Fundamentals of Canadian Nursing Concepts, Process, and Practice, 4th edition By Barbara J. Kozier T

5) Mr. Pollard, 72 years old, is scheduled for a hernia repair at 8 AM the following morning. He is in the preoperative clinic having lab work drawn and an EKG. What statement by Mr. Pollard to the nurse would prompt the need for further health teaching?

A) I should take all my medications the morning of surgery.

B) I will get pain medication regularly after surgery.

C) Deep breathing and coughing will help my recovery.

D) I need to shower with chlorhexidine wash the morning of surgery.

Answer: A Explanation: A) Correct. Mr. Pollard should be advised which medications to take by the anaesthetist. For many clients, they are instructed to take cardiac medications only with a small sip of water. Otherwise, they should not be taking anything by mouth before surgery.

B) Incorrect. This is an accurate statement by Mr. Pollard. In order for Mr. Pollard to be able to participate in activities that promote recovery, he should be medicated regularly.

C) Incorrect. This is also an accurate statement. Mr. Pollard will do deep breathing and coughing exercises in order to prevent atelectasis and pneumonia.

D) Incorrect. Mr. Pollard will be given instructions on specific skin preparations before his surgery.

Type: MC Learning Outcome: 36-5 6) On the morning of his surgery, Mr. Pollard tells the nurse that he takes St John's wort regularly. Why is it important that the nurse pass this information along to the surgeon and anaesthetist?

A) When it is combined with some anaesthetic agents, it may cause hemorrhage.

B) It potentiates the hypotensive action of some anaesthetic agents.

C) It decreases the antiinflammatory response required for healing.

D) It causes hypoglycemia when taken along with anaesthetic agents.

Answer: B Explanation: A) Incorrect. This is an inaccurate statement about the use of St. John's wort.

B) Correct. St. John's wort, a herbal product, increase the hypotensive action of certain anaesthetic agents.

C) Incorrect. This would be an accurate statement about corticosteroid use.

D) Incorrect. This is an inaccurate statement about the use of St. John's wort.

Type: MC Learning Outcome: 36-3

For exam and test prep, contact excellentessaywriters@gmail.com

3 .

7) Mrs. Koloneles has had her surgery and is transferred to the PACU. Which of the following interventions would the nurse implement to reduce the risk of thrombophlebitis?

A) Oxygen by mask B) Deep breathing and coughing C) Ambulate every 2 hours D) Leg exercises Answer: D Explanation: A) Incorrect. Oxygen will not prevent thrombophlebitis.

B) Incorrect. Deep breathing and coughing are measures that will help prevent atelectasis and pneumonia, not thrombophlebitis.

C) Incorrect. It is too early to begin ambulating Mrs. Koloneles because she is unlikely to be awake enough to safely do so.

D) Correct. In the post anaesthetic care unit (PACU), the leg exercises can be implemented to help prevent thrombophlebitis.

Type: MC Learning Outcome: 36-5 8) Jane has returned from the PACU to the surgical unit. Which of the following nursing interventions should the nurse do first?

A) Check to see if the correct intravenous (IV) solution is hanging B) Check to see in what position Jane should be placed C) Check for estimated blood loss D) Check the appropriate health care provider's orders Answer: D Explanation: A) Incorrect. The nurse would need to review the orders first to see what IV has been ordered.

B) Incorrect. If there are specific recommendations for how she should be positioned, they would be in the orders.

C) Incorrect. Estimated blood loss would be in the documentation from PACU; this is information the nurse would review after checking physician orders.

D) Correct. The nurse's priority is to check the appropriate health care provider's orders. There may be orders that must be carried out immediately.

Type: MC Learning Outcome: 36-8

4 .

9) Which of the following laboratory tests are performed to help determine the nutritional status of a client considered high risk for heart surgery?

A) Complete blood count B) Cardiac enzymes C) Troponin D) Albumin and pre-albumin Answer: D Explanation: A) Incorrect. This is a screening that would be done on most clients going for surgery, but does not provide any information specific to a client's nutritional status.

B) Incorrect. Cardiac enzymes are drawn when the client presents with symptoms of acute coronary syndrome.

C) Incorrect. Troponin levels are also drawn for clients presenting with symptoms of acute coronary syndrome and would not provide information about a client's nutritional status.

D) Correct. Albumin and pre-albumin would give an indicator of a client's general nutritional status and would be appropriate for clients who are deemed high risk for any surgery.

Type: MC Learning Outcome: 36-3 10) The operating room nurse is preparing Mr. Jacobs's skin for femoral bypass surgery. What is the purpose of the skin preparation prior to surgery?

A) Sterilize the skin by killing all organisms B) Remove operative site hair by shaving C) Assess the surgical site for abrasions and wounds D) Reduce the risk of post-operative wound infection Answer: D Explanation: A) Incorrect. The skin cannot be sterilized.

B) Incorrect. While hair removal is recommended, shaving is not. The Safer Healthcare Now! (2010) campaign to reduce surgical site infections indicates that no surgical site hair removal should be performed by shaving with a razor. In cases when surgical site hair removal is required, then it is to be done with clippers. Shaving causes microscopic skin abrasions that provide a portal of entry for microorganisms, a risk factor in the development of surgical site infections.

C) Incorrect. While assessment of the skin is important, it is not the intended reason for skin prep.

D) Correct. The purpose of skin preparation prior to surgery is to reduce the risk of postoperative wound infection by cleansing the skin.

Type: MC Learning Outcome: 36-6

5 .

11) Eighty year-old Mr. Janisse has arrived on the surgical unit following a right femoral bypass.

He has chronic obstructive pulmonary disease (COPD), as a result of many years of smoking.

Which of the following nursing interventions is of most importance to Mr. Janisse's general recovery?

