl e gi a . Which intervention will help

prevent damage to the patient’s right shoulder? a. Place the patient’s right arm in a sling whenever the patient is sitting upright. b. Set up the patient’s meal trays so that all food is within easy reach for the left arm. c. Elevate the head of the patient’s bed at least than 30 degrees in the lateral position. d. Assess for increased joint resistance when repositioning the patient.

ANS: A

Placing the patient’s right arm in a sling will help reduce strain to the right shoulder. This is important whenever the patient is sitting upright and the arm weighs heavily on the shoulder joint. Putting food in easy reach of the patient’s left arm will facilitate eating but will not prevent damage to the patient’s right shoulder. Joint assessment is not an intervention.

Elevating the head of the patient’s bed will not prevent shoulder damage.

DIF: Cognitive Level: Apply (Application) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort MULTIPLE RESPONSE 1. Which home care equipment should be ordered for a patient who had a massive stroke with

right-sided hemiplegia? (Select all that apply.) a. Crutches b. Quad cane

NURSINGTB.COM

Essentials for Nursing Practice 9th Edition Potter Test Bank c. d. e. f.

Wheelchair Knee walker Shower bench Toilet safety rails

ANS: C, E, F

Toilet safety rails are important to ensure that the patient can sit down and stay seated on the toilet. The wheelchair will be necessary as the patient will be unable to use a walker, cane, or crutches. The shower bench will allow the patient to sit in the shower and avoid bed baths.

DIF: Cognitive Level: Apply (Application) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Planning MSC: NCLEX: Basic Care and Comfort 2. Which nursing goals are appropriate for a patient with the nursing diagnosis of impaired

walking related to neuromuscular weakness and deconditioning? (Select all that apply.) a. The patient will be able to ambulate 25 feet in the hallway. b. The patient will demonstrate correct use of a rollator walker. c. The nurse will keep the patient’s heels elevated off the mattress. d. The patient will use the over-bed trapeze to reposition self every 2 hours. e. The nurse will ensure that the floors are kept free of clutter or spills. f. The nurse will assess the patient’s pulse before and after ambulation.

ANS: A, B

Ambulating 25 feet in the hallway and demonstrating correct use of a rollator walker are both appropriate goals for the impaired walking nursing diagnosis. Use of the bed trapeze does not apply to the impaired walking nursing diagnosis. Goals are always achieved by the patient rather than the nurse. ElevatiN ng t R he S pIatN i eGnTt ’ sBh.eO eCl s , M keeping the floor clean, and monitoring the U patient’s pulse are all nursing interventions.

DIF: Cognitive Level: Apply (Application) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Planning MSC: NCLEX: Basic Care and Comfort 3. Which assessment findings lead the nurse to select the nursing diagnosis impaired bed

mobility for the patient? (Select all that apply.) a. The patient uses a seat belt and footrest when seated in the wheelchair. b. The patient utilizes a rollator walker to ambulate to and from the bathroom. c. The patient struggles to use the over-bed trapeze for repositioning in bed. d. The nursing staff must log-roll the patient to get on and off the bedpan. e. The patient transfers to the wheelchair with assistance of the nurse and a gait belt.

ANS: C, D

Impaired bed mobility is appropriate for the patient who struggles to reposition in bed and requires much assistance to get on and off the bedpan. The use of wheelchair seat belt, rollator walker, and gait belt do not indicate impaired bed mobility.

DIF: Cognitive Level: Apply (Application) OBJ: Formulate nursing diagnoses for patients experiencing alterations with activity and exercise.

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

NURSINGTB.COM

Essentials for Nursing Practice 9th Edition Potter Test Bank

Chapter 29: Immobility Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who suffered a fractured arm. Which assessment finding is

expected after the patient’s cast is removed after 6 weeks? a. The skin is thin with no hair growth. b. The radial pulse is weak and thready. c. The arm muscles are atrophied and weak. d. The fingernail beds are thick and clubbed.

ANS: C

The patient’s arm muscles will have atrophied and become weak due to 6 weeks of immobilization in the cast. Thin skin, weak radial pulse, and clubbed nail beds are not expected after immobilization.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss the physiological and psychosocial changes associated with immobility and identify the impact changes have on nursing interventions.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 2. The nurse is caring for a patient who is recovering from a cerebrovascular accident. Which

assessment finding indicates that the patient’s cerebellum was damaged by the stroke? a. The patient has continuous double vision. b. The patient has slurred speech and dysphagia. c. The patient is incontinentNoU fR boSwI elNaG ndTbBla.dC deOr.M d. The patient has poor balance and has an unsteady gait.

ANS: D

Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip. The cerebellum does not control speech, continence, or vision.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Explain the techniques for assessing body alignment and impaired mobility.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 3. The nurse is caring for a patient who must lay flat in bed for several days after spinal surgery.

Which is the priority nursing diagnosis for this patient? a. Impaired social interaction related to prolonged bed rest b. Toileting self-care deficit related to inability to use the restroom c. Ineffective breathing pattern related to prolonged supine position d. Ineffective thermoregulation related to lengthy period of immobility ANS: C

Prolonged bed rest leads to decreased lung expansion and ineffective breathing pattern.

Toileting self-care deficit and impaired social interaction are not as important as oxygenation.

Prolonged immobility does not affect thermoregulation.

DIF:

Cognitive Level: Analyze (Analysis)

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Essentials for Nursing Practice 9th Edition Potter Test Bank OBJ: Describe complications associated with the physiological changes of immobility.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Adaptation 4. Which is the priority nursing diagnosis for a patient with orthostatic hypotension after several

days of bed rest? a. Risk for falls related to light-headedness upon standing and getting out of bed b. Dressing/grooming self-care deficit related to cognitive impairment and fatigue c. Impaired bed mobility related to inability to move from supine to sitting position d. Excess fluid volume related to insensible fluid loss due to prolonged immobility ANS: A

The patient with orthostatic hypotension is at risk for falls due to light-headedness when standing. Dressing/grooming self-care deficit is not a high priority diagnosis. Impaired bed mobility and excess fluid volume are not relevant for this patient.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify appropriate nursing diagnoses for patients with impaired mobility.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Reduction of Risk Potential 5. Which is the appropriate outcome for the patient with the nursing diagnosis risk for ineffective

peripheral tissue perfusion related to prolonged immobility? a. The patient’s urinary output will remain at least 30 mL/hour. b. The patient’s legs will maintain strong peripheral pulses and no edema. c. The patient’s abdomen will stay soft with bowel sounds present  4 quadrants. d. The patient will remain alert and appropriate with no changes in mental status.

ANS: B

The appropriate outcome fo r Nthe RpatiIent G with t.heCnuM rsing diagnosis risk for ineffective U the S patient’s N T Blegs O will maintain strong peripheral pulses and peripheral tissue perfusion is that no edema. Urinary output indicates renal perfusion. Bowel sounds indicate gastrointestinal perfusion. Mental status indicates cerebral perfusion.

DIF: Cognitive Level: Apply (Application) OBJ: Evaluate patient outcomes of nursing care for improving or maintaining mobility.

TOP: Nursing Process: Planning MSC: NCLEX: Reduction of Risk Potential 6. A patient had surgery two days ago. Which intervention will be included in the plan of care

for this patient wearing compression stockings? a. The patient’s stockings should be removed at night for washing. b. Slippers should not be applied over the stockings for ambulation. c. Regular size stockings are for females and large size are for males. d. Make sure that the patient’s toes are not sticking out of the stockings.

ANS: D

The patient’s toes must not stick out from the compression stockings as circulation will be impaired. The stockings should not be taken off at night in the immediate postoperative period. Slippers should be worn over the stockings for ambulation. Failure to do so may cause a patient to fall. The patient’s legs should be measured to ensure that the appropriate size compression stockings are applied.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss risks for development of deep vein thrombosis and the appropriate interventions to use

NURSINGTB.COM

Essentials for Nursing Practice 9th Edition Potter Test Bank for prevention.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 7. Which is the appropriate intervention for a patient with risk for constipation related to

prolonged immobility? a. Check the patient’s rectum for the presence of a fecal impaction. b. Encourage the patient to consume plenty of fluids and dietary fiber. c. Instruct the patient about the body’s need for daily bowel movements. d. Recommend the use of daily laxatives to prevent constipation or impaction.

ANS: B

Intake of fluids and fiber will help prevent development of constipation. The nurse should not check the rectum for fecal impaction unless one is suspected. It is not necessary to have daily bowel movement and the use of daily laxatives is not recommended.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 8. Which intervention will be most effective for prevention of foot drop in an immobile patient? a. Apply high-top tennis shoes to the patient’s feet. b. Obtain a podiatry consult for all toenail and foot care. c. Encourage the patient to wear sturdy shoes when ambulating. d. Apply moisturizing lotion to the heels of the feet and between the toes.

ANS: A

High-top tennis shoes can help prevent foot drop by keeping the feet in a neutral position without plantar flexion. ToenNail R ca reIandGl o tB i o.n Cw i l lMnot prevent foot drop. Using sturdy shoes U S N T for ambulation is not appropriate for the immobileOpatient.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 9. Which assessment finding indicates that the patient developed osteoporosis after a long period

of immobility? a. The patient fractured three ribs after coughing on spicy food. b. The patient is unable to dorsiflex the foot, leading to an unsteady gait. c. The patient has a steppage gait with exaggerated flexion of the hip and knee. d. The patient’s knees curve inward and bump against each other with ambulation.

ANS: A

Fracturing three ribs due to coughing indicates weakened bone structure consistent with osteoporosis. Inability to dorsiflex the foot, walking with a steppage gait, and knock knees do not demonstrate osteoporosis.

DIF: Cognitive Level: Apply (Application) OBJ: Describe complications associated with the physiological changes of immobility.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

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Essentials for Nursing Practice 9th Edition Potter Test Bank 10. The nurse is caring for a patient with nonblanchable redness of the coccyx after a lengthy

surgical procedure in the supine position. Which nursing diagnosis is appropriate for this patient? a. Risk for impaired skin integrity related to lengthy surgical procedure b. Noncompliance related to failure to frequently reposition self c. Ineffective therapeutic regimen management related to improper positioning d. Impaired skin integrity related to tissue pressure from prolonged supine position ANS: D

The patient has impaired skin integrity related to the reddened area on the coccyx. The patient was not noncompliant as immobility was required for the surgical procedure. Ineffective therapeutic regimen management refers to daily compliance with the prescribed treatment regimen.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify appropriate nursing diagnoses for patients with impaired mobility.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Adaptation 11. The nurse is caring for a patient who is ordered to remain on bed rest. Which is the

appropriate action of the nurse to facilitate emptying of the patient’s bladder? a. Assist the patient to the bedside commode for voiding. b. Insert an indwelling urinary catheter to bedside drainage. c. Place the patient in high Fowler’s position when using the bedpan. d. Place the patient in Trendelenburg’s position when using the bedpan.

ANS: C

The nurse should place the patient’s bed in high Fowler’s position when using the bedpan in order to facilitate emptying oN f t hR e paI tienG t’s bBl a.dC d e r .MT h e patient’s head is lower than the feet U S N T O in Trendelenburg’s position and that would make it impossible for the patient to use the bedpan. The patient should not be assisted to the commode unless the orders specifically allow the nurse to do so. An indwelling urinary catheter should be avoided due to the risk of urinary tract infection.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 12. The nurse is to transfer an obese, hemiplegic patient from the bed to the chair. Which is the

safest way for the nurse to do this? a. Use of a mechanical patient lift device b. Use of a gait belt around the patient’s waist c. Use of three staff members to assist the patient d. Use of a roller board to slide from the bed to the chair ANS: A

The safest option is for the nurse to utilize a mechanical patient lift device for moving the obese hemiplegic patient. Use of a gait belt, multiple staff members, or a roller board could result in injury to the patient and/or staff members.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the appropriate decision-making process when choosing equipment needed for safe patient handling and movement.

TOP: Nursing Process: Implementation

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Essentials for Nursing Practice 9th Edition Potter Test Bank MSC: NCLEX: Reduction of Risk Potential 13. Which is the appropriate intervention for the patient with the diagnosis powerlessness related

to pain and weakness after right hip fracture? a. Place the patient’s personal items within view on the left side of the bed. b. Encourage the patient to participate in self-care and recreational activities. c. Assess the patient’s sleep patterns and potential for obstructive sleep apnea. d. Reposition the patient and pad bony prominences to prevent skin breakdown.

ANS: B

Powerlessness can be minimized by encouraging the patient to participate in self-care and recreational activities as much as possible. This will provide motivation and enable the patient to feel a sense of control over the situation. Placing the patient’s personal items within reach, assessing sleep patterns, and repositioning the patient will not minimize powerlessness.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the physiological and psychosocial changes associated with immobility and identify the impact changes have on nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 14. Which is an appropriate outcome for an elderly patient with the nursing diagnosis adult

failure to thrive related to placement in extended care agency after right hip fracture? a. The patient will participate in social activities and maintain usual weight. b. The patient will exercise both legs to minimize effects of unilateral neglect. c. The patient will verbalize need for extended nursing care during rehabilitation. d. The patient will not demonstrate symptoms of deep vein thrombus development.

ANS: A

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Adult failure to thrive is a continual deterioration of mental and cognitive function often seen after traumatic injury such as hip fracture. The appropriate outcome is that the patient will participate in social activities and maintain usual weight. Unilateral neglect is the unawareness of a body part following a stroke. Verbalizing need for extended nursing care will not minimize mental and cognitive decline. DVT prevention is not an outcome for the adult failure to thrive diagnosis.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the physiological and psychosocial changes associated with immobility and identify the impact changes have on nursing interventions.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 15. The nurse suspects that the postoperative patient has developed a deep vein thrombosis.

Which is the priority action of the nurse? a. Obtain an order for STAT bleeding time, D-dimer, and platelet count. b. Elevate the patient’s leg and assess for chest pain or shortness of breath. c. Apply a mobile compression device (MCD) to the patient’s affected leg. d. Use a Doppler machine to confirm the presence of bilateral pedal pulses.

ANS: B

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Essentials for Nursing Practice 9th Edition Potter Test Bank The nurse should elevate the patient’s leg if DVT is suspected. The nurse should assess for chest pain or shortness of breath to determine if a clot has broken off and become a pulmonary embolism. Ordering laboratory tests and assessing pedal pulses is less important than assessing for chest pain and elevating the leg. The MCD should be removed from the leg if DVT is suspected.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the physiological and psychosocial changes associated with immobility and identify the impact changes have on nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 16. Which scale is used to assess the patient’s risk for development of pressure injury? a. Baker b. Morse c. Braden d. Hendrich ANS: C

The Braden Scale is used to assess the patient’s risk for development of pressure injury. The Morse and Hendrich scales are used to assess the patient’s risk for falls. The Wong-Baker scale is used to assess the patient’s pain.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Explain the techniques for assessing body alignment and impaired mobility.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 17. The nurse is caring for a pregnant mother of two small children who is on bed rest for several

months until the baby is b o r nN. WR hichIouG tcom s mM o s t appropriate to address the diagnosis of Be.iC U S N T O compromised family coping related to mother’s prolonged bed rest? a. The family will verbalize need for support and identify available resources. b. The family will discuss alternatives to bed rest with the health care provider. c. The mother will verbalize need for bed rest to minimize risk of premature birth. d. The mother will report increased psychological comfort with each passing week.

ANS: A

The entire family is affected when the patient must be on bed rest for several months. The most appropriate outcome is for the family to verbalize need for support and identify available resources. Discussing alternatives to bed rest and verbalization of need for bed rest do not meet the family’s need for assistance with coping. The mother’s report of increased psychological comfort does not reflect the needs of the entire family.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the physiological and psychosocial changes associated with immobility and identify the impact changes have on nursing interventions.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 18. Which action of the nurse will help to reduce the effects of orthostatic hypotension? a. Perform isometric and range-of-motion exercises. b. Encourage the patient to move from a sitting position to standing position slowly. c. Place trochanter rolls on either side of the patient’s hips. d. Participate in chest physiotherapy and incentive spirometry.

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Essentials for Nursing Practice 9th Edition Potter Test Bank ANS: B

Moving positions slowly will help with orthostatic hypotension by allowing the body to adapt.

Isometric exercises improve activity tolerance but do not have any effect on preventing orthostatic hypotension. Participating in chest physiotherapy assists patients with decreasing effects of pulmonary complications. Trochanter rolls help prevent external rotation of the patient’s hips when in the supine position.

DIF: Cognitive Level: Understand (Comprehension) OBJ: List appropriate nursing interventions for an immobilized patient.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 19. Which patient would benefit from the use of a hand roll? a. A patient with paralysis of the right hand after a left-sided stroke b. A paraplegic patient who requires assistance moving up in the bed c. A confused patient who is attempting to pull out the urinary catheter d. A patient with lymphedema of the right arm and hand after mastectomy ANS: A

A hand roll is a rolled washcloth that is placed in the palm of the hand to keep the fingers in a slightly flexed position. The hand roll is useful for preventing development of hand muscle contractures. The hand roll is not used for restraining patients, treating lymphedema, or to assist with repositioning.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the appropriate decision-making process when choosing equipment needed for safe patient handling and movement.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential

NURSINGTB.COM 20. Which outcome is most appropriate for a patient with the diagnosis impaired wheelchair mobility related to neuromuscular impairment and fatigue? a. The patient will feel comfortable navigating the motorized wheelchair. b. The patient will demonstrate ability to safely operate the motorized wheelchair. c. The patient will understand the need to use a motorized wheelchair for mobility. d. The patient will demonstrate correct use of the trapeze bar for repositioning self.

ANS: B

The most appropriate goal for impaired wheelchair mobility is for the patient to demonstrate how to safely operate the motorized wheelchair. The trapeze bar is used for repositioning in the bed. Feeling comfortable and understanding concepts are not examples of measurable outcomes.

DIF: Cognitive Level: Apply (Application) OBJ: Evaluate patient outcomes of nursing care for improving or maintaining mobility.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 21. Which outcome is appropriate for the patient with the nursing diagnosis ineffective protection

related to use of anticoagulant medications? a. The patient will remain free of signs or symptoms of infection. b. The patient will have a soft formed stool at least every other day. c. The patient will verbalize precautions to take in order to prevent bleeding. d. The patient will have clear lung sounds bilaterally and no sign of cyanosis.

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Essentials for Nursing Practice 9th Edition Potter Test Bank ANS: C

The patient taking anticoagulant medications is at risk for bleeding. An appropriate goal is that the patient will verbalize precautions to take in order to prevent bleeding. Infection, constipation, and oxygenation are not appropriate goals for a patient at risk for bleeding.

DIF: Cognitive Level: Apply (Application) OBJ: Evaluate patient outcomes of nursing care for improving or maintaining mobility.

TOP: Nursing Process: Planning MSC: NCLEX: Reduction of Risk Potential 22. Which is the best position for a patient who is acutely short of breath? a. Lateral b. Prone c. High-Fowler’s d. Sims’ ANS: C

In high-Fowler’s position the head of the bed is at a 60- to 90-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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss physiological and pathological influences on body alignment and joint mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 23. Which position should be avoNideR d foIr a G patiB en. tC whoMi s unconscious? a. b. c. d.

Semi-Fowler’s

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Sims’ Supine 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-Fowler’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss physiological and pathological influences on body alignment and joint mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 24. The patient refuses to get out of bed to ambulate after surgery. Which is the appropriate

response of the nurse? a. “No problem. You should rest quietly in bed today so that you can heal.” b. “It is important to get out of bed and walk to prevent blood clots or pneumonia.” c. “I will notify your doctor that you refused and make a notation in your chart.” d. “You can have your next dose of pain medication after you get up and walk.”

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Essentials for Nursing Practice 9th Edition Potter Test Bank ANS: B

The nurse should inform the patient of the risks associated with prolonged bed rest. The nurse should not readily allow the patient to rest in bed when ambulation has been ordered. The patient should be informed of the risks before the nurse notifies the doctor of the patient’s refusal to get out of bed. Pain medication should be administered prior to ambulation whenever possible and should never be withheld due to patient’s refusal to complete a prescribed activity.

DIF: Cognitive Level: Apply (Application) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Planning MSC: NCLEX: Communication and Documentation 25. Which intervention will help prevent the development of footdrop for a comatose patient? a. Place high-top tennis shoes on the patient’s feet. b. Place pillows under the legs to keep the heels off the mattress. c. Apply sequential compression devices to the patient’s feet. d. Assist the patient to a lateral position whenever possible.

ANS: A

High-top tennis shoes will help keep the patient’s feet from becoming locked in plantar flexion known as footdrop. Elevating the heels off the mattress will prevent the development of decubitus ulcers on the heels. Sequential compression devices will help prevent formation of blood clots. Lateral position will not help prevent footdrop.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss physiological and pathological influences on body alignment and joint mobility.

TOP: Nursing Process: ImplemNentR ationI GMSB C:.C NCLMEX: Basic Care and Comfort

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MULTIPLE RESPONSE 1. Which assessment findings place the patient at high risk of pulmonary embolism due to

immobility? (Select all that apply.) a. The patient has had polycythemia vera for the last 5 years. b. The patient refuses daily injections of enoxaparin. c. The patient has worn compression hose since the day of surgery. d. The patient has an indwelling urinary catheter to bedside drainage. e. The patient cannot tolerate intermittent sequential compression devices.

ANS: A, B, E

Polycythemia vera increases blood viscosity, increasing the risk of DVT and PE. Enoxaparin is an anticoagulant used to prevent formation of DVT. The patient’s refusal to take enoxaparin increases risk of DVT and PE. Inability to tolerate SCDs also increases risk of DVT and PE as venous return is impaired by immobility. Compression (TED) hose will reduce risk of DVT and PE. Indwelling urinary catheter does not increase risk of DVT and PE. DIF: Cognitive Level: Apply (Application) OBJ: Explain the techniques for assessing body alignment and impaired mobility.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential

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Essentials for Nursing Practice 9th Edition Potter Test Bank 2. Which are the appropriate interventions for the patient with the diagnosis impaired bed

mobility related to hemiplegia after stroke? (Select all that apply.) a. Assist the patient to reposition in the bed at least every 3 hours. b. Maintain the patient’s bed in high Fowler’s position whenever possible. c. Instruct the patient how to use the over-bed trapeze to reposition self in bed. d. Utilize a sliding sheet to minimize skin trauma during repositioning of the patient. e. Position the patient’s affected limbs in neutral alignment between ranges of motion.

ANS: C, D, E

The patient should be taught how to use the over-bed trapeze to reposition self in bed to encourage independence and frequent repositioning. A sliding sheet will minimize skin trauma during repositioning of the patient. The patient’s limbs should be positioned in neutral alignment between ranges of motion to prevent contractures. The patient should be repositioned at least every 2 hours. Maintaining the bed in high Fowler’s position will facilitate the development of pressure injuries on the patient’s coccyx, sacrum, and back.

DIF: Cognitive Level: Apply (Application) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 3. Which interventions are appropriate for the patient at risk for peripheral neurovascular

dysfunction related to casted right ankle? (Select all that apply.) a. Regularly assess the patient’s toes for warmth and capillary refill. b. Apply graduated compression stockings to both legs to prevent DVT. c. Encourage the patient to frequently wiggle the toes to increase circulation. d. Educate the patient that numbness and tingling of the area is to be expected.

N R If tGh TeB.C M e. Elevate the ankle above theUlevSel oN heart O a n d apply ice to the ankle area.

ANS: A, C, E

The toes should be regularly assessed for warmth and capillary refill. The patient should be encouraged to frequently wiggle the toes to increase circulation. The ankle should be elevated and iced to reduce swelling that can impede circulation. Numbness and tingling is not to be expected and should be reported to the physician immediately. TED hose cannot be applied to the casted leg.

DIF: Cognitive Level: Apply (Application) OBJ: Develop an individualized nursing care plan for a patient with impaired physical mobility.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential

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Essentials for Nursing Practice 9th Edition Potter Test Bank

Chapter 30: Safety Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who has ongoing headaches, nausea, dizziness, and fatigue

since the weather turned cold and snowy. Which assessment question is most important to ask the patient? a. “Has your furnace been inspected lately?” b. “Have you checked your roof for any leaks?” c. “When was the last time your house was painted?” d. “When did you change your smoke detector batteries?”

ANS: A

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 leaking roof and lead paint would not cause the patient’s symptoms.

DIF: Cognitive Level: Apply (Application) OBJ: Describe environmental hazards that pose risks to patient safety.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 2. Which assessment finding inN diU caR teS sI thN atGthTeBp. atC ieO ntM is at risk for developing hypothermia? a. The patient is disoriented due to senile dementia. b. The patient is 5-foot 6-inch tall with a BMI of 35. c. The patient has a history of congestive heart failure. d. The patient takes three different antihypertensive medications.

ANS: A

Elderly confused patients are at risk for hypothermia due to wandering and unawareness of surroundings. The patient’s BMI of 35 indicates obesity which would not put the patient at risk for hypothermia. Antihypertensive medications and a history of CHF do not increase risk of hypothermia.

DIF: Cognitive Level: Apply (Application) OBJ: Assess risks to patients’ safety within health care settings and the home.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 3. Into which seating position will the nurse teach a family to place their 18-month-old toddler in

the family car? a. Front seat facing backward b. Rear seat facing backward c. Front seat facing forward d. Rear seat facing forward ANS: B

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Essentials for Nursing Practice 9th Edition Potter Test Bank Infants and toddlers should be in a rear-facing car safety seat until 2 years of age. The rear seat is the safest location for children less than 13 years of age.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe developmentally appropriate nursing interventions for reducing risks for falls, fires, poisonings, and electrical hazards.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 4. When a parent asks how to seat a 6-year-old child in the family car, how will the nurse

respond? a. In the rear seat with lap and shoulder seat belts b. In the front seat with lap and shoulder seat belts c. In the rear seat with a belt-positioning booster seat d. In the front seat with a belt-positioning booster seat ANS: C

All children under age 13 should ride in the rear seat. Children less than 8 years of age should be in a belt-positioning booster seat as they are not tall enough to fit into the lap and shoulder seat belts.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe developmentally appropriate nursing interventions for reducing risks for falls, fires, poisonings, and electrical hazards.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 5. Which assessment finding indicates that the patient is at higher risk for a motor vehicle

accident? a. The patient is 18 years o fNag eR. I G B.C M U S N T O b. The patient drives a bright blue sedan. c. The patient is the youngest of six children. d. The patient has a history of juvenile arthritis.

ANS: A

According to the CDC, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. Therefore the patient’s age of 18 years indicates a higher risk of a motor vehicle accident. Driving a bright blue sedan, being the youngest child and a history of arthritis do not put the patient at higher risk of motor vehicle accident.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Assess risks to patients’ safety within health care settings and the home.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 6. The nurse is caring for a patient who took 60 acetaminophen tablets. Which resource will the

nurse contact for treatment guidelines when the patient arrives in the emergency room? a. American Association of Poison Control Centers b. Centers for Disease Control and Prevention c. Agency for Healthcare Research and Quality d. Institute for Safe Medication Practices ANS: A

NURSINGTB.COM

Essentials for Nursing Practice 9th Edition Potter Test Bank The American Association of Poison Control Centers supports the Poison Help Line and should be contacted for information about acetaminophen overdose. The CDC manages infectious diseases. The AHRQ conducts research about health care practices. The ISMP promotes safe administration of medications by practitioners.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe environmental hazards that pose risks to patient safety.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 7. A patient’s spouse smokes cigarettes in the kitchen while the patient uses supplemental

oxygen in the bedroom. Which is the priority nursing diagnosis for this family? a. Risk for injury related to smoking near supplemental oxygen b. Risk-prone health behavior related to inability to quit smoking c. Ineffective health maintenance related to continued use of cigarettes d. Ineffective family therapeutic regimen management related to noncompliance ANS: A

The highest priority nursing diagnosis is risk for injury (burns, fire) related to smoking near supplemental oxygen. A life-threatening fire could easily develop as the supplemental oxygen is near the spouse’s cigarettes. Risk-prone health behavior, ineffective health maintenance, and ineffective family therapeutic regimen management are not the priority nursing diagnoses; these can be addressed after the safety risk has been mitigated.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify relevant nursing diagnoses associated with risks to safety.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Safety and Infection Control

NiU 8. The patient’s home is filled w thRpS apI erN sG anTdBtr. asChOthMat has accumulated over the last 20 years.

Which is the priority nursing diagnosis for the patient? a. Unilateral neglect related to inadequate support systems b. Ineffective coping related to hoarding behaviors c. Risk for falls related to cluttered walkways and untidy environment d. Readiness for enhanced comfort related to desire for nicer surroundings ANS: C

The highest priority nursing diagnosis is risk for falls related to cluttered walkways and untidy environment. Fall risk is more important than ineffective coping or readiness for enhanced comfort. Unilateral neglect is the lack of awareness of a body part following a stroke.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify relevant nursing diagnoses associated with risks to safety.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Safety and Infection Control 9. The patient keeps more than 30 cats in the home and is unable to adequately care for them.

Which is the priority nursing diagnosis for this patient? a. Disturbed sensory perception related to inability to smell cat feces b. Caregiver role strain related to inability to adequately care for 30 cats c. Impaired home maintenance related to unhygienic, unclean surroundings d. Risk for situational low self-esteem related to neglected home environment ANS: C

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Essentials for Nursing Practice 9th Edition Potter Test Bank Impaired home maintenance related to unhygienic, unclean surroundings is the priority nursing diagnosis because the unhygienic conditions can lead to illness, injury, or infection.

The inability to smell cat feces is not as important as the overall impaired home maintenance.

Caregiver role strain is not appropriate for this patient. Risk for situational low self-esteem is not a high priority.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify relevant nursing diagnoses associated with risks to safety.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Safety and Infection Control 10. Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan? a. The patient takes alprazolam 0.25 mg every 8 hours. b. The patient rinses with a fluoride mouthwash after brushing the teeth. c. The patient takes acetaminophen 1000 mg every 4 hours around the clock. d. The patient frequently uses an alcohol-based sanitizer for hand hygiene.

ANS: C

The safe maximum daily dosage of acetaminophen is 4000 mg daily. The patient is taking 6000 mg daily, leading to a risk of poisoning. The patient is taking an appropriate dosage of alprazolam daily. Use of fluoride mouthwash daily and an alcohol-based sanitizer for hand hygiene do not put the patient at risk of poisoning.

DIF: Cognitive Level: Apply (Application) OBJ: Assess risks to patients’ safety within health care settings and the home.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 11. Which assessment finding leads the nurse to add ineffective protection to the patient’s care

NURSINGTB.COM plan? a. The patient follows a gluten-free, low-sodium, antiinflammatory diet. b. The patient has not received immunizations against influenza or pneumonia. c. The patient recently divorced after being in an unhappy marriage for 4 years. d. The patient takes levothyroxine daily to treat hypothyroid disease.

ANS: B

The patient is susceptible to influenza and pneumonia due to lack of immunization against these diseases. Ineffective protection is an appropriate nursing diagnosis for the patient as there is a decreased ability to protect itself from infection. Levothyroxine, divorce, and dietary preferences do not lower the patient’s defenses.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Assess risks to patients’ safety within health care settings and the home.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 12. Which is the highest priority nursing diagnosis for a college student who is living away from

home for the first time? a. Sleep deprivation related to noisy dormitory environment b. Risk-prone health behavior related to weekend binge drinking c. Relocation stress syndrome related to moving away from home d. Risk for loneliness related to being away from family and old friends ANS: B

NURSINGTB.COM

Essentials for Nursing Practice 9th Edition Potter Test Bank Weekend binge drinking indicates a risk-prone health behavior that could lead to liver damage, injury, or death. Sleep deprivation is not as important as binge drinking. Relocation stress syndrome and risk for loneliness relate to psychosocial needs, making these diagnoses lower priority than physical need for safety and rest.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify relevant nursing diagnoses associated with risks to safety.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Safety and Infection Control 13. The patient lives in an apartment and has difficulty getting on and off of the toilet. Which is

the best intervention to protect the patient’s safety? a. Place a bedside commode over the toilet. b. Screw grab bars into the wall by the toilet. c. Attach suction cup grab bars to the wall by the toilet. d. Instruct the patient to lean forward when rising to stand.

ANS: A

A bedside commode should be placed over the patient’s toilet to make it safer for the patient.

Grab bars should not be screwed into the wall as the patient is renting the apartment. Suction cup grab bars may not attach securely to the wall. The patient should not be instructed to lean forward when rising to stand.

DIF: Cognitive Level: Apply (Application) OBJ: Develop a nursing care plan for patients whose safety is threatened.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 14. Which is the highest priority intervention for a patient with diabetic neuropathy who has lost

NURSINGTB.COM sensation in both feet? a. Encourage the patient to participate in tai chi exercises to promote balance. b. Instruct the patient to wear a medical alert bracelet that identifies risk for falls. c. Evaluate the patient’s blood pressure for orthostatic hypotension. d. Teach the patient to wear low-heeled, comfortable, supportive footwear at all times.

ANS: D

It is essential for patients with diabetic neuropathy to wear supportive footwear at all times to prevent injury to the feet. Patients with neuropathy will not realize if the foot has been injured or punctured, leading to the risk of ulceration, serious wound, or even amputation. Tai chi exercises are not a priority. Fall alert bracelets may be worn in the hospital but are not appropriate for use at home. There is no need to check the patient for orthostatic hypotension.

DIF: Cognitive Level: Apply (Application) OBJ: Develop a nursing care plan for patients whose safety is threatened.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 15. A small amount of mercury was spilled on the floor after an old sphygmomanometer was

broken. What is the priority action of the nurse? a. Disinfect the area with a solution of chlorine bleach. b. Contact the housekeeping staff to mop up the liquid. c. Wipe up the liquid using paper towels and nitrile gloves. d. Consult the agency’s materials safety data sheets (MSDS).

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Essentials for Nursing Practice 9th Edition Potter Test Bank ANS: D

Mercury is a toxic chemical so the nurse should consult the MSDS to determine how the spill should be cleaned. Mercury cannot be mopped up by a housekeeper or wiped with paper towels. The area should not be disinfected with chlorine bleach.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe environmental hazards that pose risks to patient safety.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 16. Which intrinsic assessment finding could lead a patient to fall? a. The patient has orthostatic hypotension and faints when standing too quickly. b. The patient’s room is located at the end of the hall far from the nursing station. c. The patient’s roommate sometimes spills the contents of a urinal on the floor. d. The patient’s room is crowed with walkers, wheelchairs, and bedside commodes.

ANS: A

Intrinsic factors that can lead to falls are patient-related such as orthostatic hypotension.

Extrinsic factors are environmentally related, such as spills, clutter, and patient room location.

DIF: Cognitive Level: Apply (Application) OBJ: Assess risks to patients’ safety within health care settings and the home.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 17. Which is the role of the nurse regarding a malfunctioning IV pump? a. Contact the IV pump manufacturer. b. Initiate a work order on the IV pump. c. Tag the IV pump and remove it from the area. d. Clean the fixed IV pumpN andRretuIrn G it toBth.eCflooMr.

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ANS: C

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 within the nurse’s role 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the nurse’s role in prevention of serious reportable events.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 18. Which is an example of a procedure-inherent accident? a. The patient suffered a burn due to a malfunctioning heating pad. b. The patient suffered a tongue laceration during a grand mal seizure. c. The nurse suffered a back injury when repositioning a heavy patient in bed. d. The physician suffered a broken wrist after it was caught in the elevator door.

ANS: C

NURSINGTB.COM

Essentials for Nursing Practice 9th Edition Potter Test Bank A procedure-inherent accident occurs when a patient or staff member is injured in the process of providing patient care. An example of a procedure-inherent accident is a back injury caused by moving a heavy patient in bed. A malfunctioning heating pad caused an equipment-related accident. A tongue laceration from a seizure is a patient-inherent accident. A broken wrist in an elevator door could be considered an equipment-related accident.

DIF: Cognitive Level: Apply (Application) OBJ: Describe factors that create a culture of safety.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 19. The nurse is applying soft wrist restraints to the patient. Where will the restraints be tied to the

patient’s bed? a. Side rails b. Bedframe c. Footboard d. Headboard ANS: B

Attach restraint straps to the portion of the bedframe 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 bedframe that does not move (headboard or footboard) will injure the patient.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify factors to consider in the use of restraints.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 20. The patient is aggressively attempting to pull out IV lines and hurt staff members. Which is

the first action of the nurse? NURSINGTB.COM a. Conduct a thorough mental status assessment. b. Contact the health care provider to obtain an order for restraints. c. Place the patient in soft restraints to prevent injury. d. Document the patient’s actions in the medical record.

ANS: C

The first priority of the nurse is to restrain the patient to prevent injury to the patient or others.

The health care provider can then be contacted to obtain an order for restraints. The patient’s actions can later be documented in the medical record. A thorough mental status assessment can be performed once the patient has been restrained and there is no risk of injury.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe approaches to reducing violence in the health care workplace.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 21. The wrong type of medication was administered to the patient. Which type of error is this? a. Exposure-related accident b. Procedure-related accident c. Equipment-related accident d. Organization-related accident ANS: B

NURSINGTB.COM

Essentials for Nursing Practice 9th Edition Potter Test Bank 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. An equipment-related accident results from misuse, disrepair, malfunction, or electrical hazard. There is no classification of exposure-related accident or organization-related accident.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Assess risks to patients’ safety within health care settings and the home.

TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 22. Which is the appropriate intervention for a patient with the nursing diagnosis wandering

related to disorientation, memory loss, and urge incontinence? a. Raise three of the four side rails on the patient’s bed. b. Assign the patient to a room close to the nursing station. c. Remind the patient to always ask for help before getting up. d. Place a bed alarm to notify staff when the patient is getting up.

ANS: D

Alarm devices warn nursing staff that a patient is attempting to leave a bed or chair unassisted. Staff can then provide assistance before the patient is fully out of the bed.

Although moving the patient to a room closer to the nursing station allows the nurse to keep a closer eye on the patient, this action does not discourage wandering behavior. Raising side rails has the potential to trap parts of the patient’s body, producing a hazard. The use of side rails alone for a disoriented patient often causes more confusion and further injury. Reminders are not effective for this patient due to memory loss.

DIF: Cognitive Level: Apply (Application) OBJ: Explain approaches for eN stU abR liS shI inN gG a rT esB tr. ainCt-O frM ee environment.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 23. Which nursing diagnosis is the highest priority for a family with small children? a. Risk for suffocation related to unattended swimming pool in back yard b. Risk for caregiver role strain related to four children under 6 years of age c. Readiness for enhanced immunization status related to request for medical records d. Readiness for enhanced parenting related to attachment between family members ANS: A

Risk for suffocation related to unattended swimming pool in back yard is the highest priority nursing diagnosis because drowning could lead to permanent injury or death. Risk for caregiver role strain, readiness for enhanced immunization status, and readiness for enhanced parenting are lower priority diagnoses as they address psychosocial needs. They can be attended to after the immediate risk for danger is addressed.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify relevant nursing diagnoses associated with risks to safety.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Safety and Infection Control 24. Which nursing diagnosis is the highest priority for a sexually active adolescent? a. Risk for infection related to participation in unprotected sexual activity b. Disturbed body image related to depersonalization and fear of rejection c. Spiritual distress related to inability to integrate sexuality with church teaching

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Essentials for Nursing Practice 9th Edition Potter Test Bank d. Risk for compromised human dignity related to loss of respect from peer group ANS: A

Risk for infection related to participation in unprotected sexual activity is the highest priority nursing diagnosis as the patient’s physical health is in danger. Disturbed body image, spiritual distress, and risk for compromised human dignity may be addressed once the patient has demonstrated understanding of safe sex practices.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify relevant nursing diagnoses associated with risks to safety.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Safety and Infection Control 25. A patient smokes in the hospital bathroom and starts a fire. Which is the nurse’s first

response? a. Remove the patient to a safe area. b. Close the door to contain the fire. c. Call the operator to activate the fire alarm. d. Utilize a fire extinguisher to put out the fire.

ANS: A

Use the mnemonic RACE to set priorities in case of fire: R—Rescue and remove all patients in immediate danger.

A—Activate the alarm. Always do this before trying to extinguish even a minor fire.

C—Confine a fire by closing doors and windows and turning off oxygen and electrical equipment.

E—Extinguish a fire using an appropriate extinguisher.

Reporting, attempting to extinguish, and closing the door all occur after assisting patients to a safe area.

NURSINGTB.COM DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe methods to evaluate interventions designed to maintain or promote safety.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 26. Which is the appropriate disposal method for used insulin syringes at home? a. Engage the safety cap over the needle and place it in the recycle bin. b. Remove the needle from the syringe and then flush it down the toilet. c. Place the used syringes in a sharps container that is mailed back for destruction. d. Place the used needles in a plastic can that is placed in the center of the trash bin.

ANS: C

The safest method is to place the used syringes in a sharps container that is mailed back for destruction. The next best option is to place the used needles in a coffee can (not a plastic can) that is placed in the center of the trash bin. This will help protect sanitation workers from needlestick injury. Syringes and needles should never be flushed down the toilet. Individual syringes should never be placed in the trash even if the safety cap is engaged.

DIF: Cognitive Level: Apply (Application) OBJ: Describe factors that create a culture of safety.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 27. Which patient care need may be delegated to the nursing assistant? a. Providing discharge teaching about fall precautions in the home

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Essentials for Nursing Practice 9th Edition Potter Test Bank b. Responding to the patient’s bed alarm as the patient attempts to get up c. Performing a mental status assessment to check for confusion or delirium d. Obtaining a consult for physical therapy for strengthening/balance exercises ANS: B

The nursing assistant can respond to the patient’s bed alarm as the patient attempts to get up.

The registered nurse should provide teaching, perform assessments, and obtain consults for the patient.

DIF: Cognitive Level: Apply (Application) OBJ: Describe factors that create a culture of safety.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 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. Stay with the patient. b. Medicate the patient for pain. c. Notify the health care provider. d. Remove the restraint immediately. e. Tell the patient to relax and it will feel better shortly.

ANS: A, C, D

If a patient has altered neurovascular status (tingling and numbness) remove the restraint I NG B.CtheM immediately, stay with the patiN Uent,RSand noT tify Ohealth 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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify factors to consider in the use of restraints.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. The patient’s electricity has been shut off after failure to pay the utility bills. Which actions by

the patient pose health hazards? (Select all that apply.) a. The gas oven is used to warm the kitchen. b. Extra layers of warm clothing are worn. c. Food is smelled to determine if it is edible. d. Dry ice is used to keep milk and eggs cold. e. Lit taper candles are placed around the house.

ANS: A, C, E

The oven should never be used to warm the house, especially since a gas oven is the only option without electricity. Food should be thrown out if there is any doubt about its safety, rather than relying on its smell. Flashlights should be used for light as candles can cause fires.

Dry ice is an option for keeping milk and eggs cold when there is no electricity. Extra layers of warm clothing should definitely be worn to prevent hypothermia.

DIF:

Cognitive Level: Analyze (Analysis)

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Essentials for Nursing Practice 9th Edition Potter Test Bank OBJ: Assess risks to patients’ safety within health care settings and the home.

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

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Essentials for Nursing Practice 9th Edition Potter Test Bank

Chapter 31: Hygiene Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which is the best approach to change nasogastric tube tape that has become crusted with

secretions? a. Soften the secretions using a warm moist washcloth. b. Use blunt-edged scissors to loosen the tape from the skin. c. Saturate the tape with a denatured alcohol solution. d. Soak the crusted areas of tape 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. Alcohol and adhesive remover are not recommended. Scissors should not be used near tubes as the scissors may inadvertently cut or damage the tube.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss appropriate interventions for hygiene problems.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 2. The nurse is caring for a diabetic patient who has rough skin on the feet and thick, overgrown

N R INofGTthe B.C Stion toenails. Which is the best inteU rven nurO sM e? a. Liberally apply lotion to the patient’s feet, especially between the toes. b. Use a pumice stone to smooth roughened areas of skin on the patient’s feet. c. Gently trim the patient’s toenails after soaking the feet in warm soapy water. d. Obtain a consultation for a podiatrist to assess the feet and provide nail care.

ANS: D

The nurse should refer all diabetic patient foot care to a podiatrist, including trimming of nails. Foot issues in the patient with diabetes can quickly turn into a serious problem with slow healing and infection. Lotion should not be applied between the patient’s toes as it can cause maceration of the skin.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the importance of foot care for a patient with diabetes.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 3. Which patient would benefit from the use of lubricant eye ointment? a. A patient with chronic viral conjunctivitis b. A stroke patient whose right eye does not close fully c. A patient who has extended-wear contact lenses in place d. A patient with an eye infection after swimming in a pond ANS: B

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Essentials for Nursing Practice 9th Edition Potter Test Bank An eye that does not close fully is at risk for dryness and corneal ulceration. A stroke patient whose right eye does not close fully would benefit from a lubricant eye ointment. Patients with eye infections or contact lenses should not use lubricant eye ointment.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss appropriate interventions for hygiene problems.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 4. Which bath time assessment of the diabetic patient is most important? a. Presence of fingernail clubbing b. Presence of any petechiae or bruises c. Presence of abdominal rebound tenderness d. Presence of pedal pulses and intact sensation ANS: D

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 people with diabetes.

The other responses are necessary to assess but not the highest priority for this patient with a diabetic diagnosis.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the importance of foot care for a patient with diabetes.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. Which patient outcome is most important for the patient with the nursing diagnosis

bathing/hygiene self-care defN icU itR reSlaIteNdGtoTnBe. urC om OuMscular impairment and fatigue? a. The patient’s skin will remain intact and free of body odor. b. The patient will report feeling of cleanliness after morning care. c. The patient’s privacy and dignity will be maintained during the bath. d. The patient will verbalize understanding of need for bathing assistance.

ANS: A

The highest priority outcome for the patient is maintenance of intact skin without body odor.

Privacy and dignity must be maintained but the most important goal is skin integrity. It is less important for the patient to report feeling clean and to verbalize understanding of the need for assistance than for the skin to remain intact.

DIF: Cognitive Level: Apply (Application) OBJ: Perform a comprehensive assessment of a patient’s hygiene needs.

TOP: Nursing Process: Planning MSC: NCLEX: Basic Care and Comfort 6. Which intervention is appropriate to prevent the patient from reinfection after recovery from

oral thrush? a. The teeth should be flossed after each meal. b. The patient’s toothbrush should be replaced. c. Lip balm should be applied to prevent chapping. d. An antiseptic mouthwash should be used twice daily.

ANS: B

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Essentials for Nursing Practice 9th Edition Potter Test Bank Instruct patients to obtain a new toothbrush after recovering from thrush, strep throat, or upper respiratory infections. Dental floss, lip balm, and antiseptic mouthwash will not prevent reinfection.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss conditions that place patients at risk for impaired oral mucus membranes.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. What will the nurse do with extra clean linens that were left over after the patient’s bath? a. Place them back in the linen closet. b. Place them on the patient’s bedside table. c. Use them to bathe the patient’s roommate. d. Place them 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 patient’s room. Once you bring linen into a patient’s 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 patient’s room. Excess linen lying around a patient’s room creates clutter and obstacles for patient care activities.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Make an occupied and unoccupied hospital bed.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 8. The nurse notes red, moist patches on the skin under the female patient’s breasts. What is the

appropriate action of the nurse when caring for this area? a. Gently clean and dry the N arU eaRaS ndIoNbG taT inBa. nC orO dM er for antifungal powder. b. Apply a rich moisturizer cream to the area after washing with soap and water. c. Apply a topical antibiotic cream to the area after rinsing with peroxide and water. d. Wash the area with moisturizing soap and apply a lanolin-based cream to the area.

ANS: A

Red, moist patches on the skin under the female patient’s breasts are indicative of topical candidiasis (yeast infection). The area should be cleaned and a topical antifungal powder should be applied. Applying moisturizer will foster growth of yeast and worsen the infection.

Topical antibiotic ointment will not treat yeast infections. Lanolin-based creams should not be applied to the skin. Rinsing the area with peroxide can cause discomfort and skin damage.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss factors that affect the condition of the skin, mouth, hair, scalp, nails, and feet.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 9. The nurse is caring for a patient who has just undergone shoulder replacement surgery. Which

is the best option for washing the patient’s hair? a. Utilize a no-rinse shampoo cap. b. Use a handheld shower sprayer. c. Have the patient lean back into the sink. d. Have the patient lean over the wash basin.

ANS: A

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Essentials for Nursing Practice 9th Edition Potter Test Bank The safest and most comfortable option is for the nurse to use a no-rinse shampoo cap to wash the patient’s hair. Using a handheld shower sprayer will get the operative site wet. Having the patient lean forward or backward will cause significant shoulder discomfort and should be avoided.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss appropriate interventions for hygiene problems.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 10. Which assessment finding leads the nurse to question the physician’s order for irrigation of

the patient’s ear? a. The patient has some short soft hairs present on the pinna. b. A large amount of cerumen is noted in the patient’s ear canal. c. The patient has ear pain with purulent drainage in the ear canal. d. The patient’s tympanic membrane is a translucent pearl-gray color.

ANS: C

Ear pain with purulent drainage in the ear canal can indicate an ear infection with a ruptured eardrum. The nurse should not irrigate the patient’s ear if an active infection is present or if the eardrum is ruptured. It is not unusual to have soft hairs present on the pinna and it will not lead the nurse to question the order for ear irrigation. The patient’s tympanic membrane should be a translucent pearl-gray color.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly perform hygiene procedures for care of a patient’s skin, perineum, feet, nails, mouth, eyes, ears, and nose.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential

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11. The nurse is caring for a bedridden patient with long straight hair. Which is the appropriate

intervention to prevent the hair from becoming matted? a. Apply no-tangle conditioner to the hair. b. Cut the matted hair. c. Braid the patient’s hair into several pigtails. d. Wash the patient’s hair daily with baby shampoo.

ANS: C

Braiding the patient’s hair is the best option to prevent matting. Do not cut a patient’s hair without consent. Applying conditioner is messy and washing the patient’s hair daily is often not feasible.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss appropriate interventions for hygiene problems.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 12. Which is the priority nursing intervention for a patient with confusion and the diagnosis

impaired dentition related to inability to perform oral care? a. Assess the patient’s preferred methods for oral hygiene. b. Brush the patient’s teeth twice daily with a soft toothbrush. c. Use foam swab sticks to clean the oral cavity every morning. d. Encourage the patient to chew sugarless gum during the day.