A) Explaining how to perform leg exercises B) Restricting fluid intake to less than 1000 mL C) Ambulating Mr. Janisse to the end of the hall and back every 2 hours D) Having Mr. Janisse demonstrate coughing and deep breathing Answer: D Explanation: A) Incorrect. While Mr. Janisse should also be taught and encouraged to perform leg exercises, he is more at risk for pulmonary complications due to his history.

B) Incorrect. There is nothing to suggest Mr. Janisse should have a fluid restriction. Adequate fluid intake is necessary to replace fluids lost in intraoperative and post-operatively.

C) Incorrect. Mr. Janisse does not need to ambulate every 2 hours, but should gradually increase the amount of time spent ambulating.

D) Correct. The nursing intervention of most importance to Mr. Janisse is deep breathing and coughing exercises. These are important for removal of the secretions from his chest and prevention of pneumonia and atelectasis.

Type: MC Learning Outcome: 36-5 12) Mrs. Maddison, 25, is preparing for an upper GI endoscopy. Which of the following types of anaesthesia would the nurse anticipate she will receive?

A) Local anaesthesia B) General anaesthesia C) Surface anaesthesia D) Conscious sedation Answer: D Explanation: A) Incorrect. Local anaesthesia interrupts the transmission of nerve impulses to a specific small area (e.g., index finger). Local anaesthesia is used for minor surgical procedures, such as performing a biopsy, or during tooth extraction.

B) Incorrect. General anaesthetics have effects of depressing respiratory and cardiac functions and should only be considered when a state of total unconsciousness is required.

C) Incorrect. Surface or topical anaesthesia is used to provide topical anaesthesia before the injection of a medication. It is usually applied directly on skin or mucous membranes.

D) Correct. Conscious sedation is often used for procedures such as endoscopies, breast biopsies, and drainage of abscesses. These procedures require only a minimal depression of the level of consciousness while the client retains the ability to consciously maintain an open airway and respond appropriately to commands.

Type: MC Learning Outcome: 36-7

6 .

13) Which of the following clients would be the best candidate for a general anaesthetic? A) Mrs. Caron, who is anxious about a right mastectomy that cannot be postponed B) Mr. Richards, who is having a minor surgical procedure done same-day surgery C) Mrs. Alice, who has a serious chronic respiratory problem D) Mr. George, who has circulatory insufficiency Answer: A Explanation: A) Correct. Mrs. Caron is undergoing major surgery; she is the most appropriate candidate for a general anaesthetic. B) Incorrect. Mr. Richards's procedure is minor and does not require a general anaesthetic. C) Incorrect. Mrs. Alice has respiratory problems which increase the risk of post-operative complications. The better choice for her would be an option that did not have the depressive effects on the respiratory and cardiac system. D) Incorrect. Mr. George has circulatory problems which increase the risk of post-operative complications. The better choice for him would be an option that did not have the depressive effects on the respiratory and cardiac system. Type: MC Learning Outcome: 36-7 14) The nurse is caring for Mrs. Blok in the PACU after a right pneumonectomy. In the immediate post-anaesthesia phase, which of the following positions should Mrs. Blok be placed in until she regains consciousness? A) Supine B) Prone C) Sidelying D) Semi-Fowlers Answer: C Explanation: A) Incorrect. Mrs. Blok could be at risk for aspiration if positioned in the supine position. B) Incorrect. The prone position would not be recommended immediately after surgery. It would not allow for wound assessment or continued assessment of her respiratory status. C) Correct. Mrs. Blok is unconscious and should be positioned on her side, with her face slightly down. This allows for drainage of secretions and minimizes the risk of aspiration. D) Incorrect. Mrs. Blok is unconscious, and has no protective reflexes. The best position for her to prevent risk of aspiration, and for continued assessment of her respiratory status and her wound, is side-lying. Type: MC Learning Outcome: 36-8

7 .

15) On her second post-op day, an X-ray determines that Mrs. Edwards has bilateral atelectasis.

She is not showing any clinical signs at this time. What initial interventions should be recommended by the nurse?

A) Encourage deep breathing and coughing B) Encourage ambulation C) Encourage adequate intake of fluids D) Oxygen by cannula Answer: A Explanation: A) Correct. Atelectasis is the collapse of alveoli in the lungs. Continued deep breathing and coughing, and use of the incentive spirometry will help to open up the collapsed airways.

B) Incorrect. While ambulation should be continued, it will not have as direct an effect on the alveoli as deep breathing and coughing.

C) Incorrect. Fluid intake will not affect the alveoli.

D) Incorrect. Oxygen may be needed if Mrs. Edwards develops clinical signs from the collapsed airways. At this time, she is asymptomatic and oxygen will not help to restore the collapsed airways.

Type: MC Learning Outcome: 36-9 16) Mr. Elliott is scheduled to have a bowel resection in 1 hour. He has been fasting since midnight and states that his mouth is very dry. What can the nurse suggest for Mr. Elliott?

A) Offer him a small sip of water or some ice chips B) Give him a piece of hard candy to suck on C) Explain that he cannot have anything by mouth until after surgery D) Encourage him to brush his teeth and rinse his mouth, but not to swallow the water Answer: D Explanation: A) Incorrect. Sips of water or ice chips would not be appropriate for this client because his surgery is only an hour away. According to guidelines published by the Canadian Anesthesiologists' Society, clear fluids should be held if surgery is within 2 hours.

B) Incorrect. Hard candies within an hour of anaesthesia could place the client at risk for aspiration and would not be appropriate.

C) Incorrect. This explanation does not provide any rationale for why he cannot take anything by mouth. It does nothing to address Mr. Elliott's concerns.

D) Correct. The nurse should encourage Mr. Elliott to brush his teeth and rinse his mouth, taking care that he does not swallow the water. This could be repeated if necessary.

Type: MC Learning Outcome: 36-4

8 .