ANS: B

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Essentials for Nursing Practice 9th Edition Potter Test Bank The confused patient’s teeth should be brushed twice daily with a soft toothbrush. Foam swab sticks should be used only when brushing the teeth is not an option as they do not adequately remove tartar. It is unsafe for confused patients to chew sugarless gum. Brushing the patient’s teeth is more important than assessing the patient’s preferred methods for oral hygiene, especially as the patient is confused.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly perform hygiene procedures for care of a patient’s skin, perineum, feet, nails, mouth, eyes, ears, and nose.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 13. Which is the highest priority nursing diagnosis for a patient who is frequently incontinent of

stool and urine? a. Risk for impaired skin integrity related to exposure to urine and stool b. Powerlessness related to inability to control release of bowel and bladder c. Readiness for enhanced comfort related to expressed desire to smell fresh d. Social isolation related to unpleasant odor from stool and urine ANS: A

The highest priority nursing diagnosis is risk for impaired skin integrity as the perineal tissues can readily break down due to exposure to urine and stool. The nurse can address powerlessness, comfort, and social isolation once the perineal tissues have been protected.

DIF: Cognitive Level: Apply (Application) OBJ: Identify common problems involving the skin, feet, nails, hair, and scalp.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Reduction of Risk Potential 14. Which nursing intervention iN s apR prop tN e wB h e.nCbO a tM hi ng older adult patients?

Iria G U S T a. Use warm water, mild skin cleanser, and moisturizing lotion. b. Apply a topical steroid cream to dry skin areas after bathing. c. Assist the patient to take relaxing, long hot showers twice weekly. d. Wash the patient’s skin using plain water and dry with a soft towel.

ANS: A

Older patients’ skin is more fragile; therefore avoid hot water (warm water is preferred) and use a mild cleansing agent. 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. Topical steroid creams should not be routinely applied to skin. A mild cleanser is usually needed to effectively remove debris from the skin.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe how hygiene for older adults differs from that for younger patients.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 15. How can the nurse best respect the patient’s cultural preferences for hygiene? a. Shave the patient’s facial hair every morning after the bath. b. Add scented bath oils to the water before bathing the patient. c. Ensure that a staff member of the same sex bathes the patient. d. Accommodate the patient’s wish to wash before morning prayers.

ANS: D

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Essentials for Nursing Practice 9th Edition Potter Test Bank A patient’s cultural beliefs and personal values influence hygiene care. The patient’s preferences should be accommodated whenever possible, such as washing before morning prayers. Not all cultures believe in shaving facial hair and some cultures do not believe in the use of scented hygiene products. Some cultures require that a staff member of the same sex bathe the patient while other cultures do not have this requirement.

DIF: Cognitive Level: Apply (Application) OBJ: Describe factors that influence personal hygiene practices.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 16. Which assessment finding leads the nurse to lightly wash the patient’s legs rather than using

long, firm strokes? a. The patient’s platelet count was 40,000/mm3 this morning. b. The patient is taking ciprofloxacin for a bladder infection. c. The patient is taking levothyroxine for hypothyroidism. d. The patient’s urinalysis was positive for protein and white blood cells.

ANS: A

The nurse should not use long, firm strokes to wash the legs of a patient with bleeding disorders or deep vein thrombosis. The patient’s platelet count is dangerously low, putting the patient at risk for bleeding. Bladder infection and hypothyroid disease do not affect how the nurse washes the patient’s legs.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly perform hygiene procedures for care of a patient’s skin, perineum, feet, nails, mouth, eyes, ears, and nose.

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

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MULTIPLE RESPONSE 1. Which interventions are appropriate for a patient with the nursing diagnosis impaired oral

mucus membranes related to immunosuppression, thrush, and ulceration? (Select all that apply.) a. Rinse the mouth with warm saline solution every few hours. b. Rinse the mouth with half strength hydrogen peroxide twice daily. c. Use cotton swabs soaked in lemon-glycerin solution to clean the oral mucosa. d. Use a tongue scraper to remove the thick coating from the oral mucosa. e. Encourage the patient to have soft foods such as yogurt, ice cream, and pudding.

ANS: A, E

The patient’s mouth should be rinsed with warm saline solution every few hours. Soft foods should be consumed to maintain nutrition without further irritating the oral mucosa. Peroxide and lemon-glycerin swabs should not be used. A tongue scraper should not be used as it will cause pain and damage to the fragile mucosa.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss appropriate interventions for hygiene problems.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 2. Which hygiene interventions are appropriate for a patient with the nursing diagnosis

ineffective protection related to impaired blood clotting? (Select all that apply.)

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Essentials for Nursing Practice 9th Edition Potter Test Bank a. b. c. d. e.

Use an emery board to file the patient’s nails.

Use a soft toothbrush and avoid flossing the teeth.

Rinse with a chlorhexidine mouthwash after meals.

Use antibacterial soap for showering each morning.

Use an electric razor to shave the patient’s facial hair.

ANS: A, B, E

An electric razor should be used rather than a safety razor to prevent nicks and bleeding.

Flossing and using a firm toothbrush can cause bleeding of the oral mucosa. Using clippers on the patient’s nails can cause nicks and bleeding so an emery board should be used instead.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify common problems involving the skin, feet, nails, hair, and scalp.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 3. Which interventions are appropriate when providing oral care to an intubated patient receiving

mechanical ventilation? (Select all that apply.) a. Floss the gums gently after brushing the teeth each morning. b. Rinse the mouth with a solution of peroxide and baking soda. c. Suction the patient’s mouth throughout the cleaning procedure. d. Keep the head of the patient’s bed elevated at least 30 degrees. e. Clean the oral mucosa using a chlorhexidine-based mouthwash.

ANS: C, D, E

The patient’s mouth should be suctioned throughout the cleaning procedure to prevent fluids from entering the trachea. The head of the bed should be elevated at least 30 degrees to prevent aspiration. A chlorhexidine-based mouthwash has been shown to reduce the risk of ventilator-associated pneumoNnia. umsMis not possible with the endotracheal tube U RFlo S INssinTGg thBe.gOC in place. Peroxide should not be used on the oral mucosa as it can cause damage to tissues.

DIF: Cognitive Level: Apply (Application) OBJ: Correctly perform hygiene procedures for care of a patient’s skin, perineum, feet, nails, mouth, eyes, ears, and nose.

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

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Essentials for Nursing Practice 9th Edition Potter Test Bank

Chapter 32: Oxygenation Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which term is used to describe a machine that helps to move air in and out of the patient’s

lungs? a. Aerator b. Diffuser c. Respirator d. Ventilator ANS: D

Ventilation is the movement of air in and out of the lungs so a machine that helps to move air in and out of the patient’s lungs is called a ventilator. A respirator is an ultrafine filtration mask used to prevent inhalation of dust or microbes. An aerator adds bubbles to fish tanks or ponds. A diffuser turns a liquid into a fine mist for spraying in an area.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the structure and function of the cardiopulmonary system.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 2. The nurse is caring for a patient with a pulmonary embolism that prevents blood flow to the

lower lobe of the right lung. Which breathing process is impaired for this patient? a. Perfusion b. Diffusion NURSINGTB.COM c. Respiration d. Ventilation ANS: A

Perfusion refers to the movement of blood into and out of the lungs to the organs and tissues of the body. The patient’s blood flow through the lungs is blocked by the clot so the patient’s pulmonary perfusion is impaired. Diffusion is the movement of gases between air spaces and the bloodstream. Ventilation refers to the movement of air in and out of the lungs. Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the structure and function of the cardiopulmonary system.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 3. Which respiratory problem is experienced by premature infants due to lack of surfactant in

their lungs? a. The alveoli shrivel and are unable to exchange oxygen for carbon dioxide. b. Weakness of the respiratory muscles limits airflow in and out of the lungs. c. Swelling of abdominal organs limits expansion and contraction of the diaphragm. d. Insufficient hemoglobin impairs delivery of oxygen to tissues throughout the body.

ANS: A

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Essentials for Nursing Practice 9th Edition Potter Test Bank Surfactant works to keep alveoli expanded so that oxygen can be exchanged for carbon dioxide. Lack of surfactant leads the alveoli to shrivel up preventing diffusion of gases across the alveolar membrane. Lack of surfactant does not affect diaphragm function, hemoglobin levels, or respiratory muscle strength.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify the physiological processes involved in ventilation, perfusion, and exchange of respiratory gases.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 4. Which assessment finding is expected for a patient with impaired lung compliance? a. The patient’s respirations are very deep and rapid. b. The patient reports sharp left-sided rib and chest pain. c. The patient struggles to take a deep breath and exhale. d. The patient’s breathing pattern is irregular with periods of apnea.

ANS: C

Compliance refers to the elasticity of the lungs to expand and contract with each breath. A patient with impaired lung compliance struggles to inhale and exhale due to stiffness of the lungs. Lung compliance does not affect breathing patterns or cause left-sided rib pain.

DIF: Cognitive Level: Apply (Application) OBJ: Identify the physiological processes involved in ventilation, perfusion, and exchange of respiratory gases.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 5. Which laboratory finding indicates that the patient is likely to experience hypoxemia? a. Hematocrit 31% NURSINGTB.COM b. Serum creatinine 0.8 mg/dL c. Glycosylated hemoglobin 7% d. White blood cell count 4600/mm3 ANS: A

Hemoglobin transports most oxygen and serves as a carrier for both oxygen and carbon dioxide. A hemoglobin level of 8.4 is dangerously low and puts the patient at risk of hypoxemia due to impaired oxygen carrying capacity of the blood. Glycosylated hemoglobin reflects the average blood sugar level for the last 6 weeks rather than oxygen carrying capacity. White blood cell count is a laboratory test to measure infection and is within normal range. Creatinine level of 0.8 mg/dL reflects normal kidney function.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 6. The nurse is caring for a patient with end-stage chronic obstructive pulmonary disease

(COPD). The patient’s pulse oximetry reading is 90% on room air. What is the priority action of the nurse? a. Administer 4L/NC oxygen immediately. b. Assist the patient into a recumbent position. c. Determine the patient’s normal pulse oximetry values. d. Obtain an order for STAT arterial blood gases (ABGs).

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Essentials for Nursing Practice 9th Edition Potter Test Bank ANS: C

The nurse must determine the patient’s normal pulse oximetry values. The patient with end-stage COPD uses low oxygen levels to stimulate breathing rather than elevated carbon dioxide levels. When caring for patients with COPD and chronically elevated PaCO2 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. Patients with respiratory difficulty should be assisted to sit up to facilitate lung expansion. STAT arterial blood gases are not needed.

DIF: Cognitive Level: Analyze (Analysis) 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: NCLEX: Physiological Adaptation 7. Which laboratory finding indicates that the body is attempting to compensate for the patient’s

end-stage chronic obstructive pulmonary disease (COPD)? a. Hemoglobin 22.1 g/dL b. Serum sodium 130 mEq/L c. Serum cholesterol 236 mg/dL d. Serum albumin level 4.8 g/dL ANS: A

Elevated hemoglobin level indicates that the body has increased oxygen carrying capacity to compensate for end-stage COPD. Serum sodium 130 mEq/L and albumin level 4.8 g/dL are within normal limits. Elevated cholesterol levels do not compensate for the patient’s end-stage chronic obstructive pulmonary disease.

N R I G B.C M

S N T O DIF: Cognitive Level: Analyze U (Analysis) OBJ: Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 8. Which assessment finding indicates that the patient is experiencing hypercapnia during sleep? a. The patient sleeps in the lateral position with at least two pillows. b. The patient wakes up feeling hung over after consuming no alcohol. c. The patient has difficulty falling asleep and wakes up early each morning. d. The patient works the night shift and is unable to sleep well during the day.

ANS: B

Waking up feeling hung over after no alcohol consumption can indicate hypercapnia during sleep. The patient feels better as the day progresses as the elevated carbon dioxide level slowly returns to normal. Sleeping in the lateral position, working the night shift, and insomnia do not demonstrate hypercapnia.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 9. Which assessment finding indicates that the sinoatrial node was damaged as a result of the

patient’s heart attack?

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Essentials for Nursing Practice 9th Edition Potter Test Bank a. b. c. d.

The patient’s jugular vein is distended.

The patient’s heart rate is 34 beats/minute.

Faint wheezes are heard in the patient’s lungs.

The patient has developed a new heart murmur.

ANS: B

The conduction system originates with the sinoatrial node, the “pacemaker” of the heart.

Damage to the sinoatrial node results in bradycardia as the ventricles set the rhythm. Damage to the sinoatrial node would not lead to jugular venous distention, wheezes, or new heart murmur.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the structure and function of the cardiopulmonary system.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 10. Which assessment finding indicates why the patient does not have signs of respiratory

alkalosis despite a respiratory rate of 30 breaths/minute? a. The patient’s hematocrit is 28%. b. The patient’s oral temperature is 99.2° F. c. The patient is experiencing a panic attack. d. The patient has a large pulmonary embolism.

ANS: D

A large pulmonary embolism reduces blood flow through the lungs leading the patient to feel acutely short of breath. The patient will not develop signs of respiratory alkalosis because the rapid breathing rate is compensating for impaired perfusion. Elevated hematocrit level, slightly elevated temperature, or panic attack would all cause the patient to have signs of hyperventilation with a respi N r aU toR r ySraIteNoGf T 30Bb.rC e aO thM s/minute.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify the physiological processes of cardiac output and respiratory gas exchange.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 11. The patient’s blood pressure is 180/100. Why does the patient’s heart have to work harder due

to the high blood pressure? a. Increased preload b. Increased afterload c. Decreased contractility d. Increased stroke volume ANS: B

Afterload is the resistance to the blood being pumped from the left ventricle. The patient’s hypertension increases afterload and increases the heart must work harder to push against it.

Hypertension does not increase cardiac workload due to increased preload, decreased contractility, or increased stroke volume.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the interrelationship of cardiac output, preload, afterload, contractility, and heart rate.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 12. How can the parents best protect their premature infant from developing respiratory syncytial

virus (RSV)?

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Essentials for Nursing Practice 9th Edition Potter Test Bank a. b. c. d.

Immunize the infant against RSV. Ensure that the infant’s bottles are sterilized.

Limit the baby’s exposure to crowds of people.

Daily administration of prophylactic antibiotics.

ANS: C

Limiting exposure to crowds of people will limit the exposure to respiratory viruses including RSV. Sterilizing bottles will not protect the infant from RSV. There is no vaccine available for RSV. Antibiotics are not effective for viral infections such as RSV. DIF: Cognitive Level: Understand (Comprehension) 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: NCLEX: Physiological Adaptation 13. Which assessment finding explains why the patient developed right-sided heart failure? a. The patient’s resting heart rate is usually 55 to 60 beats/minute. b. The patient’s resting heart rate is usually 58 to 60 beats/minute. c. The patient has 2+ pitting edema of the legs, feet, and abdomen. d. The patient was diagnosed with cystic fibrosis at 2 years of age.

ANS: D

Chronic respiratory conditions such as cystic fibrosis predispose the patient to right-sided heart failure as the heart must work harder to compensate for the respiratory disease. Resting heart rate of 55 to 60 beats/minute is normal for some patients and will not lead to right-sided heart failure. 2+ pitting edema of the legs, feet, and abdomen is a symptom of right-sided heart failure rather than a cause of it. Athletic training will not lead to right-sided heart failure.

N R I G B.C M

U S N T O DIF: Cognitive Level: Apply (Application) OBJ: Identify the physiological processes of cardiac output and respiratory gas exchange.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 14. Which assessment finding explains the patient’s tachycardia? a. The patient drinks at least eight cans of diet cola every day. b. The patient takes digoxin 0.125 mg PO daily. c. The patient has a history of untreated hypothyroid disease. d. The patient takes metoprolol 50 mg PO daily.

ANS: A

Caffeine in diet cola causes elevation of the heart rate and tachycardia. Untreated hypothyroid disease, digoxin, and metoprolol cause bradycardia.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 15. The nurse is caring for a patient who has shallow breaths following abdominal surgery. Which

respiratory complication is most likely to occur as a result of the patient’s breathing pattern? a. Aspiration b. Atelectasis c. Cor pulmonale

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Essentials for Nursing Practice 9th Edition Potter Test Bank d. Pulmonary fibrosis ANS: B

Atelectasis is collapse of the alveoli due to shallow breathing after surgery and general anesthesia. The patient should be encouraged to take deep breaths to avoid development of atelectasis. Shallow breathing will not lead to aspiration, cor pulmonale, or pulmonary fibrosis.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 16. Which intervention will most effectively maintain breathing function for a patient with muscle

weakness due to amyotrophic lateral sclerosis (ALS)? a. Teaching pursed-lip breathing exercises b. BiPAP (bi-level positive airway pressure) c. Administration of oxygen via nasal cannula d. CPAP (continuous positive airway pressure) ANS: B

ALS results in progressive respiratory muscle weakness. The patient with ALS will benefit from BiPAP to provide assistance during expiration and prevent the alveoli from collapsing during exhalation. CPAP is used to treat sleep apnea. Oxygen administration and pursed-lip breathing will not assist respiratory muscle weakness.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify nursing interventions maintenance, and restoration of cardiopulmonary N RforIpromotion, G B.C M e and continuing function in the primary care, acut U e carSe, a N n d rT e storativO care settings.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 17. Which is the highest priority nursing diagnosis for the patient admitted with pneumonia? a. Activity intolerance related to increased oxygen demand with exertion b. Ineffective airway clearance related to inability to cough up thick secretions c. Risk for fluid volume deficit related to inadequate intake of fluids with fever d. Imbalanced nutrition related to loss of appetite and increased metabolic demand ANS: B

Ineffective airway clearance is the highest priority nursing diagnosis as it relates to oxygen, the body’s most basic need. Risk for fluid volume deficit, imbalanced nutrition, and activity intolerance may be addressed once the airway is clear.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Adaptation 18. Which is the priority outcome for the patient with pulmonary embolism and the nursing

diagnosis impaired gas exchange related to impaired pulmonary perfusion? a. The patient’s pulse oximetry will stay at least 93%. b. The patient’s lung sounds will remain clear bilaterally. c. The patient will verbalize understanding of oxygen therapy.

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Essentials for Nursing Practice 9th Edition Potter Test Bank d. The patient will walk 50 feet in the hallway without dyspnea.

ANS: A

Maintenance of pulse oximetry greater than 93% is the highest priority outcome as it demonstrates adequate oxygenation in the patient with pulmonary embolism. Lung sounds may remain clear with pulmonary embolism as the problem is caused by blockage of blood vessels within the lung. Verbalizing understanding of oxygen therapy and walking in the hall without dyspnea are less important outcomes.

DIF: Cognitive Level: Apply (Application) 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: Planning MSC: NCLEX: Physiological Adaptation 19. Which assessment finding is expected for a patient with a chest tube for treatment of

hemothorax? a. Constant bubbling in the water-seal chamber b. Presence of bloody drainage from the chest tube c. The patient denies having pain at the chest tube site d. Subcutaneous emphysema is present around the chest tube site ANS: B

Hemothorax occurs when the pleural space is filled with blood. The nurse expects the patient’s chest tube drainage to be bloody during treatment of hemothorax. Constant bubbling in the water-seal chamber and subcutaneous emphysema indicate leakage of air from the tube into the chest. It would be unusual for the patient to deny having pain at the chest tube site.

DIF: Cognitive Level: UndersN tandR(CoImpG reheB ns. ioC n) M U S N T O 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: NCLEX: Physiological Adaptation 20. When will the nurse clamp the patient’s chest tube? a. When the patient ambulates in the hallway b. When changing the drainage collection unit c. Before assisting the patient to take a shower d. When disconnecting the chest tube from suction ANS: B

The drainage collection unit should be changed when it is full or damaged. The chest tube must be clamped when changing the unit in order to prevent air from entering the chest cavity.

The tube should not be clamped during ambulation or when disconnecting the chest tube from suction. The patient with a chest tube cannot shower as the site must be kept clean and dry.

DIF: Cognitive Level: Understand (Comprehension) 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: NCLEX: Physiological Adaptation 21. Which type of sterile dressing will be applied to the chest wall after removal of the patient’s

chest tube? a. Dry gauze dressing

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Essentials for Nursing Practice 9th Edition Potter Test Bank b. Absorbent foam dressing c. Petroleum gauze dressing d. Nonadherent gauze dressing ANS: C

An occlusive dressing must be applied to the chest tube site following removal to prevent entry of air into the chest cavity. Gauze impregnated with petroleum jelly is an example of an occlusive dressing. Dry gauze is not occlusive and will allow air into the chest cavity.

Absorbent foam dressings are used to absorb large amounts of drainage from wounds and are not appropriate for chest tube sites.

DIF: Cognitive Level: Understand (Comprehension) 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: NCLEX: Physiological Adaptation 22. The patient’s tuberculosis test appears red and flat after the injection 48 hours ago. Which is

the appropriate action of the nurse? a. Repeat the tuberculosis test because the results are inconclusive. b. Measure the reddened area in millimeters and document the result. c. Document the results as a negative reaction to the tuberculosis test. d. Contact the state health department about the patient’s positive test.

ANS: C

A reddened flat area is not a positive reaction that does not need to be measured. A positive tuberculosis skin result is a palpable, elevated, hardened area around the injection site.

DIF: Cognitive Level: UndersN tandR(CoImpG reheB ns. ioC n) M U S N T O 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: NCLEX: Physiological Adaptation 23. Which nursing diagnosis is appropriate for a patient using CPAP therapy to treat sleep apnea? a. Readiness for enhanced sleep related to desire for restful sleep b. Disturbed body image related to use of CPAP mask for sleeping c. Risk for disuse syndrome related to discomfort from CPAP mask d. Risk for impaired skin integrity related to tight-fitting mask on face ANS: D

The patient’s facial skin may become irritated from the tight-fitting CPAP mask. This is the highest priority diagnosis as it addresses a patient safety need. Risk for disuse syndrome is inappropriate for sleep apnea as the diagnosis relates to deterioration of a body part because of inactivity. Disturbed body image and readiness for enhanced sleep are lower priority nursing diagnoses for this patient.

DIF: Cognitive Level: Analyze (Analysis) 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: Diagnosis MSC: NCLEX: Physiological Adaptation 24. The nurse assists a patient who collapsed in cardiac arrest. Which is the first action of the

nurse?

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Essentials for Nursing Practice 9th Edition Potter Test Bank a. b. c. d.

Determine the patient’s cardiac rhythm.

Administer fast, deep chest compressions.

Ensure that a patent airway is maintained.

Ventilate the patient using a barrier device.

ANS: B

The first action of the nurse is to begin chest compressions. Determining the cardiac rhythm, ensuring a patent airway, and ventilating the patient are done after chest compressions are initiated.

DIF: Cognitive Level: Understand (Comprehension) 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: NCLEX: Physiological Adaptation 25. The nursing staff is caring for a patient who collapsed in cardiac arrest. When will breaths be

delivered via the bag-valve mask device? a. After the patient is intubated b. After every 30 chest compressions c. When the patient’s lips start to become cyanotic d. When another nurse takes over chest compressions ANS: B

Two breaths are delivered via the bag-valve mask device after each set of 30 chest compressions. The mask device is not used after the patient is intubated. Frequency of breaths is not determined by the presence or absence of cyanosis or change of staff providing chest compressions.

N R I G B.C M

U (Comprehension) S N T O DIF: Cognitive Level: Understand 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: NCLEX: Physiological Adaptation 26. Which patient would benefit from education about pursed-lip breathing? a. A patient with emphysema after many years of smoking b. A patient with a pneumothorax and a chest tube to suction c. A patient with a tracheostomy following throat cancer surgery d. A patient with respiratory muscle paralysis after spinal cord injury ANS: A

A patient with emphysema would benefit from pursed-lip breathing as it facilitates exhalation of air from the lungs. Pursed-lip breathing is not recommended for patients with chest tubes.

Patients with tracheostomy or respiratory muscle paralysis would not be able to do pursed-lip breathing.

DIF: Cognitive Level: Apply (Application) 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: NCLEX: Physiological Adaptation 27. Which patient would benefit from BiPAP therapy? a. Surgical patient under general anesthesia

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Essentials for Nursing Practice 9th Edition Potter Test Bank b. Confused, agitated patient with no gag reflex c. Patient with pulmonary edema due to CHF exacerbation d. Stroke patient who frequently aspirates fluids and saliva ANS: C

A patient with pulmonary edema would benefit from BiPAP therapy as it will assist with inspiration, prevent alveolar collapse during exhalation, and improve oxygenation. BiPAP is not appropriate for patients who are confused or unable to swallow. Patients under general anesthesia must be intubated in order to maintain the airway as well as ventilation.

DIF: Cognitive Level: Analyze (Analysis) 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: NCLEX: Physiological Adaptation 28. The nurse has orders to titrate the patient’s oxygen to maintain a pulse oximetry level greater

than 94%. The patient’s pulse oximetry will not rise above 90% despite use of a nonrebreather mask. Which is the appropriate action of the nurse? a. Insert an oral airway and apply a full face oxygen mask. b. Call respiratory therapy to consider BiPAP support for the patient. c. Remove the nonrebreather mask and replace it with a Venturi mask. d. Place an oxygen nasal cannula underneath the patient’s nonrebreather mask.

ANS: B

BiPAP is a form of noninvasive ventilation that is used to assist patients in respiratory failure without intubation. The nurse should respiratory therapy to consider BiPAP support for the patient because oxygen via nonrebreather mask is not sufficient to maintain oxygenation.

Inserting an oral airway will N cauR se t hIe p G a t i e nBt .t oCg a M g . The nonrebreather mask covers the U S N T O mouth and nose already. Venturi mask will deliver less oxygen than a nonrebreather mask. An oxygen nasal cannula should not be placed underneath the nonrebreather mask.

DIF: Cognitive Level: Analyze (Analysis) 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: NCLEX: Physiological Adaptation 29. The nurse is caring for a dying patient in hospice. The patient’s respirations are slow and

uneven with deep breaths and long periods of apnea. Which term best describes this breathing pattern? a. Rhonchal bradypnea b. Forrest-Shiley breaths c. Kussmaul’s respirations d. Cheyne-Stokes breathing ANS: D

Cheyne-Stokes respirations have uneven with deep breaths and long periods of apnea.

Kussmaul respirations are deep and rapid to blow off excess carbon dioxide with metabolic acidosis. Rhonchal bradypnea and Forrest-Shiley breaths are not accepted terms.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.

TOP: Nursing Process: Assessment

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Essentials for Nursing Practice 9th Edition Potter Test Bank MSC: NCLEX: Physiological Adaptation 30. The nurse assesses distended neck veins in a patient sitting in a chair to eat. Which is the

priority intervention of the nurse? a. Document the observation in the chart. b. Assess the patient’s deep tendon reflexes. c. Measure urine specific gravity and volume. d. Check the patient’s pulse and blood pressure.

ANS: D

Distended neck veins indicate venous congestion in the systemic circulation and possibly right-sided heart failure. The nurse’s priority action is to check the patient’s pulse and blood pressure. Distended neck veins may be documented in the chart but that is not the priority action of the nurse. There is no need to check specific gravity or deep tendon reflexes.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the interrelationship of cardiac output, preload, afterload, contractility, and heart rate.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 31. The nurse is caring for a patient a serum potassium level of 7.4 mEq/L. Which is the highest

priority nursing diagnosis for this patient? a. Nausea related to side effects from medications b. Ineffective tissue perfusion related to altered mental status c. Fluid volume excess related to increased isotonic fluid retention d. Risk for decreased cardiac output related to altered heart rhythm ANS: D

The patient’s dangerously hi gNh pRo t a sIs i u m l e v e l Cc a uM s e s risk of ventricular fibrillation. The U for S the N Gpatient T B .isOrisk highest priority nursing diagnosis for decreased cardiac output related to altered heart rhythm. Nausea is not the highest priority diagnosis. Fluid volume excess is not expected with a potassium level of 7.4 mEq/L. There is no indication of the patient having an altered mental status.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the interrelationship of cardiac output, preload, afterload, contractility, and heart rate.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Adaptation 32. The nurse is caring for a patient who has pneumonia and chronic bronchitis. The patient is

very congested, coughing up copious amounts of thick green sputum. Which breath sounds will the nurse expect to hear? a. Fine crackles b. Coarse rhonchi c. Diminished bases d. Scattered wheezes ANS: B

Coarse rhonchi are heard when thick sputum is heard in the airways. Fine crackles are heard when there is watery fluid in the airways. Diminished bases are heard when the patient is taking shallow breaths. Scattered wheezes are heard when there is narrowing of the airways such as from asthma.

DIF:

Cognitive Level: Apply (Application)

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Essentials for Nursing Practice 9th Edition Potter Test Bank OBJ: Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 33. Which is the priority action of the nurse for a patient with ventricular tachycardia? a. Assess the patient for signs of digoxin toxicity. b. Draw serum electrolytes to check for hyperkalemia. c. Start chest compressions if there is no palpable pulse. d. Check the patient’s BP and administer sublingual nitroglycerin.

ANS: C

The patient with ventricular tachycardia may or may not have a pulse. The most appropriate option is for the nurse to start chest compressions if there is no palpable pulse. Checking the patient’s BP, drawing blood for laboratory testing, and assessing for digoxin toxicity are not priority interventions for a patient without a palpable pulse.

DIF: Cognitive Level: Understand (Comprehension) 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: NCLEX: Physiological Adaptation 34. The nurse assesses a patient during suctioning. Which finding indicates that the procedure

should be stopped immediately? a. Pulse oximetry decreases from 98% to 92%. b. Heart rate decreases from 78 to 40 beats/minute. c. Respiratory rate increases from 16 to 20 breaths/minute. d. Blood pressure increases from 110/70 to 120/80 mm Hg. ANS: B

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Decreased heart rate to 40 beats/minute indicates that the patient is not tolerating the suction procedure and it should be stopped immediately. Pulse of 92%, respiratory rate of 20, and BP 120/80 do not warrant immediately stopping suction.

DIF: Cognitive Level: Apply (Application) 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: NCLEX: Physiological Adaptation MULTIPLE RESPONSE 1. Which assessment findings indicate to the nurse that the patient is hypoxic? (Select all that

apply.) a. Heart rate is 55 beats/minute and irregular. b. Urine output is 300 mL over the last 8 hours. c. The patient is drowsy and difficult to arouse. d. Hands and feet are pale and cool to the touch. e. Abdomen is soft with bowel sounds  4 quadrants.

ANS: A, C, D

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Essentials for Nursing Practice 9th Edition Potter Test Bank Bradycardia, impaired mental status, and poor circulation all indicate that the patient is hypoxic. Soft abdomen with bowel sounds  4 quadrants and urine output at least 30 mL/hour are normal findings.

DIF: Cognitive Level: Apply (Application) OBJ: Identify and describe clinical outcomes for hyperventilation, hypoventilation, and hypoxemia.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 2. Which assessment findings indicate that the patient is at risk for developing ventricular

fibrillation? (Select all that apply.) a. Serum potassium level 7.6 mEq/L b. Long history of coronary artery disease c. Impaired conduction through the SA node d. Recent incidents of ventricular tachycardia e. Vagal stimulation from removal of fecal impaction ANS: A, B, D

Hyperkalemia, coronary artery disease, and recent incidents of ventricular tachycardia are all risk factors for development of ventricular fibrillation. Impaired SA node conduction and vagal stimulation would lead to bradycardia rather than fibrillation.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 3. Which interventions are appropriate for the patient with the nursing diagnosis decreased

cardiac output related to reduN ceUdRsS troIkN eG voTluBm.eCa O ndMcontractility? (Select all that apply.) a. Frequent lung sound assessment and continuous pulse oximetry. b. Strict intake and output monitoring with daily weights before breakfast. c. Administer oxygen to maintain pulse oximetry levels between 90% and 92%. d. Provide stool softeners and encourage dietary fiber to prevent constipation. e. Encourage the patient to consume additional salt to maintain blood pressure.

ANS: A, B, D

Lung sounds and pulse oximetry will monitor for impaired oxygenation and pulmonary edema. Strict intake and output will monitor for weight gain seen with congestive heart failure. Constipation should be avoided as straining at stool can lead to dysrhythmias. The patient’s pulse oximetry should be kept at least 95% to promote oxygenation of tissues.

Additional salt will increase cardiac workload and lead to worsening of heart failure.

DIF: Cognitive Level: Analyze (Analysis) 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: NCLEX: Physiological Adaptation

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Essentials for Nursing Practice 9th Edition Potter Test Bank

Chapter 33: Sleep Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which assessment finding indicates to the nurse why the patient is having difficulty sleeping

at night? a. The patient follows an organic, low-carbohydrate diet. b. The patient enjoys doing crossword puzzles and reading. c. The patient’s job includes many hours of hard labor each day. d. The patient now works in Alaska with extended daylight hours.

ANS: D

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.

Low-carbohydrate diet, reading, and manual labor will not cause the patient’s sleep problems.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the effect the 24-hour sleep-wake cycle has on biological function.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 2. Which is the priority nursing diagnosis for an adolescent who gets up at 5:00 a.m. every

morning for school and studies until midnight every night? a. Fatigue related to insufficient rest and stress of academic demands N eS RntiI b. Risk for injury related to i nU att oNn G aT nB.C d exceO sM sive daytime sleepiness c. Deficient diversional activity related to lack of time for recreation and leisure d. Impaired social interaction related to time required to study and maintain grades ANS: B

Adolescents need between 8 to 10 hours of sleep each night. An adolescent who gets only 5 hours of sleep at night is at risk of injury due to intention and effects of excessive daytime sleepiness. This is particularly true if the adolescent is driving. Fatigue, deficient diversional activity, and impaired social interaction are all less important than the risk for injury.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Compare and contrast the characteristics of sleep for different age-groups.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 3. The nurse is caring for a patient with congestive heart failure. The patient reports frequently

waking up at night gasping for air. What is the cause of the patient’s awakenings? a. The patient is going to bed too early every night. b. The patient consumed caffeine just before going to bed. c. The patient consumed too much fiber before going to bed. d. The pulse, respirations, and blood pressure drop during sleep.

ANS: D

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Essentials for Nursing Practice 9th Edition Potter Test Bank Heart rate, respirations, and blood pressure drop during sleep. This can cause the patient with congestive heart failure to wake up gasping during the night as the blood oxygenation drops to dangerously low levels. Going to bed early and consuming fiber or caffeine before bed would not cause the patient to wake up gasping for air.

DIF: Cognitive Level: Apply (Application) OBJ: Identify factors that promote or disrupt sleep.

MSC: NCLEX: Physiological Adaptation

TOP: Nursing Process: Diagnosis

4. A new mother is exhausted because her 4-week-old infant is unable to sleep through the night.

Which is the best recommendation of the nurse? a. “Try to sleep when your baby is sleeping.” b. “Try keeping the room warm during the night.” c. “Try not to let your baby nap during the day.” d. “Try laying the baby on his stomach at night.”

ANS: A

Infants usually develop a nighttime pattern of sleep by 3 to 4 months of age. The neonate and infant up to the age of 3 months average about 16 to 18 hours of sleep a day. The mother should be encouraged to sleep when the baby is sleeping. Infants sleep best when the room temperature is 18° C to 21° C (64° F to 70° F). The infant is likely to become irritable and overtired if napping during the day is prevented. Infants should be laid on their backs to sleep to prevent Sudden Infant Death Syndrome.

DIF: Cognitive Level: Apply (Application) OBJ: Describe interventions appropriate to promoting sleep for patients with various sleep disorders.

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

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5. What is the best intervention to help a school-age child fall asleep at night? a. Encourage exercise in the evening to promote fatigue. b. Provide the child with a high-protein snack before bed. c. Have the parent read a quiet bedtime story to the child. d. Have the child complete homework before going to bed.

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 eating are not quiet activities.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss differences in sleep interventions for patients of different age-groups.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. Which intervention is most appropriate to treat ongoing insomnia for a middle-aged adult with

a busy career? a. Obtain a prescription for zolpidem to be taken at bedtime. b. Suggest having warm milk with a shot of whisky before going to bed. c. Encourage the patient to practice peaceful meditation before bedtime. d. Recommend the use of sleep aids such as triazolam.

ANS: C

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Essentials for Nursing Practice 9th Edition Potter Test Bank The patient should be encouraged to try nonpharmaceutical methods to reduce stress and reduce insomnia. Meditation is a calming activity that can help prepare the patient to fall asleep. Zolpidem and triazolam should not be taken for long periods of time and carry the risk of side effects. Alcohol disrupts sleep patterns and should be avoided.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss differences in sleep interventions for patients of different age-groups.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. Which assessment finding indicates that the patient’s CPAP is effectively treating the

patient’s sleep apnea? a. The patient is able to fall asleep within 30 minutes of going to bed. b. The patient is getting an average of 7 to 8 hours of sleep each night. c. The patient does not require trazodone to fall asleep. d. The patient sleeps through the night without having to get up and urinate.

ANS: D

Nocturia is a sign of sleep apnea so the patient’s ability to sleep through the night without having to get up and urinate indicates that the CPAP therapy is effective. Getting 7 to 8 hours of sleep at night, not requiring trazodone, and falling asleep readily do not indicate effective treatment of sleep apnea.

DIF: Cognitive Level: Apply (Application) OBJ: Describe ways to evaluate the effectiveness of sleep therapies.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation 8. Which nighttime activity will keep the patient from being able to fall asleep easily? a. Doing crossword puzzlesNoU nR aS taI blN etGcom terOM TBp.uC b. Turning down the temperature in the bedroom c. Listening to recordings of soothing classical music d. Always going to bed at approximately the same time ANS: A

Doing crossword puzzles on a tablet computer engages the brain and makes it hard to fall asleep. In addition, the bright background light of the computer screen interferes with the brain’s ability to fall asleep. Turning down the temperature in the bedroom and listening to soothing music will facilitate falling asleep. Keeping a consistent bedtime will also help the body to relax and fall asleep.

DIF: Cognitive Level: Apply (Application) OBJ: Identify factors that promote or disrupt sleep.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 9. Which is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for

sleep apnea? a. Risk for impaired skin integrity related to tight-fitting mask on face b. Impaired bed mobility related to presence of CPAP mask on face c. Health-seeking behaviors related to expressed desire for better sleep d. Risk for powerlessness related to inability to breathe regularly during sleep ANS: A

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Essentials for Nursing Practice 9th Edition Potter Test Bank The CPAP mask can cause impaired skin integrity to the face unless it is applied and fitted correctly. The CPAP mask on the face will not cause impaired bed mobility. The patient is at low risk for powerlessness. Health-seeking behaviors are less important than the risk of skin breakdown.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify factors that promote or disrupt sleep.

MSC: NCLEX: Basic Care and Comfort

TOP: Nursing Process: Diagnosis

10. Which outcome is most appropriate for the patient with the nursing diagnosis insomnia

related to night shift work? a. The patient will rotate day/night work shifts frequently. b. The patient will obtain at least 48 hours of sleep per week. c. The patient will use caffeine sparingly to wake up before shifts. d. The patient will use bright lights to stay awake through the night.

ANS: B

The patient should obtain at least 48 hours of sleep per week, during the day and night as shifts permit. Frequent rotation of night/day shifts will worsen insomnia. Use of bright lights and caffeine are interventions rather than goals.

DIF: Cognitive Level: Apply (Application) OBJ: Describe ways to evaluate the effectiveness of sleep therapies.

TOP: Nursing Process: Planning MSC: NCLEX: Basic Care and Comfort 11. Which nursing intervention is appropriate for a patient with a history of parasomnia? a. Use of a bed alarm during the night b. Padded side rails for the pNaU tieRnS t’I s bNeG d TB.COM c. Use of a CPAP machine during the night d. Continuous pulse oximetry during the night ANS: A

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. A bed alarm is useful so that the nursing staff will be notified if the patient attempts to sleepwalk. Padded side rails, CPAP machine, and continuous pulse oximetry are not needed for parasomnia.

DIF: Cognitive Level: Apply (Application) OBJ: Describe interventions appropriate to promoting sleep for patients with various sleep disorders.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 12. Which assessment is most important to determine if a patient is receiving sufficient sleep? a. Sleep-wake pattern b. Frequency of nocturia c. Hours of sleep each night d. Whether the patient feels rested ANS: D

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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 of times awake for nocturia are not the most important to assess to determine effectiveness of the patient’s sleep, the subjective experience of the patient is the most important.

DIF: Cognitive Level: Apply (Application) OBJ: Summarize the elements of a sleep history and assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 13. Which is the safest sleep aid for the elderly patient with insomnia? a. Melatonin b. Trazodone c. Temazepam d. Triazolam ANS: A

Melatonin is the safest option for an elderly patient with insomnia although it is meant for short-term use. Trazodone can cause orthostatic hypotension. Temazepam and triazolam can cause cognitive impairment in older adults.

DIF: Cognitive Level: Apply (Application) OBJ: Describe interventions appropriate to promoting sleep for patients with various sleep disorders.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 14. Which assessment findings leNad R the I nursG e toBs. usC pecM t that the patient has obstructive sleep

U S N T

O

apnea? a. Daytime sleepiness, snoring, and obesity b. Insomnia, inability to concentrate, and anemia c. Early morning awakening, shift work, and attention deficit disorder (ADD) d. Latex allergy, stressful career, and recent divorce ANS: A

Daytime sleepiness and snoring in an overweight patient indicates the strong possibility of sleep apnea. The patient should be referred for further testing. Insomnia, early morning awakening, and stressful career do not lead to sleep apnea.

DIF: Cognitive Level: Apply (Application) OBJ: Summarize the elements of a sleep history and assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15. Which patient assessment finding leads the nurse to suspect that the patient may have central

sleep apnea? a. Use of nicotine chewing gum to stop smoking b. History of iron deficiency anemia and hemoglobin 13 g/dL c. History of cervical spine degeneration d. Use of nitrofurantoin to treat urinary tract infection ANS: C

Degeneration of the cervical spine can lead to central sleep apnea as the brain fails to send stimuli to breathe. Iron deficiency anemia, nicotine chewing gum, and nitrofurantoin do not lead to central sleep apnea.

DIF: Cognitive Level: Apply (Application) OBJ: Summarize the elements of a sleep history and assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 16. Which nursing intervention is appropriate for a postoperative patient with a history of sleep

apnea? a. Padded side rails b. Bedside commode c. Continuous pulse oximetry d. Suction equipment at bedside ANS: C

Continuous pulse oximetry is important for postoperative patients with sleep apnea to monitor for hypoxemia. Pain medications and anesthesia are likely to worsen sleep apnea. Padded side rails, bedside commode, and suction equipment are not needed.

DIF: Cognitive Level: Apply (Application) OBJ: Describe interventions appropriate to promoting sleep for patients with various sleep disorders.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. Which is the appropriate outcome for a patient with the nursing diagnosis insomnia related to

overwhelming parental and job responsibilities? a. The patient will sleep longer throughout the night. b. The patient will wake up N M orning. mU oR reS reIfrN esGhT edBi. nC thO em c. The patient will fall asleep within 30 minutes of going to bed. d. The patient will take a warm bath nightly before going to bed.

ANS: C

Falling asleep within 30 minutes of going to bed is a measurable, appropriate goal. Waking up more refreshed or sleeping longer is not measurable. Taking a warm bath before bed is an intervention rather than a goal.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe ways to evaluate the effectiveness of sleep therapies.

TOP: Nursing Process: Planning MSC: NCLEX: Basic Care and Comfort 18. Which nursing intervention can cause an unsafe sleeping environment for the hospitalized

patient? a. A small night-light left on in the bedroom. b. The patient’s bed is in high position with side rails up. c. All clutter is removed between the bed and the bathroom. d. Call bell at the bedside for the patient to contact the nurse.

ANS: B

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 patient’s reach. The call light helps alert the nursing staff, not the family. A small night-light is beneficial to help with vision.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss differences in sleep interventions for patients of different age-groups.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 19. Which bedtime action by the nurse may make it more difficult for the patient to fall asleep? a. Giving the patient a gentle backrub b. Providing a warm cup of hot chocolate c. Encouraging the patient to use the bathroom d. Giving the patient an extra blanket when cold ANS: B

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 backrub, and offer an extra blanket to prevent chilling when trying to fall asleep.

DIF: Cognitive Level: Apply (Application) OBJ: Describe interventions appropriate to promoting sleep for patients with various sleep disorders.

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

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20. Which is the highest priority nursing diagnosis for a patient who developed sleep-related

eating disorder when taking zolpidem? a. Risk for falls related to ambulating to kitchen while asleep b. Wandering related to cognitive impairment from sleeping aid c. Powerlessness related to inability to keep from eating during sleep d. Risk for imbalanced nutrition: more than body requirements related to sleep eating ANS: A

The highest priority nursing diagnosis is the risk for falls as serious injury may result.

Wandering and powerlessness are less important than falls. Weight gain is less dangerous than the patient’s risk of falling. Significant weight gain should not occur once the patient stops taking the medication.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss characteristics of common sleep disorders.

MSC: NCLEX: Safety and Infection Control

TOP: Nursing Process: Diagnosis

21. Why is it important for a postoperative patient to get enough sleep after being discharged from

the hospital? 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 is to help the body to heal by restoring biological processes. Sleep allows the body to restore biological processes.

During deep slow-wave (NREM N3) 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 body’s 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Explain the functions of sleep.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 22. How can the nurse best assist a hospitalized young child to fall asleep? a. Eliminate a daytime nap. b. Offer the child warm chocolate milk. c. Maintain the child’s 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 parent’s lap while N B.C MOtines associated with preparing for bed. listening to music or praying, aU ndR cSo I l oNrG i n gT a r e rou 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss differences in sleep interventions for patients of different age-groups.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 23. Which bedtime snack will best help the patient to fall asleep easily? a. Bowl of cereal with milk b. Ham sandwich, fruit, and juice c. Glass of red wine with wheat crackers d. Chocolate chip cookies and a cup of hot tea 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. Alcohol disrupts sleep patterns and can make it difficult to fall asleep.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss differences in sleep interventions for patients of different age-groups.

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

24. Why will the patient with sleep apnea be encouraged to use the CPAP machine while in the

hospital after surgery? a. It will keep the patient in deep levels of REM, which will decrease the need for pain medication. b. It will help decrease noise from the roommate and hospital environment that may 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 patient’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe interventions appropriate to promoting sleep for patients with various sleep disorders.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE

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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. Provide personal hygiene before bedtime. b. Straighten and change any soiled bed linens. c. Assist the patient to use the toilet before bed. d. Administer sleep aids every night at the same time. e. Synchronize the schedule for medications and vital signs.

ANS: A, B, C, E

You will make the patient more comfortable in an acute care setting by providing personal hygiene before bedtime. Have patients void before going to bed so they are not kept awake by a full bladder. Clean, dry linens make the patient comfortable for falling asleep. Medications and vital signs should be scheduled to wake the patient as infrequently as possible. Sleep aids should be avoided as they carry risk of side effects and long-term dependency.

DIF: Cognitive Level: Apply (Application) OBJ: Describe interventions appropriate to promoting sleep for patients with various sleep disorders.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 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. Impaired judgment e. Increased periods of sleep ANS: A, C, D

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 individual’s usual sleep-wake cycle negatively influences the person’s overall health.

DIF: Cognitive Level: Apply (Application) OBJ: Explain the effect the 24-hour sleep-wake cycle has on biological function.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is reviewing a patient’s medical history. Which medication findings are likely to

cause insomnia? (Select all that apply.) a. Takes a beta-adrenergic blocker b. Takes a muscle relaxant c. Has antihistamine abuse d. Has a diuretic ordered in the a.m. e. Takes a benzodiazepine ANS: A, C

Beta-adrenergic blockers and antihistamines when used in excess can cause insomnia. Muscle relaxants and benzodiazepine can cause drowsiness. Diuretics do not cause insomnia but if administered late in the day cN anUlR eaSdItoNnGoT ctB ur. iaC , cOa M u s i n g nighttime awakenings.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Summarize the elements of a sleep history and assessment.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies

Chapter 34: Pain Management Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which is the highest priority nursing diagnosis for a patient with a spinal cord injury and no

pain sensation below the waist? a. Potential for injury related to lack of sensation and protective reflexes b. Disturbed body image related to loss of body function and sensation c. Readiness for enhanced self-care related to desire for increased independence d. Risk for loneliness related to discomfort in social situations due to disability ANS: A

The patient is at high risk of injury to the lower body due to the inability to feel pain or other sensations. The patient will not be able to tell when a body part is being pinched or burned before significant damage occurs. Risk for injury is higher priority than the patient’s psychosocial needs for body image, self-care, or loneliness.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Develop appropriate nursing diagnoses for a patient experiencing pain.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Adaptation 2. Why is acute pain particularly dangerous for a patient having a heart attack? a. Release of endorphins causes dangerous elevation of blood pressure. b. Release of substance P narrows the airways and leads to hypoxemia. c. Release of prostaglandins lowers the patient’s heart rate and blood pressure.

NUetic RSner I Nvou G T B.C M d. Stimulation of the sympath Owill increase cardiac workload. s system ANS: D

Acute pain of low-to-moderate intensity and superficial pain cause the fight-or-flight response from the sympathetic branch of the autonomic nervous system and elevates pulse. Endorphins are natural morphine-like substances that decrease pain. Substance P helps transmit pain impulses from periphery to higher brain centers and causes vasodilation and edema.

Prostaglandins increase sensitivity to pain.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the physiology of pain.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 3. Which is an example of nociceptive pain? a. Neuropathy due to uncontrolled diabetes b. Phantom pain after amputation of a limb c. Pain from rheumatoid arthritis joint damage d. Chronic nerve pain after shingles infection ANS: C

Nociceptive pain is due to damaged tissues such as bones, skin, and organs. An example of nociceptive pain would be pain resulting from rheumatoid arthritis joint damage. Neuropathy, phantom pain, and chronic nerve pain are all examples of neuropathic pain.