17) Ms. Farron is a nursing student completing an observation shift in the OR. After completion of the surgery, she asks the scrub nurse what impact the use of surgical safety checklists have had on client outcomes. What would the nurse respond? A) Decreased complications B) Decreased lawsuits C) Decreased wait times D) Mortality rates stable Answer: A Explanation: A) Correct. According to a study by deVries et al, the number of complications dropped from 27.3 per 100 patients to 16.7 per 100 patients after the checklist was introduced! Mortality rates actually reduced as well. B) Incorrect. There is no data on whether lawsuits have been decreased due to surgical safety checklists. C) Incorrect. Wait times have not been impacted by surgical safety checklists. D) Incorrect. Mortality rates actually reduced from 1.5% to 0.8%. Type: MC Learning Outcome: 36-10 18) Mr. Clifton's abdomen is distended and firm to touch. He has a rapid, weak pulse. What postoperative complication is Mr. Clifton most likely experiencing?

A) Paralytic ileus B) Infection C) Post-operative hemorrhage D) Pneumonia Answer: C Explanation: A) Incorrect. Although a client with paralytic ileus may have a distended abdomen, the client would be experiencing nausea and vomiting, not a weak, thready pulse.

B) Incorrect. Signs of infection would include fever, and localized redness and swelling at the incision site.

C) Correct. A rapid, weak pulse is a cardinal sign of hemorrhaging post-operatively. Other signs of hemorrhage include overt bleeding, increased pain, increasing abdominal girth, and swelling or bruising around the incision.

D) Incorrect. Pneumonia would present with respiratory symptoms (SOB, coughing, decreased O2 saturations), and no distended abdomen.

Type: MC Learning Outcome: 36-10

9 .

19) Mr. Comartin has returned to the surgical unit with a nasogastric (NG) tube in place.

How can the nurse confirm that the NG tube is in the stomach? A) Listen over the stomach for a swishing sound when air is injected into the NG tube B) Ask Mr. Comartin to swallow and check him to see if the gag reflex is present C) Check the NG tube aspirate for acidity using a pH strip D) Connect the NG tube to suction and observe the aspirate Answer: C Explanation: A) Incorrect. Listening over the stomach by itself while injecting air is not reliable or accurate. This can be used to confirm placement after the pH test has been done.

B) Incorrect. Checking for the gag reflex will not indicate where the tube is placed. C) Correct. Using a pH strip to check the aspirate for acidity is the most accurate and reliable way of confirming that the NG tube is in the stomach. D) Incorrect. Connecting the NG tube to suction will not confirm placement. Type: MC Learning Outcome: 36-11 20) Mr. Morris has an incision with a penrose drain. How would the nurse change the dressing on Mr. Morris? A) Remove the old dressing with a sterile glove B) Clean the incision first, then around the drain C) Use one swab to clean all around the drain D) Place most of the dressings above the drain site to absorb the drainage Answer: B Explanation: A) Incorrect.

The old dressing can be removed with a clean glove. B) Correct. The incision should be cleaned first and then the drain. The main surgical incision is considered cleaner than the surgical stab wound made for the drain insertion. C) Incorrect. Drains should be cleaned after the surgical incision. Clean the skin around the drain site by swabbing in half or full circles from around the drain site outward, using separate swabs for each wipe. D) Incorrect. Place the bulk of the dressings over the drain area and below the drain, depending on the client's usual position. Layers of dressings are placed for best absorption, which flows by gravity.

Type: MC Learning Outcome: 36-12

10 .

21) The nurse is assessing Mr. Clarence's abdominal wound. Which of the following signs would alert the nurse to an infection?

A) Absence of bleeding B) Edges well approximated C) Edges warm to the touch D) Sutures in place Answer: C Explanation: A) Incorrect. The absence of bleeding does not indicate an infection.

B) Incorrect. A wound that is healing well would have well approximated edges but would not be a sign of infection.

C) Correct. If the wound becomes warm, red, and edematous, the nurse should suspect an infection and notify the appropriate health care provider. Absence of bleeding, edges well approximated, and sutures in place are all expected and are not indicators of infection.

D) Incorrect. The presence of sutures would not provide any information about whether the wound is infected or not.

Type: MC Learning Outcome: 36-10 22) Mrs. Reddy, 78 years old, had an abdominal hysterectomy 2 days ago. She has a history of COPD. Which of the following assessment findings would prompt further action by the nurse?

A) Oxygen saturation of 92% B) Every 4 hour requests for pain medication C) Urine output < 30 mL per hour D) Redness and swelling at the wound edges Answer: C Explanation: A) Incorrect. This is an acceptable oxygen saturation for a client who has COPD. B) Incorrect. It is not unusual in the first 24 hours after surgery to request pain medication every 4 hours. In fact, in order to promote the client to participate in activities that would prevent postoperative complications, frequent and regular analgesic is recommended.

C) Correct. Urine output < 30 mL per hour could indicate dehydration. The nurse would want to check electrolytes and vital signs to determine the meaning of these assessment findings.

D) Incorrect. Redness and swelling around wound edges would be considered normal in the first 3 days after surgery.

Type: MC Learning Outcome: 36-10

11 .

23) Mr. Chester returns from post-anaesthesia recovery room following an abdominal aneurism repair. He has a midline incision with a hemovac drain in place. What should the nurse do first after emptying the drain for 80 mL of sanguineous drainage?

A) Hand hygiene B) Report output to the physician C) Document output on health record D) Cleanse opening with alcohol, close opening Answer: D Explanation: A) Incorrect. Hand hygiene is important after emptying a drain with body fluids; it would not be done before the system was closed and suction resumed.

B) Incorrect. This would be a normal amount of drainage this early after surgery. There is no need to notify the physician.

C) Incorrect. The output of the drain needs to be documented, but in order to maintain the closed advantages of the drain (reduces possibility of microorganisms entering the wound through the drain), it should be closed immediately after the contents have been emptied.

D) Correct. The hemovac is compressed with one hand, while the opening is cleansed with an alcohol swab. Closing the opening while the device is compressed will reset the suction.

Type: MC Learning Outcome: 36-12 24) The nurse is applying antiembolism stockings to Mr. Clifton, a 75-year-old man with circulatory problems. What is the purpose of antiembolism stockings?

A) Facilitate venous return to the heart B) Ensure mobility and prevent contractures C) Prevent varicose veins in the legs D) Prevent atrophy of the leg muscles Answer: A Explanation: A) Correct. The purpose of antiembolism stockings is to promote venous return from the lower extremities, prevent venous stasis and venous thrombosis, and to reduce peripheral edema.

B) Incorrect. Anti-embolic stockings do not ensure or promote ambulation.

C) Incorrect. Anti-embolic stockings do not prevent varicose veins.

D) Incorrect. There is no reason to believe that Mr. Clifton is at risk for atrophy of his leg muscles. Antiembolic stockings would not be effective in preventing muscle atrophy.

Type: MC Learning Outcome: 36-12

12 .

25) Prior to an exploratory laparotomy, 60-year-old Mrs. Lily has screening tests performed.

Which of the following tests provides information about red and white blood cells and the oxygen carrying capacity of the blood?

A) Blood urea nitrogen (BUN) B) Blood grouping and cross-matching C) Serum albumin and total protein D) Complete blood count (CBC) Answer: D Explanation: A) Incorrect. BUN is a test of renal function.

B) Incorrect. Blood grouping is essential for major surgery when estimated blood loss may require need for transfusions.

C) Incorrect. Serum albumin and total protein provide information related to the nutritional status of the client.

D) Correct. A CBC measures red blood cells, hemoglobin, and hematocrit, and determines the oxygen carrying capacity of the blood.

Type: MC Learning Outcome: 36-3 26) Sixty-year-old Mrs. Lily develops sudden chest pain on her third post-operative day. She is diagnosed with a pulmonary embolism. Which of the following nursing interventions would help prevent a pulmonary embolism?

A) Early ambulation B) Deep breathing and coughing exercises C) Incisional splinting D) Monitoring intake and output Answer: A Explanation: A) Correct. Early ambulation, leg exercises, antiembolic stockings, SCDs, and adequate fluid intake are all interventions to reduce the risk for thrombophlebitis and subsequent pulmonary embolism.

B) Incorrect. Deep breathing and coughing will help prevent pneumonia post-operatively.

C) Incorrect. Incisional support will promote comfort post-operatively.

D) Incorrect. Monitoring intake and output will not in itself prevent post-operative complications. Adequate intake is one of the interventions necessary to prevent thrombophlebitis.

Type: MC Learning Outcome: 36-10

13 .

27) Mrs. Monaghan has terminal cancer. She has decided not to pursue any further curative treatments. She does agree to the removal of a small tumour that is compressing her small bowel.

What type of surgery is this considered?

A) Exploratory B) Ablative C) Diagnostic D) Palliative Answer: D Explanation: A) Incorrect. This confirms or establishes a diagnosis.

B) Incorrect. Ablative surgery removes a diseased body part, e.g., removal of a gallbladder.

C) Incorrect. This confirms or establishes a diagnosis.

D) Correct. Palliative surgery relieves or reduces pain or symptoms of a disease but does not cure.

Type: MC Learning Outcome: 36-2 28) List three responsibilities of the nurse planning the perioperative nursing care for Mr. Kent, who is having an endoscopic gastroscopy.

Answer: Assessing, teaching, and following up Explanation: Assessing, teaching, and following up are vital to successful outcomes for clients who undergo day surgery.

Type: SA Learning Outcome: 36-4

14 .

Fundamentals of Canadian Nursing, 4e(Kozier) Chapter 37 Sensory Perception 1) During a review of Mr. Dennis's admission data, the nurse learns that he has impairment of kinesthetic sensation. Which nursing measures should be planned for Mr. Dennis? A) Use the clock face as a format for describing the position of food on meal trays B) Provide all teaching materials in very large font C) Ensure that the client has assistance when ambulating D) Use only nonirritating soaps for bathing Answer: C Explanation: A) Incorrect. This would be an intervention appropriate for a client with visual impairment. B) Incorrect. This would also be an intervention for a client with visual impairment. C) Correct. Kinesthetic sensation refers to the awareness of the position and movement of body parts. The client with impairment of this sensation may be prone to injury by falling and should be assisted when ambulating. D) Incorrect. This is not an intervention required for someone with kinesthetic impairment. Type: MC Learning Outcome: 37-5 2) Mr. Clayton, a 60-year-old accountant, has been admitted to the intensive care unit (ICU) with a myocardial infarction. Two days after his admission he states that he is tired and has not slept well since admission. He appears anxious, tense, and seems disoriented at times. What type of sensory alteration is Mr. Clayton experiencing? A) Impulse conduction B) Cognitive dysfunction C) Sensory deprivation D) Sensory overload Answer: D Explanation: A) Incorrect. Impulse conduction is a part of the sensory process and is not in itself a sensory alteration. B) Incorrect. Mr. Clayton is not demonstrating any degree of cognitive dysfunction. C) Incorrect. Sensory deprivation would be manifested by excessive yawning, drowsiness, sleeping, decreased attention span, difficulty concentrating, and decreased problem solving amongst other symptoms. D) Correct. Sensory overload is common in clients admitted to hospital, and especially those admitted to ICU, where there are many new noises, lights, and equipment. Type: MC Learning Outcome: 37-4

1 .

3) Mr. Clayton, a 60-year-old accountant, has been admitted to the intensive care unit (ICU) with a myocardial infarction. Two days after his admission he states that he is tired and has not slept well since admission. He appears anxious, tense, and seems disoriented at times. Considering Mr. Clayton's symptoms, what nursing measures would be implemented?