DIF:

Cognitive Level: Understand (Comprehension)

OBJ: Describe the physiology of pain.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 4. The nurse is caring for a patient who continues to have severe pain at the site of a fracture

long after it healed. The patient’s physicians can find no rationale for the pain. What is the most likely cause of the patient’s discomfort? a. The patient is trying to obtain unneeded pain medications. b. The patient has developed a complex regional pain syndrome. c. The patient is in denial that the fracture has healed completely. d. The patient is experiencing referred pain from a fracture elsewhere.

ANS: B

An example of idiopathic pain is complex regional pain syndrome. 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. There is no evidence that the patient is trying to obtain unneeded pain medications, is in denial, or is experiencing referred pain from another fracture.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the physiology of pain.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Adaptation 5. Which medication order will provide the most consistent control of the patient’s chronic pain? a. Fentanyl transdermal patch 25 mcg b. Hydromorphone 0.5 mg IV c. Fentanyl oral lozenge 200 mcg d. Morphine sulfate liquid 10 mg ANS: A

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The fentanyl transdermal patch provides consistent release of the medication for 3 days. IV administration of pain medication works quickly but also wears off quickly. Morphine sulfate liquid and the fentanyl oral lozenge are used to treat breakthrough pain as they are short-acting medications.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss nursing implications for administering analgesics.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 6. Which medication order will provide the most immediate relief of the patient’s acute pain? a. Morphine sulfate 5 mg PO b. Hydromorphone 0.5 mg IV c. Buprenorphine transdermal patch 10 mg d. Oxymorphone 30 mg extended release ANS: B

The IV route of administration allows for the quickest onset of action for medications. IV hydromorphone will provide the most immediate relief of the patient’s pain. Morphine sulfate will provide relief when given orally but not as fast as IV. Buprenorphine transdermal patch, and oxymorphone extended-release are formulations that will take longer to work.

DIF:

Cognitive Level: Apply (Application)

OBJ: Discuss nursing implications for administering analgesics.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 7. Which instruction will the nurse give to the patient about proper use of patient-controlled

analgesia (PCA)? a. “Wait until the pain becomes severe before pushing the PCA button.” b. “The PCA will deliver medication through the IV until the pain is all gone.” c. “You or a designated family member are the only one who gets to push the PCA button—nobody else may do so.” d. “The PCA will give additional pain medication whenever the button is pushed.”

ANS: C

The patient should be instructed not to let anyone else push the PCA pain button to avoid overdosage. One family member or significant other can be the patient’s primary pain manager and is allowed to push the PCA button. The patient should not wait until the pain becomes severe to push the PCA button. The PCA will have preset time limitations to determine how frequently the patient will receive a dose of pain medication no matter how often the button is pushed. The PCA will not continue to administer medication until the pain is completely relieved.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss nursing implications for administering analgesics.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 8. The nurse is caring for a patient who is having a heart attack. The patient tells the nurse that

the pain is down his left arm N raU thR erStI haN nG inThB is.cC heOstM . What type of pain is the patient experiencing? a. Referred b. Psychogenic c. Peripheral d. Chronic ANS: A

Referred pain is when the patient experiences discomfort at an area other than the source of the pain. In this case, the patient has left arm pain even though the source of the pain is the heart. Psychogenic pain is discomfort that is associated with psychological disorders.

Peripheral pain is a type of neuropathic pain due to damaged peripheral nerves of the hands and feet. A heart attack is an example of acute pain rather than chronic pain.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the physiology of pain.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 9. The nurse is caring for a patient who just underwent knee-replacement surgery. The patient

complains of pain at the operative site but it is too soon for the nurse to administer the next dose of pain medication. What is the appropriate action of the nurse? a. Give the next dose of prescribed pain medication early. b. Contact the surgeon immediately to assess the patient’s knee. c. Caution the patient about the risk of addiction to pain medications.

d. Apply an ice pack to the knee and elevate the patient’s knee on pillows.

ANS: D

Nonpharmaceutical methods are often effective for relieving musculoskeletal pain. Elevation of the joint and ice should be applied before contacting the surgeon. The next dose of pain medication should not be given early without the physician’s approval.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe nonpharmacological nursing interventions to manage pain.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 10. The nurse observes a postoperative patient trying to take a friend’s oxycodone pain pills in

addition to the pain medication administered by the nurse. Which is the priority nursing diagnosis for this patient? a. Risk for poisoning b. Situational low self-esteem c. Ineffective impulse control d. Readiness for enhanced comfort ANS: A

The patient is at risk for overdose of pain medication by taking the friend’s medication as well as what is administered by the nurse. The nurse needs to institute safety precautions to prevent the patient from taking excessive amounts of pain medications. Low self-esteem, impulse control, and enhanced comfort may be addressed after the risk for poisoning has been resolved.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Develop appropriate nurN singRdia I gnosG es f B or .a C p a ti M e nt experiencing pain.

U S N T O TOP: Nursing Process: Diagnosis MSC: NCLEX: Reduction of Risk Potential 11. The patient takes morphine sulfate controlled release every 12 hours for chronic severe cancer

pain. The last dose was 8 hours ago. The patient is presently moaning and states that the pain is very bad. Which is the best action of the nurse? a. Give the next scheduled dose of morphine sulfate controlled release now. b. Wait for the last dose of morphine sulfate controlled release to start taking effect. c. Carefully reposition the patient and reassess the pain in 1 hour. d. Contact the physician for a breakthrough pain medication order.

ANS: D

Morphine sulfate controlled release is an extended-release medication that provides pain relief for 8 to 12 hours. The patient is experiencing breakthrough pain and needs a dose of short-acting pain medication right away to relieve the immediate discomfort. The next dose of morphine sulfate controlled release should not be administered early as it is not ordered and will take many hours to take effect. The patient’s pain is so bad that repositioning and waiting an hour is inappropriate.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe guidelines for selecting and individualizing pain therapies.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies

12. Which assessment question enables the nurse to determine provocative factors of the patient’s

pain? a. “What does your pain feel like?” b. “Does anything make your pain worse?” c. “Can you show me where the pain is?” d. “Is the pain constant or does it come and go?”

ANS: B

The comprehensive assessment of pain aims to gather information about the cause of a person’s 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 unable to do because of your pain?

DIF: Cognitive Level: Apply (Application) OBJ: Assess a patient experiencing pain.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 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 nurse’s first response is which of the following? a. Ask the patient to rate the pain on a 0-to-10 scale. b. Check the patency of the N patiU inG trav Rent’ SIs N TBen.oCusOlMine. c. Call the physician or health care provider immediately. d. Speak to the patient in a calming tone to reduce anxiety.

ANS: A

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.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Evaluate a patient’s response to interventions that manage pain.

TOP: Nursing Process: Assessment MSC: NCLEX: Pharmacological and Parenteral Therapies 14. The patient expresses frustration about not being able to function as the family breadwinner

any longer due to chronic severe pain. Which psychosocial nursing diagnosis is most appropriate for this patient’s concern? a. Risk for loneliness related to need for prescription pain medications b. Interrupted family processes related to changes in assigned roles c. Disturbed sensory perception related to insufficient environmental stimuli d. Moral distress related to time constraints for ethical decision making ANS: B

Interrupted family processes is the appropriate nursing diagnosis because the patient no longer fills the role of family breadwinner. This has led to a change in the functioning of the family.

The scenario does not indicate risk for loneliness, disturbed sensory perception, or moral distress.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify components of the pain experience.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Diagnosis

15. Which is the appropriate goal for a nonverbal, confused patient with the nursing diagnosis

chronic pain related to widespread tissue damage? a. The patient’s pain will be reduced to a minimal level. b. The nurse will assess the patient’s pain every 2 hours. c. The patient will not demonstrate moaning or grimacing. d. The patient will use a 0-to-10 pain scale to identify pain levels.

ANS: C

Objective assessments of discomfort may be used when the patient is unable to verbalize sensations or rate pain on a scale. The absence of moaning or grimacing is objective and the nurse is able to determine whether or not the goal has been met. Pain assessment is an intervention rather than a goal. Minimal pain is not objective. The nonverbal confused patient will not be able to rate pain using a 0-to-10 pain scale.

DIF: Cognitive Level: Apply (Application) OBJ: Evaluate a patient’s response to interventions that manage pain.

TOP: Nursing Process: Planning MSC: NCLEX: Basic Care and Comfort 16. Which pain relieving option N shU ouRldSbIeNaG voTidBe. dC b yOaMp a t i e n t with chronic back pain who must

continue to work as a truck driver? a. Transcutaneous electrical nerve stimulation (TENS) unit b. Naproxen sodium 200 mg PO every 12 hours c. Tramadol extended release 200 mg PO daily d. Application of hot and cold packs to the lower back area ANS: C

Tramadol is a controlled substance that can cause seizures, hallucinations, and sedation.

Tramadol should not be taken before driving a vehicle or operating machinery. TENS units, NSAIDs such as naproxen sodium, and hot/cold packs are all acceptable options for the truck driver.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for selecting and individualizing pain therapies.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 17. Which nonpharmacological pain-relief technique is appropriate for a confused, nonverbal

patient? a. Tai chi b. Biofeedback c. Massage therapy d. Guided imagery

ANS: C

Massage therapy is appropriate for use with nonverbal, confused patients as it promotes relaxation and healing without the need for the patient to follow directions. A confused, nonverbal patient will not be able to follow the directions required for tai chi, biofeedback, or guided imagery.

DIF: Cognitive Level: Apply (Application) OBJ: Describe guidelines for selecting and individualizing pain therapies.

TOP: Nursing Process: Caring MSC: NCLEX: Basic Care and Comfort 18. Which assessment finding leads the nurse to clarify the patient’s order for morphine sulfate

controlled release 60 mg PO every 12 hours? a. The patient cannot swallow pills. b. The patient is allergic to latex and NSAIDs. c. The patient’s platelet count is 200,000/mm3. d. The patient does not have an intravenous line.

ANS: A

Morphine sulfate controlled release is an extended-release tablet that may not be crushed. This assessment finding leads the nurse to clarify the order. Allergies to latex and NSAIDs, normal platelet count and lack of an IV line are not contraindications for administration of morphine sulfate controlled release.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss nursing implications for administering analgesics.

TOP: Nursing Process: Assessment MSC: NCLEX: Pharmacological and Parenteral Therapies

NURSINGTB.COM 19. Which is an appropriate goal for a patient’s preoperative teaching? a. The nurse will provide written materials about nonpharmacological

pain-management techniques. b. The patient will verbalize understanding of the pain-management techniques to be used after surgery. c. The nurse will demonstrate correct use of the patient-controlled anesthesia (PCA) pump. d. The patient will rate current pain of less than 3 out of 10 on the descriptive pain intensity scale.

ANS: B

An appropriate goal of preoperative teaching is that the patient will verbalize understanding of the pain-management techniques to be used after surgery. The patient has not undergone surgery yet so current pain assessment is not a goal of preoperative teaching. Demonstration of the PCA pump and providing written materials are interventions rather than goals.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the sequence of interventions recommended in pain management.

TOP: Nursing Process: Planning MSC: NCLEX: Reduction of Risk Potential 20. Which is an example of an adjuvant medication for pain management? a. Naloxone b. Gabapentin

c. Morphine sulfate liquid d. Fentanyl transdermal patch ANS: B

Adjuvant medications enhance the properties of analgesic medications. Gabapentin is an anticonvulsant and is a type of adjuvant medication. Fentanyl transdermal patch and morphine sulfate liquid are examples of narcotic pain medications. Naloxone is used to reverse symptoms of narcotic overdose.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss nursing implications for administering analgesics.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 21. Which is the priority nursing diagnosis for a patient with a continuous epidural infusion of

fentanyl and bupivacaine? a. Risk for impaired gas exchange related to respiratory suppression b. Activity intolerance related to generalized weakness and bed rest c. Impaired physical mobility related to presence of epidural catheter d. Delayed surgical recovery related to need for continuous pain management ANS: A

Epidural infusion of fentanyl and bupivacaine can lead to respiratory suppression and risk for impaired gas exchange. Activity intolerance, impaired physical mobility, and delayed surgical recovery are less important than gas exchange.

DIF: Cognitive Level: Apply (Application) OBJ: Develop appropriate nurN singRdia I gnosG es f B or .a C p a ti M e nt experiencing pain.

O TOP: Nursing Process: DiagnosiU s S N T MSC: NCLEX: Pharmacological and Parenteral Therapies

22. Which nursing diagnosis is the highest priority for a patient who just received local anesthesia

to the back of the throat for a diagnostic procedure? a. Feeding self-care deficit related to pain and discomfort b. Risk for aspiration related to depressed gag reflex c. Impaired social interaction related to slurred speech d. Impaired oral mucus membrane related to dry mouth ANS: B

Local anesthesia works to block motor and sensory function of the affected tissue. Local anesthesia applied to the back of the throat will impair swallowing, depress the gag reflex, and put the patient at risk for aspiration. Feeding self-care deficit, impaired social interaction, and impaired oral mucus membrane diagnoses are not high priority.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Evaluate a patient’s response to interventions that manage pain.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE

1. Which assessment findings lead the nurse to clarify the order for ibuprofen 600 mg PO every

8 hours? (Select all that apply.) a. The patient has a gastrointestinal bleed. b. The patient has allergies to shellfish, strawberries, and iodine. c. The patient takes 30 mg morphine sulfate daily. d. The patient has a history of diabetes and early renal failure. e. The patient has severe joint pain due to aggressive arthritis.

ANS: A, D

Ibuprofen and other NSAID medications should not be taken by patients who have bleeding tendencies including anticoagulation with warfarin. Ibuprofen can be toxic to the kidneys and should be avoided by patients with renal failure. Taking ibuprofen with morphine increases the pain-relieving effects of the morphine. Ibuprofen and other NSAID medications are very effective for arthritic joint pain. Allergies to shellfish, strawberries, and iodine do not contraindicate administration of ibuprofen.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss nursing implications for administering analgesics.

TOP: Nursing Process: Assessment MSC: NCLEX: Pharmacological and Parenteral Therapies 2. Which medications are appropriate for a patient with chronic pain and cannot swallow pills?

(Select all that apply.) a. Morphine sulfate liquid b. Crushed extended-release morphine sulfate c. Fentanyl nasal spray d. Acetaminophen supposito ry I G B.C M N R e. Fentanyl transdermal patchU S N T O ANS: A, C, D, E

Morphine sulfate liquid, fentanyl nasal spray, acetaminophen suppository, and fentanyl transdermal patch are all options for patients who cannot swallow pills. Crushed morphine sulfate is an extended-release drug that should never be crushed.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss nursing implications for administering analgesics.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 3. Which medications are classified as nonsteroidal antiinflammatory medications? (Select all

that apply.) a. Tramadol b. Acetaminophen c. Aspirin d. Ibuprofen e. Codeine ANS: C, D

Aspirin and ibuprofen are examples of nonsteroidal antiinflammatory (NSAID) medications.

Codeine, acetaminophen, and tramadol are not NSAIDs. DIF:

Cognitive Level: Understand (Comprehension)

OBJ: Discuss nursing implications for administering analgesics.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies

NURSINGTB.COM

Chapter 35: Nutrition Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which is the best menu option for a patient with celiac disease? a. Baked chicken breast with roll and butter b. Spaghetti with meat sauce and tossed salad c. Oatmeal with raisins, brown sugar, and milk d. Pizza with tomato sauce, cheese, and mushrooms ANS: C

Oatmeal is gluten-free so it will not worsen symptoms of celiac disease. Pizza crust, roll, and pasta all contain gluten and should be avoided by patients with celiac disease.

DIF: Cognitive Level: Apply (Application) OBJ: Recognize a plan of care that meets the nutritional needs of a patient.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 2. Which menu option is least likely to cause wide variations in the diabetic’s blood sugar? a. Ham sandwich on whole wheat bread b. Sesame bagel with vegetable cream cheese c. Spaghetti with meat sauce and parmesan cheese d. Peanut butter and jelly sandwich on white bread ANS: A

Foods with complex carbohyN dratR es sIu chGas w le wMheat bread have less impact on blood Bh.oCO U S N T sugar than simple carbohydrates such as bagels, spaghetti, and wheat bread. The ham sandwich on whole wheat bread will have the least impact on the patient’s blood sugar levels.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Recognize a plan of care that meets the nutritional needs of a patient.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a pediatric patient with the nursing diagnosis constipation related to

side effects of medications. Which menu option will the nurse recommend to the patient? a. Baked chicken nuggets and canned peaches b. Pancakes with sausage, butter, and maple syrup c. Peanut butter and jelly sandwich on white bread d. Snack mix with dried apricots, raisins, and almonds ANS: D

Dried fruits and nuts are good sources of fiber to help relieve constipation. Meats, peanut butter, white bread, and pancakes will not relieve constipation.

DIF: Cognitive Level: Apply (Application) OBJ: Recognize a plan of care that meets the nutritional needs of a patient.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. Which laboratory finding indicates that the patient has not been eating well? a. Serum albumin level 2.1 g/dL

b. Presence of nitrites in the urine c. Prothrombin time 11.5 seconds d. Serum creatinine level 0.8 mg/dL ANS: A

Serum albumin levels should be 3.5 to 5 g/dL. The patient’s low serum albumin level indicates malnutrition. Presence of nitrites in the urine indicates urinary tract infection. The prothrombin time and serum creatinine level are both within normal limits.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the major areas of nutrition assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. Which food item contains the most calories? a. 1 g of cane sugar b. 1 g of lean meat c. 1 g of butter d. 1 g of banana ANS: C

Fats contain 9 kilocalories per gram (kcalorie/g) while carbohydrates and protein provide 4 kcalorie/g. Therefore 1 g of butter would have more calories than 1 g of lean meat, sugar, or banana.

DIF: Cognitive Level: Understand (Comprehension) OBJ: List the end products of digestion for carbohydrate, protein, and lipids.

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

N R I G B.C M

6. Which nursing diagnosis is moU st aS pproNpriaTte for aOnewborn who did not receive vitamin K

supplementation immediately after birth? a. Ineffective breastfeeding related to inability to latch on b. Ineffective protection related to impaired blood clotting c. Risk for unstable blood glucose related to developmental level d. Disorganized infant behavior related to altered primitive reflexes ANS: B

Vitamin K is needed for blood clotting. Infants are born without sufficient levels of vitamin K and are at risk for bleeding unless supplemental vitamin K is administered immediately after birth. Vitamin K does not affect breastfeeding, blood glucose, or infant reflexes.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify patients at risk for nutritional problems.

MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

7. Which intervention is most effective for measuring the patient’s fluid balance over time? a. Measure daily intake and output. b. Figure the patient’s body mass index. c. Record daily weights before breakfast. d. Calculate the patient’s ideal body weight.

ANS: C

Daily weights before breakfast provide information about fluid retention and diuresis. Daily intake and output are not as effective for assessing fluid balance over time. Calculation of ideal body weight and BMI do not accurately measure the patient’s fluid balance over time.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Recognize a plan of care that meets the nutritional needs of a patient.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. Which action of the patient will facilitate aspiration of food and fluids into the airway? a. The patient avoids talking when eating or swallowing. b. The patient tilts the head backward when swallowing. c. The patient thickens liquids to the consistency of honey. d. The patient clears the throat after every few bites of food.

ANS: B

The nurse should 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. Clearing the throat after every few bites of food helps to maintain a clear airway. The patient should avoid talking when eating or swallowing in order to concentrate on aspiration prevention.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Identify methods for feeding patients who require oral intake assistance.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 9. Which outcome is most appropriate for a patient with the nursing diagnosis imbalanced

nutrition: more than body reqNuU irR em SeIntNs GreTlaBte.dCtoOrMecent pregnancy and childbirth? a. The patient will lose 1 pound per week for the next 6 weeks. b. The patient will use fashion strategies to enhance appearance. c. The patient will regain normal liver enzymes within 1 month. d. The patient will demonstrate adaptation to body changes from pregnancy.

ANS: A

The patient should aim for slow, steady weight loss such as 1 pound per week for the next 6 weeks. Fashion strategies to enhance appearance and adaptation to body changes from pregnancy are appropriate for the altered body image nursing diagnosis. There is no mention of abnormal liver enzymes so the patient would not have a goal of regaining normal liver enzymes.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Recognize a plan of care that meets the nutritional needs of a patient.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 10. Which intervention is most appropriate for the patient with the nursing diagnosis imbalanced

nutrition: more than body requirements related to overeating? a. Use of dishware that limits portion sizes b. Menu consisting of purchased premeasured food c. Ketogenic diet that restricts carbohydrate intake d. Crash diet based on lemon juice and cabbage soup ANS: A

A successful weight-loss plan involves sustainable lifestyle modifications that include physical activity, self-monitoring, portion control, and knowledge of energy content of food.

Getting the weight off quickly using a crash diet is not healthy. Ketogenic diets can be harmful for some patients. Premeasured food is expensive and it is difficult to keep the weight off afterward.

DIF: Cognitive Level: Apply (Application) OBJ: Recognize a plan of care that meets the nutritional needs of a patient.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 11. Which is the best reason why a gastrostomy tube is ordered rather than parenteral nutrition for

a patient with dysphagia? a. Parenteral nutrition can only be administered to the patient in the hospital. b. The gastrostomy tube provides more nutrition and protects intestinal function. c. Parenteral nutrition is significantly more expensive than gastrostomy feedings. d. The gastrostomy tube allows for administration of medications as well as nutrition.

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 spouse’s question. The gastrostomy placement is invasive as the tube is inserted directly into the stomach. Patients can receive parenteral nutrition in the home.

DIF: Cognitive Level: AnalyzN eU (ARnS a lyIsN i s)GTB.COM OBJ: Describe the procedure for initiating and maintaining enteral tube feedings.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. Which is the first action of the nurse when administering intermittent enteral tube feedings to

the patient? a. Irrigate the tube with sterile saline. b. Place the patient in a supine position. c. Make sure that the feeding solution is chilled. d. Check to see that the tube is in the proper position.

ANS: D

The first step is to verify tube placement; feedings instilled into a misplaced tube can cause serious injury or death. The nurse will place the patient in Fowler’s or high-Fowler’s position, not supine, before starting the feeding. After checking for residual, flush the feeding tube with 30 mL of water rather than sterile saline. The feeding solution should be warmed or at room temperature as chilled feeding solution can cause abdominal cramping.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the procedure for initiating and maintaining enteral tube feedings.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. Which nursing diagnosis is the highest priority for a patient who had the large intestine

removed?

a. b. c. d.

Risk for deficient fluid volume related to excessive fluid loss in stool Risk for compromised human dignity related to stigma from ileostomy Bathing/hygiene self-care deficit related to presence of ileostomy bag Social isolation related to perceived offensive odor from ileostomy bag

ANS: A

Risk for deficient fluid volume related to excessive fluid loss in stool as the large intestine functions to absorb water from the stool. Without the large intestine, stools are watery and the patient is at risk for dehydration due to excessive fluid loss. Compromised human dignity, self-care deficit, and social isolation are all lower priority diagnoses.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify patients at risk for nutritional problems.

MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

14. Which is the highest priority nursing diagnosis for a patient with dysphagia following a

stroke? a. Risk for aspiration related to inability to ingest food and fluids safely b. Feeding self-care deficit related to neuromuscular impairment and weakness c. Risk for constipation related to intake of low-fiber foods and thickened liquids d. Imbalanced nutrition: less than body requirements related to swallowing difficulty ANS: A

Risk of aspiration is the highest priority diagnosis as aspiration can lead to pneumonia and respiratory failure. Imbalanced nutrition would be the next highest priority. Feeding self-care deficit is less important because the patient can be assisted at mealtimes. Risk for constipation is less important than aspiration risk and can be minimized with high-fiber soft foods and liquids.

NURSINGTB.COM DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify patients at risk for nutritional problems.

MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Diagnosis

15. Which action of the nurse is best to reduce abdominal discomfort when administering

intermittent gravity feedings through a gastrostomy tube? a. Chill the formula. b. Dilute the formula. c. Infuse the formula slowly. d. Lower the head of the bed.

ANS: C

Slowly infusing the formula reduces risk for abdominal discomfort, vomiting, or diarrhea induced by bolus or too-rapid infusion of tube feedings. It is the patient’s 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. The nurse should not dilute the formula. Always administer feedings as prescribed to ensure that the patient is receiving the ordered nutrients.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the procedure for initiating and maintaining enteral tube feedings.

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

16. Which condiment is the healthiest option for the patient to reduce the chances of having a

heart attack? a. Olive oil b. Margarine c. Shortening d. Cream cheese ANS: A

Olive oil contains monounsaturated fats and can help lower cholesterol levels. Margarine and shortening contain trans fats that raise heart attack risk by lowering HDL levels and raising LDL levels. Cream cheese contains saturated fats that also raise heart attack risk.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Summarize the dietary guidelines used in the United States.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 17. Which intervention is most appropriate for the nursing diagnosis ineffective breastfeeding

related to maternal malnutrition? a. Encourage the mother to eat a diet rich in nutrients and protein. b. Provide a quiet nursing environment to reduce maternal anxiety. c. Allow the infant to room with the mother and breastfeed on demand. d. Avoid supplemental feedings for the infant to promote breastfeeding.