A) Encourage environmental changes B) Encourage visits by family and friends C) Explain sounds in the environment D) Encourage the use of crossword puzzles Answer: C Explanation: A) Incorrect. Encouraging environmental changes, such as taking a walk or sitting by a window, would be an appropriate measure for someone who is sensory deprived.

B) Incorrect. While visitors are not restricted, visits should be limited for clients experiencing sensory overload.

C) Correct. Explaining sounds in the environment will allow Mr. Clayton to organize them mentally. When Mr. Clayton understands their meaning, stimuli are frequently less confusing and more easily ignored.

D) Incorrect. Crossword puzzles are utilized to stimulate mental function of those clients with sensory deprivation.

Type: MC Learning Outcome: 37-6 4) Which of the following would indicate that a client has met the goal of preventing sensory overload?

A) Reports reduced feelings of anxiety B) Uses assistive devices for communication C) Reports decreased boredom D) Makes appropriate use of sensory aids Answer: A Explanation: A) Correct. A client who has met the goal of preventing sensory overload would report feelings of reduced anxiety and increased energy.

B) Incorrect. This would be an indicator that a goal of improved communication had been met.

C) Incorrect. This would be an outcome for the goal of preventing sensory deficit.

D) Incorrect. This would indicate that the client had met the goal of preventing injury.

Type: MC Learning Outcome: 37-5

2 .

5) Which of the following nursing measures would be included in the care of a client experiencing sensory deprivation?

A) Schedule a routine of care B) Encourage visits by family and friends C) Provide new information gradually D) Plan care to allow for uninterrupted periods of rest Answer: B Explanation: A) Incorrect. Scheduling care at the same time daily is a measure that would be included in care of the client with sensory overload.

B) Correct. Encouraging family and friends to visit provides stimulation for a person who has sensory deprivation.

C) Incorrect. Providing information gradually so that clients have time to process new information would be included in the care of a client experiencing sensory overload.

D) Incorrect. This is also a measure taken for clients experiencing sensory overload.

Type: MC Learning Outcome: 37-6 6) Mr. Clayton, a 60-year-old accountant, has been admitted to the intensive care unit (ICU) with a myocardial infarction. The nurse suspects that Mr. Clayton has a hearing deficit; however, Mr. Clayton denies not being able to hear. What initial assessment technique should the nurse employ?

A) Schedule a Weber and Rinne test B) Observe Mr. Clayton's interactions with his family C) Use an otoscope to visualize Mr. Clayton's inner ear D) Confront Mr. Clayton with the nurse's suspicion Answer: B Explanation: A) Incorrect. The Weber and Rinne test is a quick test that can detect hearing loss.

It may be a part of assessment, but will not yield as much information as simple observation.

B) Correct. By observing Mr. Clayton interact with his family, the nurse can learn a great deal about Mr. Clayton's ability to hear. The nurse should look for frequent requests to repeat, inattention to the conversation, turning one ear to the conversation, and lip-reading.

C) Incorrect. An otoscope may be a part of assessment, but will not yield as much information as simple observation.

D) Incorrect. Mr. Clayton has already denied a hearing problem, so confronting him with the nurse's suspicion will probably only serve to alienate Mr. Clayton from the nurse. Further observation may help to confirm the nurse's suspicions.

Type: MC Learning Outcome: 37-3

3 .

7) The nurse suspects that Mr. Clayton has a hearing deficit; however, Mr. Clayton denies not being able to hear. Which intervention can the nurse use to improve communication with Mr. Clayton?

A) Turn the radio on to soft music before initiating the conversation B) Frequently vary the volume of his or her voice throughout each sentence C) Talk very slowly, in a loud voice into Mr. Clayton's ear D) Ensure that Mr. Clayton can see the nurse's face easily and that the room is well lit Answer: D Explanation: A) Incorrect. Background noises should be eliminated, if possible, before speaking to the client.

B) Incorrect. It is recommended that the nurse keep her voice at the same volume, without dropping her voice at the end of each sentence.

C) Incorrect. The nurse should talk at a moderate rate and in a normal tone of voice.

D) Correct. Ensure that Mr. Clayton can see the nurse's face easily and that the room is well lit. It is very important that the person with a hearing deficit can see the face of the person he is communicating with, so the nurse should face Mr. Clayton and ensure the room is well lit.

Type: MC Learning Outcome: 37-6 8) Mr. Wilkins is a 34-year-old paraplegic hospitalized for pneumonia. He has a history of recent surgery for appendicitis, and an incisional wound infection. He lives at home with his wife and 7-year-old twin sons. What factors place Mr. Wilkins at higher risk for sensory deprivation?

A) Paraplegia B) Recent surgery C) Recent wound infection D) Home care environment Answer: A Explanation: A) Correct. Clients who are at risk for sensory deprivation include those who have mobility restrictions (quadriplegia, paraplegia).

B) Incorrect. Recent surgery would not place Mr. Wilkins at higher risk for sensory deprivation.

C) Incorrect. A recent wound infection would not place at him at higher risk for sensory deprivation.

D) Incorrect. There is no reason to believe that Mr. Wilkins' home environment is either nonstimulating or monotonous, or that he has limited interactions with his family.

Type: MC Learning Outcome: 37-4

4 .

9) Mrs. Barnes, a 45-year-old client, reports having diabetes mellitus since childhood. This morning's blood glucose reading is 20. Because of this history, the nurse would monitor Mrs. Barnes for which sensory deficit?

A) Taste B) Hearing C) Vision D) Olfactory Answer: C Explanation: A) Incorrect. Taste is not affected in a client with diabetes.

B) Incorrect. Hearing is not affected by diabetes.

C) Correct. Diabetic retinopathy is a common complication of diabetes mellitus in which tiny retinal hemorrhages can lead to blindness.