ANS: A

Maternal nutrition is the cause of the ineffective breastfeeding so that must be the primary focus. The nursing mother needs to a diet rich in nutrients and protein in order to meet the nutritional needs of the infant as well as her own body. Reducing maternal anxiety and allowing rooming-in do not aNd d rU mat erna Re s sSI G Bl .mCalOnuMtrition. The infant may require formula N T supplements if breastfeeding alone does not provide sufficient nutrition.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Recognize a plan of care that meets the nutritional needs of a patient.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 18. Which soup is appropriate for a patient who follows a vegan diet? a. Cream of broccoli and cheddar cheese soup b. Moroccan carrot, apple, and cauliflower soup c. Minestrone soup with lamb, vegetables, and pasta d. Egg drop soup with chow mein noodles and scallions ANS: B

Vegan diets eat only plant-based foods and do not allow eggs, meat, or dairy products.

Moroccan carrot, apple, and cauliflower soup is the best option for the patient following a vegan diet.

DIF: Cognitive Level: Apply (Application) OBJ: Recognize a plan of care that meets the nutritional needs of a patient.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 19. Which dish must be removed from the meal tray of an orthodox Jewish patient? a. Penne pasta with marinara sauce and soft breadsticks b. Scrambled eggs, bacon, and toast with strawberry jelly

c. Stir-fried chicken with noodles, broccoli, and teriyaki d. Green salad with red peppers, carrots, beets, and radishes ANS: B

Orthodox Jewish patients follow a kosher diet that prohibits pork products such as bacon.

Pasta, vegetables, chicken, and salad are all acceptable.

DIF: Cognitive Level: Apply (Application) OBJ: Recognize a plan of care that meets the nutritional needs of a patient.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 20. Which is the most appropriate nursing diagnosis for a patient with a BMI of 46? a. Risk for imbalanced fluid volume related to rapid intravascular fluid shift b. Risk for imbalanced body temperature related to impaired thermoregulation c. Risk for compromised human dignity related to loss of control of body functions d. Imbalanced nutrition: more than body requirements related to chronic overeating ANS: D

The patient with a BMI of 46 is obese so the appropriate nursing diagnosis is imbalanced nutrition: more than body requirements related to chronic overeating. BMI of 46 does not put the patient at risk for rapid intravascular fluid shift, impaired thermoregulation, or loss of control of body functions.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain the importance of a balance between energy intake and energy output.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 21. Which menu item should be removed f r o m the t r a y o f a patient on a full liquid diet?

N R I G B. C M O a. Cup of chicken bouillon U S N T b. Cup of tomato cream soup c. Cup of orange frozen yogurt d. Cup of strawberry applesauce ANS: D

Applesauce is not considered a liquid and should be removed from the full liquid diet tray.

Soup and frozen yogurts are considered liquids.

DIF: Cognitive Level: Apply (Application) OBJ: Recognize a plan of care that meets the nutritional needs of a patient.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 22. Which is the appropriate intervention for a patient with the nursing diagnosis feeding self-care

deficit related to neuromuscular hand and arm weakness? a. Provide meticulous oral hygiene before and after meals. b. Consult a speech-language pathologist for swallow precautions. c. Provide the patient with a pleasant, quiet environment for meals. d. Teach the patient how to use adaptive utensils to facilitate independence.

ANS: D

The patient’s self-care deficit is due to hand and arm weakness so the nurse should teach the patient how to use adaptive utensils to facilitate independence. Oral hygiene, swallow precautions, and quiet environment do not address the patient’s hand and arm weakness.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify methods for feeding patients who require oral intake assistance.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which nursing diagnoses are priorities for a patient taking prednisone 40 mg PO daily for

chronic inflammation? (Select all that apply.) a. Risk for deficient fluid volume related to excessive hormonal fluid loss through kidneys b. Risk for unstable blood glucose related to hyperglycemic side effects of corticosteroids c. Risk for impaired dentition related to loss of minerals for teeth and bone support within the jaw d. Risk for constipation related to side effects of corticosteroids with loss of urge to defecate e. Risk for imbalanced nutrition: more than body requirements related to increased appetite ANS: B, C, E

Corticosteroids such as prednisone cause increased appetite leading to risk for imbalanced nutrition: more than body requirements. Corticosteroids cause hyperglycemia leading to risk for unstable blood glucose. Corticosteroids cause osteoporosis and thinning of bones leading to risk for impaired dentition. Corticosteroids cause diarrhea and fluid retention.

DIF: Cognitive Level: AnalyzN e (ARnalyIsis)G B.C M S N problems.

T O OBJ: Identify patients at risk forUnutritional MSC: NCLEX: Pharmacological and Parenteral Therapies

TOP: Nursing Process: Diagnosis

2. Which foods are recommended options for a patient with high cholesterol? (Select all that

apply.) a. Pure Irish butter with sea salt added b. Unsalted cashews, pecans, and pistachios c. Cottage cheese made with 2% milk d. Salad dressing made with vinegar and olive oil e. Guacamole made with fresh avocado and tomato ANS: B, D, E

Ingestion of saturated fatty acids appears to increase blood cholesterol levels. Cottage cheese and butte contain saturated fatty acids. Saturated fats should be limited to lower cholesterol.

Monounsaturated fatty acids appear to lower blood cholesterol levels. Nuts, olive oil, and avocado contain monounsaturated fatty acids.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the basic food groups and their value in planning meals for good nutrition.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. Which nursing diagnoses are priorities for a patient receiving parenteral nutrition? (Select all

that apply.) a. Impaired oral mucus membranes related to irritation from nasogastric tube

b. c. d. e.

Risk for infection related to invasive peripherally inserted central catheter line Situational low self-esteem related to presence of gastrostomy tube in abdomen Risk for impaired blood glucose levels related to concentrated IV dextrose solution Health-seeking behaviors related to desire to manage parenteral nutrition at home

ANS: B, D, E

Parenteral nutrition is administered through specialized IV lines such as peripherally inserted central catheters. These catheters pose a risk for infection. Parenteral nutrition solutions contain high levels of dextrose the put the patient at risk for hyperglycemia. The patient who wishes to manage parenteral nutrition at home demonstrates health-seeking behaviors.

Parenteral nutrition is not administered via gastrostomy or nasogastric tubes.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the procedure for initiating and maintaining parenteral nutrition.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Pharmacological and Parenteral Therapies

NURSINGTB.COM

Chapter 36: Urinary Elimination Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which assessment finding supports the nursing diagnosis overflow urinary incontinence

related to urethral obstruction? a. Advanced dementia prevents the patient from indicating need to urinate b. Postvoid residual of 900 mL after incontinence of small amounts of urine c. Leakage of urine around the urostomy appliance leading to skin irritation d. Incontinence of large amounts of urine every time the patient coughs or sneezes ANS: B

Overflow urinary incontinence occurs when small amounts of urine are lost due to retention of large amount of urine in the bladder. A postvoid residual of 900 mL after incontinence of small amounts of urine supports the overflow urinary incontinence diagnosis. Overflow urinary incontinence does not apply to patients with urostomy appliances. Incontinence of urine with coughing or sneezing demonstrates stress incontinence. Inability to indicate need to urine leads to functional incontinence.

DIF: Cognitive Level: Apply (Application) OBJ: Describe how to measure postvoid residual using a bladder scan.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 2. Which assessment finding explains the cause of the patient’s stress urinary incontinence? a. The patient uses a wheelchair and cannot get to the toilet in time to void.

INwh G ToB.C b. The patient gave birth to s i U Sbi es xNbaR weigO hM ed more than 9 pounds. c. The patient suffered a spinal cord injury and has no sensation below the waist. d. The patient self-catheterizes due to urinary retention from multiple sclerosis.

ANS: B

Giving birth to six large babies causes weakness of pelvic organs and subsequent stress incontinence. Inability to reach the toilet in time to void indicates a functional incontinence.

Self-catheterization and spinal cord injury do not lead to stress incontinence.

DIF: Cognitive Level: Apply (Application) OBJ: Identify factors that influence urinary elimination.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 3. Which outcome is appropriate for the patient with risk for urinary tract infection related to

recent urinary catheterization? a. The patient’s urine will remain free from white blood cells and bacteria. b. The patient will take prescribed antibiotics until the urinary symptoms are gone. c. The patient will have serial urine cultures to ensure that the infection is resolved. d. The patient will carefully wipe the perineal area from front to back after voiding.

ANS: A

An appropriate outcome for the risk for urinary tract infection diagnosis is that the patient’s urine will remain free from white blood cells and bacteria. Antibiotics should not be prescribed unless an infection is present, which negates the risk for infection diagnosis. Serial urine cultures will take place if an infection is present. Careful perineal care is an intervention, not an outcome.

DIF: Cognitive Level: Apply (Application) OBJ: Implement nursing measures to reduce urinary tract infections.

TOP: Nursing Process: Planning MSC: NCLEX: Reduction of Risk Potential 4. The nurse is caring for a patient who feels the urge to urinate but is unable to void. Which is

the appropriate action of the nurse? a. Scan the patient’s bladder to see how much urine is present. b. Obtain a urine sample for urinalysis, culture, and sensitivity. c. Perform a focused physical assessment of the patient’s perineum. d. Help the patient to utilize absorbent undergarments for protection.

ANS: A

The appropriate action of the nurse is to scan the patient’s bladder to determine how much urine is present. The nurse may need to catheterize the patient if a very large amount of urine is in the bladder or encourage fluids if there is minimal urine present. Assessment of the perineum will not assist the patient to void. The nurse will not be able to send a urine sample until the patient voids or is catheterized. Absorbent undergarments are not needed if the patient is unable to void.

DIF: Cognitive Level: Apply (Application) OBJ: Describe how to measure postvoid residual using a bladder scan.

TOP: Nursing Process: A s s e s sN mU e nRt SINGMTSB C. : C NC OLMEX: Reduction of Risk Potential 5. The family requests insertion of a Foley catheter to address the elderly patient’s frequent

episodes of incontinence. Which is the best action of the nurse? a. Obtain an order for an indwelling urinary catheter. b. Teach family to perform intermittent straight catheterization. c. Utilize disposable absorbent undergarments for the patient. d. Implement a bladder training program to promote continence.

ANS: D

The nurse can act as a patient advocate by suggesting noninvasive alternatives to catheterization use. Bladder training programs can be used to promote continence for children and adults. Catheterization should be avoided whenever possible due to the risk of urinary infection. Disposable undergarments should be used as a last resort if bladder training is unsuccessful.

DIF: Cognitive Level: Apply (Application) OBJ: Teach patients how to promote normal urination and control incontinence.

TOP: Nursing Process: Planning MSC: NCLEX: Reduction of Risk Potential 6. Which is the appropriate method to obtain a urinalysis specimen for culture and sensitivity

from an incontinent female patient? a. Obtain a midstream specimen. b. Perform straight catheterization.

c. Obtain a double-voided specimen. d. Leave a fresh bedpan under the patient.

ANS: B

The nurse should perform straight catheterization to obtain a clean catch urinalysis from an incontinent female patient. The patient will not be able to provide a midstream or double-voided specimen. Leaving the bedpan under the patient will lead to skin breakdown and contamination of the specimen.

DIF: Cognitive Level: Apply (Application) OBJ: Describe nursing responsibilities associated with common diagnostic tests of the urinary system.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 7. Which assessment finding needs to be communicated promptly to the patient’s health care

provider? a. Postvoid residual of 15 mL of urine. b. Leakage of small amounts of urine when coughing. c. Urine output of 160 mL over the last 8 hours. d. Patient’s report of an urge to void during palpation of the bladder.

ANS: C

Urinary output should be at least 30 mL/hour so urine output of 160 mL for 8 hours should be reported promptly to the health care provider. A postvoid residual of 15 mL is not a problem.

Stress incontinence does not need to be promptly communicated to the health care provider. It is normal for patients to feel an urge to void during palpation of the bladder.

DIF: Cognitive Level: UndersN tandR(CoImpG reheB ns io n) M S Nassessment T . C Othat OBJ: Describe how to perform aUphysical focuses on urinary elimination.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 8. The patient knocked over the specimen container and spilled some of the urine that had been

collected for a 24-hour urine analysis. Which is the appropriate action of the nurse? a. Start the collection over again with a new container. b. Inform the patient that the test will have to be canceled c. Replace the lid on the container and continue the collection. d. Extend the collection period by 2 hours for a replacement void.

ANS: A

The nurse should start the collection over again with a new container as the specimen collection will not be accurate. The test does not need to be canceled. The nurse cannot extend the collection period as that will lead the test to be inaccurate.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe nursing responsibilities associated with common diagnostic tests of the urinary system.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 9. Which assessment finding leads the nurse to question an order for an abdominal flat plate test? a. The patient is very claustrophobic. b. The patient is 8 weeks pregnant. c. The patient has a history of renal failure.

d. The patient is allergic to iodine and shrimp.

ANS: B

The abdominal flat plate test is an x-ray diagnostic test so the nurse should question the order for a pregnant patient. Claustrophobia, renal failure, and shrimp allergy are not contraindications for the test.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe nursing responsibilities associated with common diagnostic tests of the urinary system.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 10. The patient reports feeling an urge to urinate even though an indwelling urinary catheter is in

place. Which is the priority action of the nurse? a. Measure the patient’s urinary output. b. Ensure that the catheter tubing is not kinked. c. Provide perineal care to the patient for comfort. d. Reassure the patient that the sensation is to be expected.

ANS: B

The patient will feel an urge to urinate if the catheter tubing becomes kinked and the urine is not able to drain. The nurse should first check to make sure that the tubing is patent and draining freely. Once this is done the nurse can measure urinary output and provide perineal care. If there is no evidence of urethral irritation or kinked tubing, the patient may be reassured that the sensation may be expected.

DIF: Cognitive Level: Apply (Application) OBJ: Describe how to performNa pR h y s iIc a l G asseB ss. meCnt tM h at focuses on urinary elimination.

O TOP: Nursing Process: ImplemeU ntatS i on N T MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

11. Which teaching will the nurse provide to the patient before having an intravenous pyelogram

(IVP)? a. Drink water and do not void so the bladder will be full during the test. b. An urge to void may be felt as the endoscope passes through the urethra. c. The urine may have an orange or pink for a day or two following the test. d. Drink plenty of water afterward to prevent kidney damage from the contrast dye.

ANS: D

Contrast dye used for the IVP can be harmful to the kidneys so the patient should drink lots of water afterward to increase urine output. The bladder should not be full for the IVP test and an endoscope is not used. No urine discoloration is expected after IVP testing.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe nursing responsibilities associated with common diagnostic tests of the urinary system.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 12. The patient’s urinalysis indicates small amounts of protein in the urine. Which diagnosis does

the nurse anticipate to see in the patient’s electronic health record? a. Diabetes mellitus b. Diabetes insipidus

c. Hypothyroid disease d. Hyperparathyroid disease ANS: A

Diabetes mellitus can cause damage to the glomerular membrane allowing protein to seep into the urine. Diabetes insipidus, hypothyroid disease, and hyperparathyroid disease do not cause proteinuria.

DIF: Cognitive Level: Apply (Application) OBJ: Describe characteristics of normal and abnormal urine.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 13. The patient’s urinalysis indicates increased specific gravity of the urine. Which finding does

the nurse anticipate will be found upon assessment? a. The patient uses supplemental oxygen due to COPD. b. The patient is thirsty with dry oral mucus membranes. c. The patient has a history of benign prostatic enlargement. d. The patient just completed antibiotics for a bladder infection.

ANS: B

Increased specific gravity occurs when the urine is concentrated. This can occur with dehydration, SIADH, or fluid restrictions. The patient’s thirst and dry oral mucus membranes are consistent with increased specific gravity. History of BPH, resolved UTI, and COPD do not correlate with increased specific gravity of the urine.

DIF: Cognitive Level: Apply (Application) OBJ: Describe characteristics of normal and abnormal urine.

TOP: Nursing Process: AssessN menR t I GMSB C:.C NCLMEX: Reduction of Risk Potential

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14. The nurse is inserting an indwelling urinary catheter before the patient has abdominal surgery.

Which type of catheter will the nurse utilize for the procedure? a. Straight catheter b. Single-lumen catheter c. Double-lumen catheter d. Triple-lumen catheter ANS: C

The nurse will use a double-lumen catheter for the patient. One lumen will inflate the balloon and the other will drain the urine from the bladder. Straight or single-lumen catheters are used for intermittent catheterization. Triple-lumen catheters are used for continuous bladder irrigation.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe how to apply a condom catheter, insert an indwelling urinary catheter, and measure postvoid residual using a bladder scan.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 15. The nurse is caring for an incontinent male patient with a large sacral pressure injury. Which

is the safest intervention that will maintain skin integrity and facilitate healing of the ulcer? a. Obtain a surgical consult for placement of a suprapubic urinary catheter. b. Apply a condom catheter attached to a bedside urinary drainage bag. c. Insert an indwelling urinary catheter attached to a small volume drainage bag.

d. Perform intermittent straight catheterization of the patient every 4 to 6 hours.

ANS: B

The safest option for this patient is to apply a condom catheter to facilitate containment of urine. Indwelling, suprapubic, and straight catheters will increase risk of urinary tract infection.

DIF: Cognitive Level: Apply (Application) OBJ: Describe how to apply a condom catheter, insert an indwelling urinary catheter, and measure postvoid residual using a bladder scan.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 16. The nurse is discontinuing the patient’s indwelling urinary catheter. The catheter is not easily

withdrawn after the balloon is deflated. Which is the appropriate nursing action? a. Reattach the syringe and attempt to withdraw more water from the balloon. b. Ask the patient to bear down as the catheter is withdrawn with gentle pressure. c. Review the patient’s chart to see how much water was inserted into the balloon. d. Explain to the patient that removal of the catheter may cause significant discomfort.

ANS: A

The syringe should be reattached to withdraw any remaining water from the balloon. The nurse should not ask the patient to bear down; catheter removal should be painless. The nurse should check the balloon for more water rather than checking the chart to see how much water was instilled.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe how to apply aNc onR d o mIc at G h e t eB r, . i nC sert M an indwelling urinary catheter, and measure postvoid residual using a bladder U scanS . N TT OP : NuOrsing Process: Implementation MSC: NCLEX: Reduction of Risk Potential

17. The home care nurse is caring for a patient with an indwelling urinary catheter after spinal

cord injury. The catheter is patent with clear yellow urine after being in place for 8 weeks.

Which is the appropriate action of the nurse? a. Request an order for a urinalysis with culture and sensitivity. b. Irrigate the patient’s catheter using 60 mL of sterile normal saline. c. Remove the catheter immediately and notify the health care provider. d. Contact the health care provider for an order to change the catheter.

ANS: D

Indwelling urinary catheters should be changed every 4 to 6 weeks. The nurse should contact the health care provider for an order to change the catheter after it has been in place for 8 weeks. Removal of the catheter is not an option for the patient with a spinal cord injury as the damage to the nerves is permanent. Irrigation and urinalysis are not needed.

DIF: Cognitive Level: Apply (Application) OBJ: Implement nursing measures to reduce urinary tract infections.

TOP: Nursing Process: Planning MSC: NCLEX: Reduction of Risk Potential 18. The nurse is performing urinary catheterization for a female patient. The catheter will not

advance any further but there is no urine output. What is the appropriate action of the nurse? a. Withdraw the catheter and notify the health care provider immediately.

b. Palpate the patient’s bladder to assess for fullness, tenderness, or distention. c. Leave the catheter in place and reattempt insertion with a new sterile catheter. d. Utilize the bladder scanner to determine how much urine is in the patient’s

bladder.

ANS: C

The catheter has been inadvertently inserted into the patient’s vagina. The nurse should leave the catheter in place and reattempt insertion with a new sterile catheter. There is no need to notify the health care provider immediately. Palpation of the bladder and bladder scanning should be completed prior to insertion of the catheter.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe how to apply a condom catheter, insert an indwelling urinary catheter, and measure postvoid residual using a bladder scan.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 19. A patient with a Foley catheter needs a urine sample for culture and sensitivity. What is the

appropriate action for the nurse to take? a. Disconnect the drainage tube from the catheter. b. Withdraw urine from the closed system drainage bag. c. Empty contents of the drainage bag into the specimen cup. d. Attach a sterile syringe to the catheter port to withdraw urine.

ANS: D

The nurse should attach a sterile syringe to the catheter port to withdraw urine. Separating 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 N draiR nagI e baGg. B.COM

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DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe how to apply a condom catheter, insert an indwelling urinary catheter, and measure postvoid residual using a bladder scan.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential MULTIPLE RESPONSE 1. The nurse is caring for an older adult patient who has a constant urge to void due to a bladder

infection. Which are the appropriate nursing diagnoses for this patient? (Select all that apply.) a. Sleep deprivation related to frequent need to use the toilet during the night b. Risk for falls related to getting up frequently to use the bathroom at night c. Impaired urinary elimination: frequency related to urinary tract inflammation d. Risk for infection related to bacterial invasion of urinary tract e. Risk for urge urinary incontinence related to urinary tract inflammation ANS: A, B, C, E

Sleep deprivation is appropriate for the patient due to frequent need to use the toilet at night.

The elderly patient is at risk for falls when ambulating to the toilet. Urinary frequency is appropriate as the patient has a constant urge to void. Risk for urge urinary incontinence is also appropriate as urinary tract inflammation can lead to loss of urine. Risk for infection is not appropriate as the patient already has a bladder infection.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Implement nursing measures to reduce urinary tract infections.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Reduction of Risk Potential 2. Which assessment findings indicate to the nurse that the older adult patient has a urinary tract

infection? (Select all that apply.) a. Confusion and irritability b. Urinalysis is positive for hyaline casts and ketones. c. Urinalysis is negative for nitrites and white blood cells. d. Reports frequency and burning with urination e. Has had two uncharacteristic episodes of incontinence ANS: A, D, E

Mental status changes, incontinence, and urinary frequency are all signs of urinary tract infection in the elderly. In the presence of a urinary tract infection, a urinalysis will be positive for nitrites and white blood cells. Hyaline casts are found when protein is lost through the urine due to renal disease. Ketones are present in the urine when the blood sugar is elevated.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Implement nursing measures to reduce urinary tract infections.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Reduction of Risk Potential

NURSINGTB.COM

Chapter 37: Bowel Elimination Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who had surgery to remove most of the large intestine. Which

finding will the nurse expect to note when assessing the patient? a. Soft formed stools b. Chronic loose stools c. Frequent stool impaction d. Intermittent constipation ANS: B

The large intestine is responsible for resorption of water from the stool. Removal of the large intestine results in loose stools as the water is not sufficiently removed from the stool before evacuation. Removal of the large intestine does not cause impaction or constipation.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Explain the physiology of digestion, absorption, and bowel elimination.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 2. The nurse is caring for a patient with painful hemorrhoids. Which is the appropriate

recommendation of the nurse to prevent their recurrence? a. Stool softener daily at bedtime b. Low-carbohydrate ketogenic diet c. Periodic bowel cleansing pro gram s B.C M N R I G d. High-fiber diet with plentyU O of lS i q u iNd s T ANS: D

Hemorrhoids are caused and aggravated by straining for defecation with constipation, pregnancy, or chronic illness. A high-fiber diet with plenty of liquids will keep stools soft and prevent straining for defecation. Low-carbohydrate ketogenic diets are often low in fiber which can lead to constipation. Bowel cleansing programs and daily stool softeners are not recommended, as they can lead to chronic constipation, and fluid-electrolyte imbalances.

DIF: Cognitive Level: Understand (Comprehension) OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Health Promotion and Maintenance 3. Which medication does the nurse identify as most likely to cause a patient’s constipation? a. Ferrous sulfate 325 mg PO BID b. Cefaclor 500 mg PO TID c. Warfarin 5 mg PO daily d. Prednisone 10 mg PO daily ANS: A

Ferrous sulfate (iron supplement) is known to cause constipation. Cefaclor and other antibiotics are known to cause diarrhea. Warfarin and prednisone do not cause constipation.

DIF:

Cognitive Level: Apply (Application)

OBJ: Discuss physiological and psychological factors that influence bowel elimination.

TOP: Nursing Process: Assessment MSC: NCLEX: Pharmacological and Parenteral Therapies 4. The nurse is caring for a patient with an ileostomy. Which assessment finding is expected

when emptying the patient’s ostomy appliance? a. Infrequent hard pellets of stool b. Daily soft formed stool c. Frequent unformed stool d. Constant watery liquid stool ANS: D

An ileostomy bypasses the entire large intestine creating frequent, liquid stools. Frequent unformed stool would be expected after removal of some of the large intestine. The patient would have a soft, formed stool after sigmoid colostomy. Infrequent hard pellets of stool is not be expected in a patient with an ostomy.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe nursing care required to manage a fecal diversion.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 5. The nurse is caring for a patient with a new, unexpected sigmoid colostomy. The nursing

diagnosis knowledge deficit related to colostomy care is included in the patient’s care plan.

Which is the appropriate outcome for the patient? a. The patient will empty and change the colostomy appliance. b. The patient will resume a sexual relationship with the spouse. c. The patient will verbalize feelings about presence of colostomy. d. The patient will use clothN inU gR toSeI ffN ecG tiT veB ly.cC onOcM eal the colostomy.

ANS: A

The appropriate outcome for the nursing diagnosis knowledge deficit related to colostomy is that the patient will empty and change the colostomy appliance. Resuming a sexual relationship, verbalizing feelings, and using clothing to conceal the ostomy do not relate to the patient’s need to learn how to care for the colostomy.