D) Incorrect. The sense of smell is not affected by diabetes.

Type: MC Learning Outcome: 37-3 10) Mrs. Carson has a long history of congestive heart failure and has been treated with large amounts of furosemide (Lasix). During this hospitalization, Mrs. Carson is receiving intravenous furosemide. Given her history, for which sensory impairment would the nurse monitor Mrs. Carson?

A) Loss of ability to taste B) Hearing loss C) Vision loss D) Loss of ability to smell Answer: B Explanation: A) Incorrect. The sense of taste is not affected by the long term use of furosemide.

B) Correct. Furosemide (Lasix) can be ototoxic if taken over long periods of time.

C) Incorrect. Vision is not affected by the use of furosemide.

D) Incorrect. The olfactory sense is not affected by the use of furosemide.

Type: MC Learning Outcome: 37-2

5 .

11) Mrs. Avalon, 33 years old, is at the health clinic with her 6-month-old daughter for a checkup. What suggestions might the nurse offer Mrs. Avalon about the prevention of sensory impairment?

A) Vaccinations for her daughter B) Regular screening for diabetes C) Annual eye exams for her and her husband D) Screening for mumps before another pregnancy Answer: A Explanation: A) Correct. Regular childhood immunizations protect children against diseases capable of causing hearing loss (e.g., rubella, mumps, and measles).

B) Incorrect. Screenings for diabetes would not be done unless there were risk factors present.

C) Incorrect. Annual eye exams are usually only recommended for clients who have a history of glaucoma and diabetes. For all other clients, eye exams every 2-3 years after the age of 40 is recommended.

D) Incorrect. Screening is necessary for rubella before pregnancy because it can cause hearing loss in the newborn. Screening for mumps is not required.

Type: MC Learning Outcome: 37-6 12) Mr. Gabbard, 79 years old, is hospitalized for an exacerbation of congestive heart failure. He does not recognize his daughter and wonders why his wife, who died years ago, has not visited him. What is Mr. Gabbard most likely experiencing?

A) Delirium B) Sensory overload C) Dementia D) Acute sensory deficit Answer: A Explanation: A) Correct. The components of delirium include a reduced ability to focus, sustain, or shift attention; a change in cognition that may include memory impairment, and/ or disorientation.

B) Incorrect. Mr. Gabbard is experiencing signs of acute confusion that came on abruptly. These are indications of delirium, not sensory overload.

C) Incorrect. Dementia is a condition that has symptoms that are gradual and irreversible. Mr. Gabbard's symptoms have appeared suddenly which is more common with delirium.

D) Incorrect. Mr. Gabbard's symptoms are not those of a sensory deficit.

Type: MC Learning Outcome: 37-7

6 .

13) The nurse is assisting Mrs. Haeger, a visually impaired client, with ambulation. How should the nurse proceed with this intervention? A) Walk about 30 cm behind Mrs. Haeger, allowing her to grasp the nurse's arm B) Walk about 30 cm in front of Mrs. Haeger, allowing her to grasp the nurse's arm C) Walk on the right side of Mrs. Haeger, allowing her to grasp the nurse's arm D) Walk on the left side of Mrs. Haeger, allowing her to grasp the nurse's arm Answer: B Explanation: A) Incorrect. This position would make it difficult for the client to grasp the nurse's arm, and may actually throw the client's balance off. B) Correct. The nurse should walk about 30 cm in front of Mrs. Haeger. C) Incorrect. The side that the nurse walks on would be determined by the client's preference. D) Incorrect. The side that the nurse walks on would be determined by the client's preference. Type: MC Learning Outcome: 37-6 14) Mr. Laberge, a 70-year-old man, was hospitalized earlier in the week. Prior to this illness, Mr. Laberge exhibited clear thought processing and was able to maintain an independent lifestyle. On assessment today, the nurse observes that he is quite confused. How would the nurse document this mental state?

A) Acute confusion B) Sundowner's syndrome C) Delirium D) Dementia Answer: A Explanation: A) Correct. The nurse should document this as acute confusion. It is descriptive of a behavioural state. Delirium is a medical diagnosis.

B) Incorrect. Sundowner's syndrome usually occurs in the evening and is associated with confusion and wandering of the client.

C) Incorrect. Delirium is acute confusion caused by illness, medication, or a change in environment. It is a medical diagnosis and, until confirmed, would not be the most accurate way of documenting his mental state.

D) Incorrect. Dementia is chronic confusion with symptoms that are gradual in onset and are irreversible.

Type: MC Learning Outcome: 37-7

7 .

15) The nurse is assessing 16-year-old Kevin, who was brought into the emergency room from a motor vehicle accident. Kevin can be aroused only with repeated or intense stimulation. How should the nurse describe this client in a report?

A) Somnolent B) Disoriented C) Comatose D) Semicomatose Answer: D Explanation: A) Incorrect. The somnolent client is very drowsy, but will respond to stimuli.

B) Incorrect. A disoriented client is alert, but not oriented to time, place, or person.

C) Incorrect. The comatose client is not arousable.

D) Correct. Since Kevin can only be aroused with intense or repeated stimuli, the correct description is semicomatose.

Type: MC Learning Outcome: 37-8 16) Kevin, who has had a traumatic brain injury, is physiologically stable but remains in a coma a week after being admitted to hospital. His family stays with him around the clock. Which of the following should the nurse encourage the family to do?

A) Dim the lights and keep noise to a minimum B) Play music while touching and talking to Kevin C) Talk to Kevin as if he was conscious D) Stay back from the bed so as not to disturb Kevin Answer: C Explanation: A) Incorrect. There is no reason to dim the lights or keep noise to a minimum.

B) Incorrect. Playing music while touching and talking to Kevin may cause sensory overload.

C) Correct. The family and nursing staff can provide sensory stimulation to Kevin by talking to him as if he were conscious.

D) Incorrect. There is no reason to dim the lights, keep noise to a minimum, or to stay back from the bed.

Type: MC Learning Outcome: 37-8

8 .

17) Mrs. Ellis's family brought her to her health care provider's office because she was having hallucinations and delusions. These two problems occur with which of the following sensory alterations?

A) Sensory deprivation B) Sensory overload C) Sensory deficit D) Delirium Answer: A Explanation: A) Correct. Hallucinations and delusions occur with sensory deprivation. When there is a decrease or lack of meaningful stimuli the balance in the reticular activating system (RAS) is disturbed. This reduced stimulation causes the person to become more acutely aware of the remaining stimuli and often perceive these in a distorted manner.

B) Incorrect. Hallucinations are not commonly experienced by clients suffering from sensory overload.

C) Incorrect. A sensory deficit involves impaired reception, perception, or both of one or more of the senses. Two forms of sensory deficit are blindness and deafness. Neither of these deficits predisposes clients to hallucinations.

D) Incorrect. Delirium is a temporary state of mental confusion and fluctuating consciousness that has an abrupt onset and a cause that, when treated, reverses the confusion. It does not predispose the client to hallucinations.

Type: MC Learning Outcome: 37-4 18) The nurse is planning care for Mr. Taylor who is experiencing delirium. Which of the following guidelines are important to consider while providing care to Mr. Taylor?

A) Background music will keep this client calm.

B) Activities should be scheduled at the same time each day.

C) Pain mediation will increase delirium.

D) Talk with the client throughout procedures.

Answer: B Explanation: A) Incorrect. The client typically is better oriented when it is quiet. Unnecessary noise should be controlled or eliminated.

B) Correct. The client with delirium benefits from a routine schedule of activities.

C) Incorrect. Uncontrolled pain can cause delirium and pain medication should be administered when required.

D) Incorrect. Procedures should be explained in direct, clearly understandable terms, but the nurse should avoid "chatter."

Type: MC Learning Outcome: 37-6

9 .

19) Which of the following measures would promote a therapeutic environment for a person with dementia?

A) Keep explanations to a minimum B) Allow clients to schedule care C) Keep activities to a minimum D) Assign consistent caregivers Answer: D Explanation: A) Incorrect. Clear, concise explanations should be offered for all care and treatments rendered.

B) Incorrect. Clients with dementia often have difficulty with decision making. Providing care at the same time each day will provide a sense of security for the client.

C) Incorrect. Participation in familiar activities will emphasize the client's strengths.

D) Correct. Clients in care facilities have interactions with many new faces daily. Limiting their interactions by the assignment of consistent caregivers will increase their sense of security.

Type: MC Learning Outcome: 37-8 20) Mrs. Gresham's vision is deteriorating. She tells you that she is having difficulty preparing her meals. Which of the following actions might help to support her visual function?

A) Suggest that she ask her husband to cook the meals B) Suggest that she get some meals from Meals on Wheels C) Suggest that she have a home health aide come to prepare her meals D) Suggest that she use colour-coded dials on her stove Answer: D Explanation: A) Incorrect. There is no information to suggest that she is married. If she is living with her husband, having him cook would not support her visual functioning.

B) Incorrect. The first step for Mrs. Gresham should be to suggest actions that will allow her to continue with her home activities. Having someone else prepare the meals would not support her visual function.

C) Incorrect. This is an action that would reduce Mrs. Gresham's independence and would not support her visual functioning.

D) Correct. The only option that supports Mrs. Gresham's visual function is using coloured rims on dishes and colour-coding dials on the stove. All other suggestions decrease the need for her to use her vision.

Type: MC Learning Outcome: 37-6

10 .

21) Which of the following would describe a client who has been diagnosed with dementia?

A) Generally normal level of alertness B) Hypervigilant level of alertness C) Recent and immediate impaired memory D) Delusions are common occurrences Answer: A Explanation: A) Correct. Persons with dementia usually experience a normal level of awareness.

B) Incorrect. A hypervigilant level of awareness fluctuating with lethargy is true of persons with delirium.

C) Incorrect. Recent and immediate impaired memory would be true of persons with delirium. A person with dementia would have impairments in recent and remote memory.

D) Incorrect. Delusions are common occurrences in persons with delirium, not dementia.

Type: MC Learning Outcome: 37-7 22) The nurse caring for Mrs. Edwards wears a large name tag and introduces herself to the client each time she enters the room. A clock and a calendar have been placed in Mrs. Edwards' room along with photographs of her family. What are these nursing interventions specifically intended to do?

A) Support Mrs. Edwards' hearing deficit B) Prevent sensory deprivation C) Support Mrs. Edwards' visual deficit D) Orient Mrs. Edwards to person, place, and time Answer: D Explanation: A) Incorrect. These are not measures that would support a hearing deficit.

B) Incorrect. Measures to prevent sensory deprivation would include increasing tactile stimulation and encouraging social interaction. The measures taken would not prevent sensory deprivation.

C) Incorrect. Not all of these measures support Mrs. Edwards' visual deficit. Wearing a name tag and introducing oneself upon entry to a client's room would be appropriate for visually impaired clients, as well as clients who may need reorienting to their surroundings. The pictures, clock, and calendar are specific to clients who need to be reoriented to time, place, and person.

D) Correct. The nurse should frequently remind Mrs. Edwards of information related to person, place, and time.

Type: MC Learning Outcome: 37-8

11 .

23) Mr. Christopher is a 90-year-old client recently admitted to a complex care facility. He is demonstrating signs of sensory deprivation. What nursing assessment needs to be completed before planning care?