DIF: Cognitive Level: Apply (Application) OBJ: Describe nursing care required to manage a fecal diversion.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 6. The nurse is caring for a patient with a colostomy. The nursing diagnosis risk for impaired

skin integrity related to leakage of effluent from appliance is included in the patient’s care plan. Which is the appropriate intervention of the nurse? a. Apply antifungal cream to the skin before attaching the ostomy appliance. b. Liberally apply a rich skin barrier cream to the skin surrounding the stoma. c. Measure the width and the length of the stoma each week for the first 6 weeks. d. Empty the effluent into the toilet before the ostomy appliance becomes half full.

ANS: D

The ostomy appliance is liable to leak if it becomes more than half full. Leakage of stool from the ostomy appliance puts the patient’s skin at risk of breakdown. The nurse can minimize the risk of skin breakdown by emptying the effluent into the toilet before the ostomy appliance becomes half full. Application of creams to the skin under the appliance will prevent adhesion and lead to leakage around the stoma. Measurement of the stoma will not help to prevent skin breakdown.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe nursing care required to manage a fecal diversion.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. Which is the appropriate nursing action after the patient’s fecal occult blood test is positive? a. Educate the patient about colonoscopy preparation. b. Obtain an order for a STAT complete blood count (CBC). c. Check the patient’s rectum for the presence of impacted stool. d. Draw blood for type and cross-match testing by the blood bank.

ANS: A

Any patient with positive fecal occult blood tests should have a colonoscopy performed to check for the presence of colon cancer. Fecal occult blood is the presence of minute amounts of blood in the stool so no CBC or transfusion is needed. There is no need for the nurse to check the patient’s rectum for impacted stool.

DIF: Cognitive Level: Apply (Application) OBJ: Perform a fecal occult blood test.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. Which assessment finding byNtU heRnS uI rseNiG ndTicBa. teC s tO hM at the patient’s colonoscopy preparation is

complete? a. The patient has stopped vomiting. b. The patient’s stool is watery clear yellow. c. The patient had a large soft formed stool. d. The patient’s abdomen is softly distended.

ANS: B

The colonoscopy preparation is complete when the patient’s colon is free of stool. This is indicated by passage of watery clear yellow liquid from the colon. Passage of soft formed stool indicates that additional cleansing of the colon is required. The abdomen should not be distended and the colonoscopy preparation should not cause vomiting.

DIF: Cognitive Level: Apply (Application) OBJ: Describe common physiological alterations in bowel elimination.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 9. The nurse is caring for a patient who has just undergone knee-replacement surgery. The

patient has incontinent of continuous oozing stool for the last few days. Which is the appropriate action of the nurse? a. Administer loperamide 8 mg PO BID. b. Check the patient’s rectum for presence of impacted stool. c. Liberally apply skin barrier cream to prevent perineal irritation. d. Encourage the patient to drink at least 2 L of fluid each day.

ANS: B

Continuous oozing stool for several days indicates the possibility of fecal impaction, especially as the patient has been recuperating after joint surgery. Loperamide would cause fecal impaction to worsen and should not be administered. Potential skin breakdown does not address the root cause of the oozing stool. Fluid intake, in the presence of continuous oozing stool, is less likely to help the patient versus assessing for a fecal impaction.

DIF: Cognitive Level: Apply (Application) OBJ: Describe common physiological alterations in bowel elimination.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is caring for a patient who relies on laxatives to ensure daily bowel movements.

Which is the appropriate nursing diagnosis for this patient? a. Risk for constipation related to irregular bowel elimination patterns b. Perceived constipation related to expectation of daily bowel movements c. Toileting self-care deficit related to inability to set regular defecation regimen d. Powerlessness related to inability to have daily bowel movements without laxatives ANS: B

Perceived constipation is the patient’s use of laxatives to ensure daily bowel movements. This leads to laxative abuse and dependence with possible damage to the colon. Risk for constipation and toileting self-care deficit are less appropriate for the patient than perceived constipation. Powerlessness is not a priority nursing diagnosis for this patient.

DIF: Cognitive Level: Analyze (Analysis) OBJ: List nursing diagnoses related to alterations in bowel elimination.

TOP: Nursing Process: Diagnosis MSC: NCLEX: PharmacologicN alUaR n dSPI arN enG teT raB l T.hC erO apM ies 11. Which is the appropriate nursing action after administering a bisacodyl suppository? a. Make sure that the bedside commode is next to the patient’s bed. b. Inform the patient to expect a bowel movement in the morning. c. Check the patient’s colon for the presence of a fecal impaction. d. Educate the patient about methods to relieve excess gas formation.

ANS: A

A bisacodyl suppository will cause the patient to have a bowel movement in approximately 30 minutes so the bedside commode should be ready next to the patient’s bed. The colon should be checked for fecal impaction prior to administration of a laxative suppository. There is no need to educate the patient about methods to relieve excess gas formation.

DIF: Cognitive Level: Apply (Application) OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP: Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 12. Which patient does the nurse identify that would benefit from a nasogastric tube to low

intermittent suction? a. A patient who is vomiting due to a complete large bowel obstruction b. A patient with constipation who has not had a bowel movement in 6 days c. A patient with constant diarrhea due to side effects of antibiotic therapy d. A patient with extensive skin irritation due to a leaking colostomy appliance

ANS: A

A patient who is vomiting due to a complete small bowel obstruction would benefit from a nasogastric tube as it will decompress the stomach and eliminate the need for vomiting. A nasogastric tube will not be of benefit for patients with constipation, diarrhea, or leaking ostomy appliance.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss physiological and psychological factors that influence bowel elimination.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 13. Which patient does the nurse identify that would benefit from administration of an

oil-retention enema? a. A constipated patient with a fecal impaction b. A patient with Clostridium difficile diarrhea c. A patient with a positive fecal occult blood test d. A patient with a serum potassium level of 7.1 mEq/L ANS: A

A patient with a fecal impaction would benefit from an oil-retention enema as the hard stool would soften and make it easier to pass. Oil-retention enemas do not benefit patients with diarrhea, positive fecal occult blood test, or a serum potassium level of 7.1 mEq/L. A sodium polystyrene sulfonate enema is administered to treat severe hyperkalemia.

DIF: Cognitive Level: Apply (Application) OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP: Nursing Process: Assessment MSC: NCLEX: PharmacologicN al a R n d PI ar e nGt eraB l T.hC erapM ies

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14. Which assessment finding leads the nurse to conclude that digital disimpaction of stool is

unsafe for the patient? a. The patient has a large mass of hard, dry stool in the rectum. b. The patient has not had a bowel movement for the last 6 days. c. The patient’s pulse is 50 beats/minute due to a history of heart block. d. The patient has taken senna every morning for the last 3 days.

ANS: C

Digital removal of stool from the rectum can cause lowering of the heart rate due to stimulation of the vagus nerve. Patients with bradycardia can experience dangerously low heart rates due to vagal stimulation. Presence of hard, dry stool in the rectum, use of senna, and no bowel movement for the last 6 days are not contraindications for digital removal of stool.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the process of removal of a fecal impaction.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15. The rehabilitation nurse is working with a patient to regain bowel continence after a stroke.

Which intervention will the nurse include as part of the patient’s bowel training program? a. The nurse will administer docusate sodium 100 mg PO BID. b. The nurse will assist the patient to the toilet every morning after breakfast. c. The nurse will check for the presence of a fecal impaction every other day.

d. The nurse will apply skin barrier cream to the perineal area after each loose stool.

ANS: B

The patient’s bowel training program will help the patient to set up a daily routine for defecation. Assisting the patient to the toilet every morning after breakfast is a good way to help set up this routine. Administering stool softeners, routinely checking for fecal impaction, and applying skin barrier creams will not help the patient to set up a daily routine for defecation.

DIF: Cognitive Level: Apply (Application) OBJ: Describe nursing measures aimed at promoting normal elimination and defecation.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 16. Which patient would benefit from a sitz bath? a. A patient who has not had a bowel movement for the last 4 days b. A patient with painful, swollen hemorrhoids after vaginal childbirth c. A patient with perineal skin breakdown due to continuous oozing of stool d. A patient who is having difficulty adhering the ostomy appliance to the skin ANS: B

A sitz bath is a shallow bath of warm water used to clean and soothe irritation of the perineum or rectum. A patient with painful hemorrhoids would benefit from soaking in a sitz bath. A sitz bath does not relieve constipation or help adhere an ostomy appliance to the skin. A patient with continuous oozing of stool should not be given a sitz bath, as bacteria from the stool could be introduced to the vaginal and/or urethral openings.

DIF: Cognitive Level: Apply (Application) OBJ: Describe nursing measurNes aR imed at prom oting nM orm al elimination and defecation.

U SINGMSC: TB.C O Physiological Integrity TOP: Nursing Process: Assessment NCLEX: MULTIPLE RESPONSE 1. Which actions of the nurse demonstrate correct administration of a soapsuds enema? (Select

all that apply.) a. The enema is administered while the patient is in the right Sims’ position. b. Liquid antibacterial soap is added to the enema bag before administration. c. The tip of the enema tube is lubricated with petroleum jelly before insertion. d. The enema bag is lowered when the patient reports abdominal cramping. e. The nurse removes the patient’s fecal impaction before administering the enema.

ANS: D, E

The enema bag is lowered when the patient complains of abdominal cramping to slow the rate and reduce discomfort. Fecal impactions should be removed before administration of soapsuds enemas. The tip of the enema tube should be lubricated with water-soluble jelly rather than petroleum jelly. Only castile soap may be used for soapsuds enemas. Liquid antibacterial soap can cause damage to the colon. The enema should be administered while the patient is in the left Sims’ position.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Articulate the steps of enema administration.

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

2. The nurse is caring for a patient with diarrhea caused by Clostridium difficile infection. Which

are the priority interventions of the nurse? (Select all that apply.) a. Perform hand hygiene with soap and water. b. Increase the patient’s dietary intake of fiber. c. Maintain strict contact isolation precautions. d. Accurate calculation of patient’s intake and output. e. Liberally apply skin barrier cream to the perineal area. f. Give loperamide 4 mg after each loose stool.

ANS: A, C, D, E

Hand hygiene with soap and water and maintenance of contact isolation precautions are essential to prevent spread of Clostridium difficile infection. Accurate calculation of intake and output is needed to assess for fluid volume deficit from diarrhea. Skin barrier cream to the perineal area will help prevent skin breakdown. Increasing dietary fiber is not recommended as it may further irritate the colon. Antidiarrheal medication such as loperamide is not administered as it will prevent removal of the Clostridium difficile infection from the colon through the diarrhea.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss physiological and psychological factors that influence bowel elimination.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 3. Which possible reasons does the nurse identify that contribute to the patient’s black stools? a. Takes ferrous sulfate 325 mg PO BID. b. Hemorrhoids are irritated and bleeding. c. Bleeding from a perforate d g astr ic u l c er .

R Sctio I Nn.G TB.COM d. Incomplete small bowelN obU stru e. Development of a Clostridium difficile infection.

ANS: A, C

Iron supplements and upper gastrointestinal bleeding will cause black stools. Hemorrhoids will cause streaks of fresh red blood on the stool. Clostridium difficile infection will cause watery diarrhea. Incomplete small bowel obstruction will not cause black stools.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss physiological and psychological factors that influence bowel elimination.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

Chapter 38: Skin Integrity and Wound Care Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse notes a reddened area on the right heel that does not turn lighter in color when

pressed with a finger. Which term will the nurse use to describe this area? a. Reactive hyperemia b. Secondary erythema c. Blanchable hyperemia d. Nonblanchable erythema ANS: D

Nonblanchable erythema 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 injury development.

There is no such condition as secondary erythema. 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.

DIF: Cognitive Level: Apply (Application) 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: NCLEX: Physiological Integrity 2. Which factor contributes to pN reU ssRuS reIinNjuGryTfBo. rmCaO tioMn when patient’s body slides downward to

the foot of the bed? a. Momentum b. Acceleration c. Applied force d. Shearing force ANS: D

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. An applied force is the movement of one object as the result of another object acting upon it.

Momentum is the force of an object as it moves forward. Acceleration is increased speed of an object as it moves.

DIF: Cognitive Level: Apply (Application) OBJ: Describe risk factors for pressure injury development.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 3. Which assessment finding indicates to the nurse that the patient is at high risk for developing

a pressure injury? a. Serum total protein level of 4.6 g/dL b. Braden Scale score of 22 c. Cetirizine 5 mg PO daily

d. Fasting serum glucose level 84 mg/dL ANS: A

Poor nutrition, specifically severe protein deficiency, causes soft tissue to become susceptible to breakdown. Serum protein level of 4.6 g/dL leads to 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 injury development; a score of 22 does not place the patient at risk. Cetirizine is a nonsedating antihistamine medication that would not place the patient at risk for developing pressure injuries. Fasting serum glucose level of 84 mg/dL is within normal limits and does not indicate risk of pressure injury development.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe risk factors for pressure injury development.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 4. The patient’s sacral pressure injury is open with exposed bone. Which pressure injury stage

will be recorded in the patient’s chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANS: D

Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling Stage 1: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence NURSINGTB.COM Stage 2: 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 3: 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 DIF: Cognitive Level: Apply (Application) OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure injury stages.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. The patient has a nonblanchable area of redness on the right malleolus. Which pressure injury

stage will be recorded in the patient’s chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANS: A

Stage 1: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence Stage 2: 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 3: 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 4: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling DIF: Cognitive Level: Apply (Application) OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure injury stages.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 6. The patient has a large red, blistered area on the left hip. Which pressure injury stage will be

recorded in the patient’s chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANS: B

Stage 2: 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 1: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence Stage 3: 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 4: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often include s u ndermin ing and tun neling

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DIF: Cognitive Level: Apply (Application) OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure injury stages.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 7. The patient has a large left hip decubitus ulcer with tunneling but no involvement of bone,

tendon, or muscle. Which pressure injury stage will be recorded in the patient’s chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANS: C

Stage 3: 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 1: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence Stage 2: 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 4: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling DIF:

Cognitive Level: Apply (Application)

OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure injury stages.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a patient with a puncture wound. How much time must have passed

since the patient’s last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department? a. 1 year b. 3 years c. 5 years d. 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss common complications of wound healing.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. The nurse is caring for a patient who has perineal skin breakdown after sitting in wet

underclothes for many hours. Which term will be used to document the patient’s condition in the medical record? a. Maceration b. Dehiscence c. Evisceration d. Debridement ANS: A

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Maceration is skin breakdown due to extended exposure to moisture. 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. Debridement is removal of dead or infected tissue from a wound.

DIF: Cognitive Level: Apply (Application) OBJ: Complete an assessment for a patient with risk for or actual impaired skin integrity.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 10. The nurse is caring for a patient with a necrotic wound. Which dressing would be the best

choice for the nurse to use on this type of wound to help with debridement? a. Transparent film b. Hydrogel dressing c. Dry nonstick gauze d. Hydrocolloid dressing ANS: B

Hydrogel dressings contain a high percentage of water and are indicated for wounds that have 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 1, 2, and 3 pressure injuries.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the mechanism of action of wound care dressings.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. Which is the first intervention of the nurse for changing the dressing to a painful burn? a. Administer pain medication 30 minutes beforehand. b. Gently irrigate the wound using sterile normal saline. c. Loosen the tape gently by pressing the skin away from it. d. Observe the wound bed for presence of granulation tissue.

ANS: A

When you plan a dressing change, consider giving the patient an analgesic at least 30 minutes beforehand. The tape should be loosened gently by pressing the skin away from it. The wound bed should be observed and then irrigation should be performed.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the purposes of and precautions taken with applying dressings and binders.

TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 12. Which intervention will the nurse use for an abscessed leg wound? a. Warm water sitz baths NURSINGTB.COM b. Cold moist compresses c. Warm moist compresses d. Epsom salt solution soaks ANS: C

A warm moist compress improves circulation, relieves edema, and promotes concentration of pus and drainage. Warm moist compresses are appropriate for an abscessed leg wound.

Epsom salt soaks increases muscle relaxation and loosens stiff joints. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the differences in therapeutic effects of heat and cold.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. The patient’s incision is fading to a pale pink following surgery 2 months previously. Which

stage of the healing describes the current status of the patient’s wound? a. Hemostasis phase b. Remodeling phase c. Proliferative phase d. Inflammation phase ANS: B

The patient’s wound is at the remodeling phase as the healing process continues to strengthen the scar tissue in the wound. The proliferative phase 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. Hemostasis phase controls bleeding.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the response of the body during each phase of the wound-healing process.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. What is the primary advantage of a hydrogel dressing for wound healing? a. Provide moisture needed for wound healing. b. Act as an absorbent to collect wound drainage. c. Provide negative pressure to promote healing. d. Provide protection from the external environment.

ANS: A

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 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 N R Ir ote GTcts B.C M transparent or hydrocolloid dreU ssi nSg p N agaiO n st the external environment.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe the mechanism of action of wound care dressings.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 15. Which is the priority nursing assessment for a patient wearing an abdominal binder after

abdominal surgery? a. Mental status and orientation b. Hourly fluid intake and output c. Lung sounds and pulse oximetry d. Presence of peripheral pedal pulses ANS: C

Evaluate the patient’s 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. Mental status, fluid balance, and peripheral pulses are not affected by the abdominal binder.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the purposes of and precautions taken with applying dressings and binders.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

16. The patient’s wound has thick creamy yellow drainage present on the dressing. How will the

nurse document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage ANS: B

Purulent is thick, yellow, green, or brown, indicating the presence of dead or living organisms and white blood cells. Serosanguineous is pale, more watery, and a combination of plasma and red cells, which may be blood streaked. Serous is clear, watery plasma. Sanguineous is fresh bleeding.

DIF: Cognitive Level: Apply (Application) 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: NCLEX: Physiological Integrity 17. How will the nurse obtain a culture of the patient’s wound? a. Obtain a sample from the patient’s wound drainage bag. b. Obtain a sample of the drainage around the edge of the wound. c. Obtain a sample of the drainage from the dressing on the wound. d. Gently swab the center of the wound after irrigating with sterile saline.

ANS: D

The nurse should gently swab the center of the wound after irrigating with sterile saline in order to obtain an accurate culture. Samples should never be taken from the edge of the wound, from the dressing, orNfrom age bag.

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DIF: Cognitive Level: Apply (Application) OBJ: Discuss common complications of wound healing.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 18. Which patient would benefit from soaking in a sitz bath? a. A patient with an abscessed tooth b. A patient with a fractured right arm c. A patient with painful back muscle spasms d. A patient who just had hemorrhoid surgery ANS: D

A patient who just had hemorrhoid surgery would benefit from a sitz bath as the perineal area is immersed in warm fluid. A sitz bath would not be appropriate for a fractured arm, abscessed tooth, or back spasms.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the differences in therapeutic effects of heat and cold.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 19. Which statement by the patient indicates that additional teaching is needed about the

application of an elastic bandage to the ankle? a. “I will take the bandage off if my toes start to tingle.” b. “I need to make sure the bandage is applied smoothly.”

c. “I need to watch my toes for swelling and feeling cold.” d. “I will to wrap the bandage from my shin toward my toes.”

ANS: D

The bandage should be wrapped from the toes up to the shin. The toes must be observed for swelling and the bandage must be applied smoothly. The bandage should be removed if the toes start to tingle.

DIF: Cognitive Level: Apply (Application) OBJ: Describe the purposes of and precautions taken with applying dressings and binders.

TOP: Nursing Process: Evaluation MSC: NCLEX: Reduction of Risk Potential 20. Which assessment charting indicates that the wound is healing by primary intention? a. The 4-inch incision edges are well approximated with intact sutures. b. Ulcerated 3-inch  1-inch area has thick yellow slough present in the center. c. Incision is 5 inch long  1 inch deep  1 inch wide with granulation tissue present. d. Superficial 3-inch  3-inch abrasion has no active bleeding, drainage or debris.

ANS: A

A clean surgical incision with sutures is healing by primary intention. Open wounds such as open incisions, ulcers, and abrasions heal by secondary intention.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate healing by primary and secondary intention.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 21. The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue.

Which term will the nurse u sN e t oRdesI crib e t h e u l c e r in the patient’s medical record?

U S N GT B .OC M a. Fluctuant b. Indurated c. Macerated d. Unstageable ANS: D

The nurse will document the ulcer as unstageable as the depth of the wound cannot be determined. Indurated skin feels hard to the touch but is not necrotic. Macerated skin has broken down due to long exposure to moisture. Fluctuant means to change or vary.

DIF: Cognitive Level: Apply (Application) OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure injury stages.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 22. The patient just sustained a deep laceration that is bleeding profusely. Which stage of healing

describes the current state of the patient’s wound? a. Hemostasis phase b. Proliferative phase c. Inflammation phase d. Remodeling phase ANS: A

Hemostasis phase controls bleeding. Inflammation phase establishes a clean wound bed and obtain bacterial balance. Proliferative phase produces new tissue, epithelialization, and contraction. Remodeling phase reorganizes the collagen to produce a more elastic, stronger collagen for the scar tissue.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss the response of the body during each phase of the wound-healing process.

TOP: Nursing Process: Assessment MSC: NCLEX: 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. Activity e. Friction 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 injuries: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Infection is not an area that is assessed on the Braden Scale.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Complete an assessmentNfor R a p aI t i e nG t w i tB h. risC k f oMr or actual impaired skin integrity.

TOP: Nursing Process: AssessmU ent S N MTS C : NCOLEX: Physiological Integrity

2. Which outcomes are appropriate for the patient with the nursing diagnosis risk for impaired

skin integrity related to immobility and muscle weakness? (Select all that apply.) a. The patient’s skin will remain intact without redness or ulceration. b. The nurse will assess the patient’s skin daily for any sign of breakdown. c. The patient will verbalize at least two methods to prevent skin breakdown. d. The patient’s wounds will be kept clean and will not develop signs of infection. e. The nurse will reposition the patient every 2 hours and pad bony prominences.

ANS: A, C

Appropriate goals for risk for impaired skin integrity include maintenance of intact skin and patient verbalization of methods to prevent skin breakdown. Daily wound assessment and repositioning are interventions. The presence of wounds makes the risk for impaired skin integrity nursing diagnosis inappropriate as wounds have already developed.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Evaluate outcomes of nursing care using appropriate criteria for a patient with risk for or actual impaired skin integrity.

TOP: Nursing Process: Planning MSC: NCLEX: Reduction of Risk Potential 3. A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse

is aware that wound healing is delayed due to complications. Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.)

a. b. c. d. e.

Dehiscence Evisceration Debridement Hemostasis 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. Debridement is the removal of dead or infected tissue from the wound which will promote healing.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss common complications of wound healing.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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Chapter 39: Sensory Alterations Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which term will the nurse use to document the patient’s age-related hearing loss? a. Tinnitus b. Meniere’s 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 Meniere’s disease is unknown, the symptoms include progressive low-frequency hearing loss, vertigo, tinnitus, and a full feeling or pressure in the affected ear.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Discuss common sensory changes that occur with aging.

TOP: Nursing Process: Assess men t MSC: NCLEX: Physiological Adaptation

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2. Which activity should be avoided by older adults due to age-related vision changes? a. Driving after dark b. Digital photography c. Typing on the computer d. Doing crossword puzzles ANS: A

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. For this reason the older adult should be encouraged to avoid driving after dark. Reading glasses are often required for typing and writing. Digital photography is not affected by age-related vision changes.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss common sensory changes that occur with aging.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 3. Which is the priority nursing diagnosis for a patient who has been diagnosed with Meniere’s

disease? a. Nausea related to constant sensation of noxious taste b. Acute confusion related to delirium and disorientation c. Risk for falls related to unsteadiness and loss of balance

d. Autonomic dysreflexia related to distention of bowel or bladder ANS: C

Meniere’s disease causes vertigo, a sensation of the environment spinning. This causes the patient to be unsteady and at high risk for falls. Nausea is less of a priority than falls.

Meniere’s disease does not cause confusion or autonomic dysreflexia.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss common sensory changes that occur with aging.

MSC: NCLEX: Safety and Infection Control

TOP: Nursing Process: Diagnosis

4. Which assessment finding indicates to the nurse that the patient is experiencing difficulty with

proprioception? a. The patient must hold on to the railing when ambulating in the hallway. b. The patient must add extra seasoning to food in order for it to have any flavor. c. The patient did not smell smoke even though the smoke detector was alarming. d. The patient suffered a first-degree burn when a heating pad was left on too long.

ANS: A

Proprioception is the patient’s ability to balance and maintain position. The patient’s proprioception is affected when the patient is unable to ambulate without holding on to the handrail. Proprioception does not affect taste, smell, or sensation.

DIF: Cognitive Level: Apply (Application) OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. Although the patient can see movement in the periphery, the patient can no longer see to read

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books or do crossword puzzlesU . WS h i c hNi s tTh e m o s O t likely cause of the patient’s vision loss? a. Cataracts b. Glaucoma c. Diabetic retinopathy d. 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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss common causes and effects of sensory alterations.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation

6. Which nursing diagnosis is most appropriate for a patient with xerostomia? a. Total urinary incontinence related to inability to feel urge to urinate b. Bathing self-care deficit related to inability to perceive left-sided body parts c. Impaired oral mucus membranes related to decreased salivation and dry mouth d. Disturbed sensory perception related to feeling of electric pain in feet and hands ANS: C

Xerostomia is a decrease in salivary production leading to dry mouth. This can cause damage to oral mucus membranes. Xerostomia does not include urinary disturbances or neuropathic pain.

DIF: Cognitive Level: Apply (Application) OBJ: Develop a plan of care for patients with sensory deficits.

MSC: NCLEX: Physiological Adaptation

TOP: Nursing Process: Diagnosis

7. How can the nurse assess if an infant is experiencing hearing loss? a. Use an otoscope to ensure that the infant’s tympanic membrane is intact. b. Review the infant’s medication list for medications that cause ototoxicity. c. Examine the infant’s outer ears to check for excessive amounts of cerumen. d. Watch to see if the infant reacts when the nurse’s hands are clapped together.

ANS: D

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 ENT specialist. Using an otoscope, reviewing the medication list, and examining the infant’s outer ears will not assess for hearing loss.

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DIF: Cognitive Level: Apply (Application) OBJ: Identify factors to assess in determining a patient’s sensory status.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 8. The nurse is caring for a patient who has a severe right-sided stroke with left-sided

hemiplegia. The patient uses the right extremities well but does not realize that the left arm and leg even exist. Which is the most appropriate nursing diagnosis for this patient? a. Deficient knowledge related to presence of paralyzed left arm and leg b. Unilateral neglect related to brain tissue damage after right-sided stroke c. Ineffective denial related to inability to accept paralysis of left arm and leg d. Noncompliance related to inability to follow directions to use left arm and leg ANS: B

Unilateral neglect occurs when the patient is unaware that a body area exists after a neurological injury or stroke. This patient demonstrates unilateral neglect by not realizing that the left arm and leg exist. Knowledge deficit, noncompliance, and ineffective denial do not explain the patient’s lack of realization of the left-sided extremities.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Develop a plan of care for patients with sensory deficits.

MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Diagnosis

9. The parent is concerned because the child has been referred to an optometrist after a routine

eye screening at school. What is the nurse’s most appropriate response to the parent?

a. b. c. d.

“Most children have a mild form of color blindness as their eyes mature.”

“You should wash the child’s eyelids every morning with a damp washcloth.”

“It is normal for children to squint to see but it should be checked out anyway.”

“Most likely your child will need glasses to see the teacher and board at school.”

ANS: D

The most common visual problem during childhood is a refractive error such as nearsightedness. The parent can be told that the child may likely require glasses in order to see clearly over far distances. Color blindness is not common in childhood and only affects males.

Squinting is not normal at any age. Washing the child’s eyelids every morning will not affect the child’s need for corrective lenses.

DIF: Cognitive Level: Apply (Application) OBJ: Identify factors to assess in determining a patient’s sensory status.

TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Health Promotion and Maintenance 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 friends or family members to interpret for the patient. b. Sit facing the patient when speaking and ensure there is adequate light. c. Repeat the entire conversation if it is not clearly understood the first time. d. Speak louder and more distinctly than normal with exaggerated lip movements.

ANS: B

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. The n uNrse R s h oI uld G be sB ea. teC d faMcing the patient and ensure that there is U S N T O enough light for the patient to see the nurse’s lips 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.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Describe nursing interventions with rationales that promote effective communication with patients who have sensory alterations.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 11. The nurse is caring for a patient with the nursing diagnosis of disturbed sensory perception

related to loud, bright hospital environment. Which is the priority intervention for the patient’s care plan? a. Maintain eye contact with the patient and avoid chewing gum. b. Ask the patient to repeat information back to ensure understanding. c. Repeatedly orient the patient to time, place, and the hospital room surroundings. d. Shut the patient’s door and avoid turning on the bright overhead lights in the room.

ANS: D

The nurse should try to reduce the patient’s sensory overload by closing the patient’s door and avoiding the use of bright overhead lights. Dimmer reading lights should be used whenever possible. Maintaining eye contact, having the patient repeat information, and orienting the patient to the surroundings will not reduce the sensory overload of the bright, loud hospital environment.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe conditions in the health care agency or patient’s home that you adjust to promote meaningful sensory stimulation.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 12. Which nursing intervention is the highest priority when caring for an impulsive, forgetful

stroke patient with right-sided paralysis? a. Complete a fall risk assessment such as the Hendrich II Fall Risk Model. b. Utilize a bed alarm and respond immediately when it is triggered. c. Place the call light within easy reach and remind the patient to use it. d. Apply a soft restraint to the patient’s left wrist to prevent getting out of bed.

ANS: B

The nurse should utilize a bed alarm for the patient and respond immediately when it is triggered indicating that the patient is starting to get up. This way the nurse will be able to intervene before the patient is able to get out of the bed. The patient is already known to be a fall risk so completing an additional fall risk assessment is unnecessary. The patient is forgetful and likely will not remember to use the call light. Restraints should be used only as a last result as they can cause significant injury and distress to the patient.

DIF: Cognitive Level: Analyze (Analysis) Be.ntCfO OBJ: Discuss ways to maintaiN nU a sR afS eI enN viG roT nm orM patients with sensory alterations.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 13. Which complication may develop as a result of frequent middle ear infections as a child? a. Meniere’s disease b. Serous otitis media c. Hearing impairment d. Impaction of cerumen ANS: C

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. Frequent middle ear infections do not lead to impaction of cerumen or Meniere’s disease. Serous otitis media is another name for a middle ear infection.

DIF: Cognitive Level: Remember (Knowledge) OBJ: Discuss common causes and effects of sensory alterations.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 14. Which assessment finding indicates that the patient has developed diabetes-induced peripheral

neuropathy? a. The nurse must speak louder than usual to be understood by the patient. b. Fine tremors of the hands that worsen when the patient tries to eat or write.

c. Painful muscle spasms with hyperreactive Achilles and quadriceps reflexes. d. No pain is felt when the patient’s feet are burned after walking on hot pavement.

ANS: D

Diabetic peripheral neuropathy may present with pain or loss of sensation in the extremities, particularly the feet. The patient who does not feel pain when the feet are burned is experiencing peripheral neuropathy. Diabetic peripheral neuropathy does not affect hearing or cause tremors or muscle spasms.

DIF: Cognitive Level: Apply (Application) OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 15. The patient tells the nurse that it is much easier to read books on the tablet computer after

applying a matte screen protector. Which is the best explanation for this? a. Glare causes headaches. b. Glare reduces visual acuity. c. Bright light overstimulates the retina. d. Too much light damages the iris.

ANS: B

When a patient ages, the pupil loses the ability to adjust to bright light. An antiglare screen protector therefore makes it easier for the patient to read text on the tablet computer. While glare can cause headaches for some people, it does not explain why the patient has an easier time reading text on the computer after the antiglare screen protector is applied. Overly bright light does not cause overstimulation of the retina or damage to the iris.

DIF: Cognitive Level: UndersN tandR(CoImpG reheB ns. ioC n) M U S N T O OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 16. Which is the most appropriate goal for a patient with the nursing diagnosis risk for loneliness

related to loss of spouse and admission to long-term nursing facility? a. The patient will use effective coping strategies to prevent self-harm. b. The patient will participate in at least one group activity every week. c. The patient will assist staff with activities of daily living every morning. d. The patient will express the desire to achieve increased levels of comfort.

ANS: B

The appropriate goal for a patient at risk of loneliness is for the patient to participate in at least one group activity every week. This will allow the patient to meet other residents and hopefully develop some friendships. The prevention of self-harm, assisting with activities of daily living, and desiring increased comfort are not appropriate goals for risk of loneliness.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Develop a plan of care for patients with sensory deficits.

MSC: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Planning

17. A patient has had no visitors during a lengthy hospitalization. The patient is bored, restless,

and irritable. Which term best describes the patient’s feelings? 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 patient’s 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.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate the processes of reception, perception, and reaction to sensory stimuli.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Which assessment findings put the patient at high risk for development of vision problems?

(Select all that apply.) a. Takes insulin glulisine for type 1 diabetes. b. Takes metoprolol to treat hypertension. c. Takes docusate sodium for constipation. d. Takes acetaminophen for osteoarthritis pain. e. Takes prednisone for mulN tiplR e scI leroG sis.B.C M

U S N T

O

ANS: A, B, E

History of diabetes and hypertension are both significant risk factors for eye diseases such as glaucoma and retinopathy. Prednisone is associated with early development of cataracts.

Constipation, osteoarthritis, acetaminophen, and docusate sodium do not put the patient at high risk for vision problems.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss common causes and effects of sensory alterations.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. Which medications can lead to development of tinnitus? (Select all that apply.) a. Furosemide b. Vancomycin c. Insulin glulisine d. Docusate sodium e. Naproxen sodium ANS: A, B, E

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.

DIF: Cognitive Level: Apply (Application) OBJ: Discuss common causes and effects of sensory alterations.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. The nurse is caring for a patient who becomes agitated when visitors stay for extended periods

or the hospital unit becomes noisy. The nurse identifies this as sensory overload. Which interventions will be of benefit to the patient? (Select all that apply.) a. Reduce the number of visitors to the patient’s room. b. Provide a dedicated period of rest time each afternoon. c. Institute a unit-wide quiet time at 10:00 p.m. each night. d. Turn on the television to drown out noise from other patients. e. Coordinate therapies and tests with other departments and providers.

ANS: A, B, C, E

Reduce sensory overload by organizing the patient’s care to control for excessive stimuli.

Reducing the number of visitors to the patient’s room and instituting a unit-wide quiet time can help the patient to rest comfortably. Coordination with other departments will reduce the time needed for therapies and tests.

DIF: Cognitive Level: Apply (Application) OBJ: Describe conditions in the health care agency or patient’s home that you adjust to promote meaningful sensory stimulation.

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

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Chapter 40: Surgical Patient Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which nursing diagnosis is the highest priority for a patient who just underwent hip

replacement surgery? a. Risk for perioperative positioning injury related to anesthesia, immobilization b. Dressing/grooming self-care deficit related to inability to bend over or cross legs c. Impaired walking related to toe-touch weight bearing to operative lower extremity d. Risk for injury related to dislodgement of prosthesis, unsteadiness with ambulation ANS: D

Risk for injury is the highest priority nursing diagnosis for this patient as the patient could fall or damage the prosthesis. Impaired walking and dressing/grooming self-care deficit are lower-priority nursing diagnoses. Risk for perioperative positioning injury is not applicable as the surgery is complete.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Construct an evidence-based plan of care designed to prevent postoperative complications.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Reduction of Risk Potential 2. Which assessment finding indicates that the patient is at high risk for development of

pulmonary embolism? a. The patient’s platelet count was 45,000/mm3 this morning. b. The patient’s last bowel movement was before surgery, 4 days ago.

N SR B.COafter M surgery. c. The patient has refused enoUxap NinjGTections arinI d. The patient required transfusion of two units of packed red blood cells.

ANS: C

Enoxaparin is a low-molecular-weight heparin used to prevent DVT and pulmonary embolism (PE). The refusal of enoxaparin significantly increases the patient’s risk of developing DVT or PE. Normal platelet count is 150,000 to 400,000/mm3 so the patient with a 45,000/mm3 platelet count is at risk of hemorrhage. Bowel movement and transfusion do not increase risk of DVT or PE. DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 3. Which surgery is classified as a palliative procedure? a. Release of bowel obstruction in a patient with end-stage colon cancer b. Thoracotomy to determine if a patient’s lung nodule is cancerous or benign c. Tummy tuck and repair of umbilical hernia after the patient gave birth to triplets d. Removal of the donor’s heart, lungs, and cornea for transplant in recipient patients ANS: A

Palliative surgeries are performed to make the patient more comfortable. An example of a palliative surgery is a release of bowel obstruction in a patient with end-stage colon cancer.

Thoracotomy for biopsy is a diagnostic surgery. Tummy tuck is a cosmetic procedure.

Removal of donor organs is termed procurement for transplant.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate among classifications of surgery and types of anesthesia.

TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 4. Which is the priority nursing diagnosis for a patient with shallow respirations following

abdominal surgery? a. Ineffective breathing pattern related to incisional pain and anesthesia b. Deficient diversional activity related to boredom from hospitalization c. Readiness for enhanced comfort related to desire for rest after surgery d. Risk for suffocation related to emotional and cognitive stress after surgery ANS: A

Ineffective breathing pattern is the priority nursing diagnosis because the patient’s respirations are shallow after surgery. The patient is at risk for developing pneumonia or atelectasis if the nurse does not encourage deep breathing. Deficient diversional activity and readiness for enhanced comfort are not priority diagnoses. Risk for suffocation is not applicable as stress after surgery would not lead to suffocation.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Construct an evidence-based plan of care designed to prevent postoperative complications.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Reduction of Risk Potential 5. The nurse is caring for a p a t i N e nUt R unS dI erN goG inTgBa. suCrgOiM cal procedure that will take 7 to 8 hours to

complete. Which is the appropriate outcome for the diagnosis risk for perioperative positioning injury related to prolonged immobilization? a. The patient’s skin will be assessed prior to surgery to identify areas at risk. b. The patient’s privacy and dignity will be maintained throughout the procedure. c. The patient’s bony prominences will be padded with pressure-reducing cushions. d. The patient’s skin will be free of redness or breakdown when surgery is complete.

ANS: D

The appropriate outcome for risk for perioperative positioning injury is that the patient’s skin will be free of redness or breakdown when surgery is complete. Privacy and dignity is less important than prevention of injury to the skin. Padding bony prominences and assessing the skin are both examples of nursing interventions rather than outcomes.

DIF: Cognitive Level: Apply (Application) OBJ: Describe intraoperative factors that affect a patient’s postoperative care.

TOP: Nursing Process: Planning MSC: NCLEX: Reduction of Risk Potential 6. Which assessment finding leads the nurse to include risk for ineffective airway clearance to

the surgical patient’s care plan? a. The patient is extremely anxious about the upcoming surgery. b. The patient will be receiving a local anesthetic for the procedure. c. The patient sleeps poorly and wakes up every morning with a headache. d. The patient speaks no English and requires the services of an interpreter.

ANS: C

Frequent arousals and waking up every morning with a headache are signs of potential obstructive sleep apnea. Collapse of the patient’s upper airway during sleep leads to ineffective airway clearance. Anxiety, language fluency, and local anesthesia do not indicate risk for ineffective airway clearance.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 7. The nurse is teaching the patient about postoperative exercises including incentive spirometry.

How can the nurse best determine that the teaching was effective? a. The patient states that the preoperative anxiety has decreased significantly. b. The patient correctly demonstrates the exercises and how to use the spirometer. c. The patient senses a caring presence of the nurse in the therapeutic relationship. d. The patient explains to the nurse why the exercises and spirometer are important.

ANS: B

The nurse can best determine that the teaching was effective by having the patient demonstrate the exercises and how to use the spirometer. Statements about anxiety, caring presence, and rationales do not demonstrate that the patient is able to use the spirometer and perform the exercises.

DIF: Cognitive Level: Apply (Application) OBJ: Design an evidence-based, patient-centered preoperative teaching plan.

TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 8. The nurse is caring for a patiN e nt U whoS R IwilN Gl beTBh.avCing O Memergency surgery in a few minutes for

appendicitis. Which preoperative teaching is most important? a. What to expect when waking up in the postanesthesia care unit b. Interventions to minimize risk of postoperative wound infection c. Demonstration of incentive spirometer and deep-breathing exercises d. Importance of early ambulation to prevent pneumonia and atelectasis ANS: A

The patient does not have time to learn about exercises and activities to prevent postoperative complications. The nurse should inform the patient about what to expect in the immediate postoperative period. Information about wound care, deep breathing, and ambulation can wait until after surgery is completed.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss methods of preparing a patient for surgery.

MSC: NCLEX: Reduction of Risk Potential

TOP: Nursing Process: Planning

9. Four hours after major abdominal surgery, the nurse notes that the patient does not have any

bowel sounds. What is the appropriate action of the nurse? a. Notify the surgeon immediately and prepare the patient for emergency surgery. b. Keep the patient NPO and document the finding in the patient’s medical record. c. Allow the patient to have clear liquids as tolerated to help bowel function return. d. Provide meticulous oral care and allow the patient to have ice chips for dry mouth.

ANS: B

Absence of bowel sounds is common for the first few hours to days following major abdominal surgery. The nurse should keep the patient NPO as any oral intake will lead to nausea and vomiting. The surgeon does not need to be notified and the patient does not require emergency surgery.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. Which nursing diagnosis is the highest priority for a patient who had spinal anesthesia for

hysterectomy surgery? a. Nausea related to side effect of spinal anesthesia b. Constipation related to manipulation of bowel during surgery c. Risk for falls related to impaired motor function from anesthesia d. Impaired oral mucus membranes related to NPO status before surgery ANS: C

The priority nursing diagnosis is risk for falls related to impaired motor function from anesthesia because spinal anesthesia causes temporary paralysis of the lower extremities.

Nausea, constipation, and impaired oral mucus membranes are all less important nursing diagnoses.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate among classifications of surgery and types of anesthesia.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Reduction of Risk Potential 11. Which type of anesthesia will the patient receive during surgery on the cervical spine? a. Local NURSINGTB.COM b. Spinal c. General d. Epidural ANS: C

General anesthesia must be used for cervical spinal surgery. Epidural and spinal anesthesia must be placed below the cervical spine. Local anesthesia is not appropriate for spinal surgery.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate among classifications of surgery and types of anesthesia.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 12. Which surgical procedure may be performed using conscious sedation? a. Knee-replacement surgery b. Coronary artery bypass surgery c. Cataract removal with lens implant d. Modified radical mastectomy surgery ANS: C

Conscious sedation may be used for minor surgical procedures such as endoscopy or cataract removal. Major surgeries such as joint replacement, heart bypass, and mastectomy require spinal or general anesthesia.

DIF: Cognitive Level: Apply (Application) OBJ: Differentiate among classifications of surgery and types of anesthesia.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 13. Which is the highest priority nursing diagnosis for the patient undergoing a lengthy surgery in

the operating room? a. Powerlessness related to unconscious state from general anesthesia b. Hypothermia related to cool ambient temperature in the operating room c. Risk for impaired oral mucus membranes related to prolonged NPO status d. Risk for caregiver role strain related to lengthy waiting period for family members ANS: B

The operating room environment is cool, and the patient’s depressed level of body function results in a lowering of metabolism and fall in body temperature. Hypothermia is a priority nursing diagnosis for patients undergoing lengthy surgeries. Powerlessness, risk for impaired oral mucus membranes, and risk for caregiver role strain are all less important diagnoses.

DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe intraoperative factors that affect a patient’s postoperative care.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 14. The postanesthesia care unit nurse receives a patient from the operating room. Which

assessment will the nurse perform first? a. Foley catheter and surgical fluid intake b. Intravenous lines for patency or redness c. Airway, lung sounds, and pulse oximetry d. Nasogastric tube and presence of bowel sounds ANS: C

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The priority assessment is airway and oxygenation. Urinary output, intravenous lines, and bowel sounds may be assessed afterward.

DIF: Cognitive Level: Apply (Application) OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 15. Which is the most appropriate outcome for the postoperative patient with the nursing

diagnosis ineffective breathing pattern related to side effects of pain medication? a. The patient will correctly demonstrate how to use pursed-lip breathing. b. The patient will report the ability to breathe comfortably without anxiety. c. The patient’s pulse oximetry will stay greater than 94% with at least 12 breaths/minute. d. The patient will rest comfortably and rate pain no higher than 4 on 0-to-10 scale.

ANS: C

The appropriate outcome for ineffective breathing pattern is that the patient’s pulse oximetry will stay greater than 94% with at least 12 breaths/minute. Pursed-lip breathing will not be of benefit for respiratory depression due to pain medication. Comfortable breathing is not as measurable as pulse oximetry and respiratory rate. Pain rating is not an appropriate outcome for ineffective breathing pattern.

DIF:

Cognitive Level: Apply (Application)

OBJ: Construct an evidence-based plan of care designed to prevent postoperative complications.

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 16. The patient will be having knee-replacement surgery at 2:00 p.m. What is the latest time that

the patient can have a cup of coffee with cream? a. 6:00 a.m. b. 8:00 a.m. c. 10:00 a.m. d. 12:00 noon ANS: B

Patients must not have milk products for at least 6 hours before surgery. Patients can have clear liquids until 2 hours before surgery. Meats and fried foods must not be consumed within 8 hours before surgery.

DIF: Cognitive Level: Understand (Comprehension) OBJ: Discuss methods of preparing a patient for surgery.

TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Reduction of Risk Potential 17. Which is the priority outcome for the patient with the nursing diagnosis fluid volume deficit

related to ongoing postoperative bleeding? a. The patient’s urine output will be at least 30 mL/hour. b. The patient’s temperature will remain within normal limits. c. The patient’s surgical incision will remain intact with sutures. d. The patient will verbalize measures to reduce fluid volume loss.

ANS: A

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Urine output is a sensitive indicator of fluid volume. Urine output of at least 30 mL/hour is an indicator that the patient’s fluid volume is not significantly low. Temperature and incision appearance are not appropriate outcomes for fluid volume deficit. It is not appropriate to expect the patient to verbalize measures to stop postoperative bleeding.

DIF: Cognitive Level: Apply (Application) OBJ: Construct an evidence-based plan of care designed to prevent postoperative complications.

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. Which assessment finding leads the nurse to question the order to remove the patient’s

indwelling urinary catheter? a. The patient does not wish to get out of bed and ambulate to the toilet. b. The patient just underwent radical prostatectomy surgery 2 days ago. c. The drainage bag contains 300 mL of clear yellow urine from the last 4 hours. d. The patient is to be discharged home after a final assessment by the surgeon.

ANS: B

The indwelling catheter is usually left in for an extended period of time following radical prostatectomy surgery. The catheter should be removed regardless of the patient’s desire to use the toilet. 300 mL of clear yellow urine in the last 4 hours is an excellent sign. The patient may be discharged home with a urinary catheter once discharge teaching has been completed.

DIF: Cognitive Level: Apply (Application) OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Assessment

MSC: NCLEX: Reduction of Risk Potential

MULTIPLE RESPONSE 1. Which assessment findings indicate increased risk of infection following hip replacement

surgery? (Select all that apply.) a. The patient has been a type 2 diabetic for the last 5 years. b. The patient had an indwelling urinary catheter during surgery. c. The patient takes adalimumab for rheumatoid arthritis. d. The patient received two units of packed red blood cells after surgery. e. The patient’s platelet count has been 300,000 to 350,000/mm3 after surgery ANS: A, B, C

Diabetes, urinary catheterization, rheumatoid arthritis, and immunosuppressant medication all increase the risk of infection for the patient. Need for transfusion and normal platelet counts do not increase the risk of infection.

DIF: Cognitive Level: Apply (Application) OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 2. Which interventions are appropriate for the postoperative patient with the nursing diagnosis

risk for ineffective peripheral tissue perfusion related to venous thromboembolism from immobility after surgery? (Select all that apply.) a. Apply graduated compression stockings after measuring the patient’s legs. b. Encourage weight loss in order to minimize risk of chronic venous insufficiency. c. Carefully assess for any sNw elR l i n gIo r G rednBe. ssCin tM h e patient’s upper and lower legs.

U S N T O d. Apply sequential compression devices to the patient’s legs when resting in bed. e. Carefully assess the patient for dyspnea, tachycardia, and low pulse oximetry. f. Teach the patient to inspect the legs daily for dry skin, coolness, and hair loss.

ANS: A, C, D, E

Graduated compression stockings and sequential compression devices are important tools for DVT prevention. The nurse should carefully assess the patient’s legs for redness or swelling that could indicate DVT. Respiratory difficulty and low pulse oximetry can indicate pulmonary embolism that has broken off from DVT. Weight loss should not be encouraged in the immediate postoperative patient. Dry skin, coolness, and hair loss are all indicators of chronic arterial insufficiency rather than postoperative DVT. DIF: Cognitive Level: Analyze (Analysis) OBJ: Construct an evidence-based plan of care designed to prevent postoperative complications.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential 3. The nurse is caring for a patient with shallow respirations and diminished breath sounds

following abdominal surgery yesterday. Which are the appropriate actions of the nurse?

(Select all that apply.) a. Assist the patient to sit up in the chair and ambulate in the hallway. b. Watch the patient use the incentive spirometer and ensure hourly usage. c. Teach the patient to splint the incision when coughing to minimize pain. d. Dim the lights, provide warm blankets, and maintain a quiet environment. e. Maintain patient privacy and use therapeutic touch as desired by the patient.

ANS: A, B, C

Assisting the patient to sit up in the chair and ambulate in the hallway will facilitate chest expansion for deeper breaths. Incentive spirometry is crucial for prevention of atelectasis and pneumonia. The patient should be taught to splint the incision when coughing to minimize pain. A peaceful environment, privacy, and therapeutic touch will not help prevent atelectasis or pneumonia.

DIF: Cognitive Level: Apply (Application) OBJ: Construct an evidence-based plan of care designed to prevent postoperative complications.

TOP: Nursing Process: Implementation MSC: NCLEX: Reduction of Risk Potential

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