A) Determine if deprivation is due to inadequate stimuli or inability to receive or process stimuli B) Find out from family what activities he did at home C) Provide a variety of stimuli to determine what may be effective D) Refer to occupational health for further assessment Answer: A Explanation: A) Correct. It is important that the nurse determine if deprivation is due to inadequate stimuli or inability to receive or process stimuli. The type and need for stimulation will depend upon the reason for sensory deprivation.

B) Incorrect. This option assumes that his deprivation is due to inadequate stimuli. This has not been determined yet.

C) Incorrect. It is important that the nurse determine if deprivation is due to inadequate stimuli or inability to receive or process stimuli. Providing stimuli for Mr. Christopher would be an intervention, not an assessment.

D) Incorrect. While occupational therapists may be able to assist in planning activities for the client with sensory deprivation, this is actually an intervention not an assessment. Mr. Christopher needs an assessment to determine what the cause of his sensory deprivation is.

Type: MC Learning Outcome: 37-5 24) Which of the following describes the ability to perceive environmental stimuli and respond appropriately?

A) Awareness B) Sensorium C) Cognition D) Stereognosis Answer: A Explanation: A) Correct. Awareness is the ability to perceive environmental stimuli and body reactions and to respond appropriately through thought and action.

B) Incorrect. Sensorium is the state of an individual in relation to consciousness or mental awareness.

C) Incorrect. Cognition is the act of knowing, perceiving, or remembering.

D) Incorrect. Stereognosis is the awareness of an object's shape, size, and texture.

Type: MC Learning Outcome: 37-1

12 .

25) Mrs. Jorgens, an 86-year-old widow, recently became a resident of an extended care facility. Three days after she was admitted, the nurse found her to be somewhat confused and disoriented about person, place, and time. Which intervention by the nurse would be most appropriate? A) Use a posey restraint to prevent falls B) Encourage diversional activities such as watching television C) Reorient her to place, person, and time as often as possible D) Use of tactile stimulation when providing care Answer: C Explanation: A) Incorrect. There is no indication that she is at risk for a fall. A posey restraint is not appropriate and may, in fact, place Mrs. Jorgens at risk for injury. B) Incorrect. Watching television is not an appropriate activity for a confused person. C) Correct. The most appropriate nursing intervention with Mrs. Jorgens is to reorient her to place, person, and time as often as possible. D) Incorrect.

Tactile stimulation (touching and massage) would be appropriate if Mrs. Jorgens was unconscious. While it may also be included for care of Mrs. Jorgens, the most appropriate action to take here is to reorient her. Type: MC Learning Outcome: 37-8 26) Three weeks after 86-year-old Mrs. Jorgens is admitted to an extended care facility, she is found staff yawning and drowsy, her memory is impaired, she seems depressed, and accuses the of trying to poison her. Which sensory problem do these manifestations fit?

A) Stereognosis B) Sensoristasis C) Sensory deprivation D) Sensory overload Answer: C Explanation: A) Incorrect. Stereognosis is the awareness of an object's size, shape, and texture by touch. This is not what Mrs. Jorgens is experiencing.

B) Incorrect. Sensoristasis is the term used to describe optimum arousal for an individual. It refers to an ability to receive and interpret stimuli. It does not explain what Mrs. Jorgens is experiencing.

C) Correct. Mrs. Jorgens has manifestations of sensory deprivation.

D) Incorrect. Sensory overload may cause complaints of fatigue, sleeplessness, irritability, anxiety, disorientation, decreased problem-solving ability, and scattered thoughts.

Type: MC Learning Outcome: 37-4

13 .

27) When caring for Mr. Robson, a 70-year-old man with diabetes, you note that he has decreased tactile sensation in his lower extremities. Which safety measure should the nurse emphasize while teaching him?

A) Maintain a constant temperature in the house B) Wear shoes with rubber soles when going outside C) Ensure that his socks are snug enough so that they will not fall down D) Check water temperature on the forearm before getting into the tub Answer: D Explanation: A) Incorrect. Maintaining a constant temperature will not promote safety for Mr. Robson.

B) Incorrect. Mr. Robson should be wearing shoes on his feet at all times, not just when he is going outside.

C) Incorrect. Wearing snug socks will not promote safety for Mr. Robson.

D) Correct. It is important for Mr. Robson to check the water temperature on his forearm, as he is at risk for burns due to the decreased sensation in his lower extremities.

Type: MC Learning Outcome: 37-6 28) Which of the following measures would promote safety for Mr. Robinson, a 73-year-old client, post CVA, who has impaired olfactory sense?

A) Smoke detector by the stove B) Clear uncluttered pathways C) Adjust temperature on hot water heater D) Avoid using hot water bottles Answer: A Explanation: A) Correct. Mr. Robinson's sense of smell is altered. He may not be able to detect burning smells. Having a smoke detector by the stove will alert him to smoke or fire.

B) Incorrect. Clearing uncluttered pathways would be a safety recommendation for a client who has vision loss.

C) Incorrect. This would be appropriate for a client with reduced tactile sensation.

D) Incorrect. This would be an appropriate safety measure for someone with altered tactile sense.

Type: MC Learning Outcome: 37-6

14 .

Fundamentals of Canadian Nursing, 4e(Kozier) Chapter 38 Sleep 1) Mrs. Andrea calls the pediatric clinic with concerns about her newborn. She states that when her baby first goes to sleep she can see her eyes dart around under her eyelids and she doesn't breathe regularly. What should the nurse's response to Mrs. Andrea be?

A) You should bring your baby in immediately for a checkup.

B) These are common behaviours in newborns and are normal.

C) Ask the physician about these symptoms at your next checkup.

D) If it happens again, take her to the emergency department.

Answer: B Explanation: A) Incorrect. This is a normal stage of sleep and does not require that the baby be checked at the clinic.

B) Correct. These are indications of normal rapid eye movement (REM) sleep in the newborn.

The mother should be reassured that this is normal.

C) Incorrect. The nurse is able to explain to Mrs. Andrea that this is a normal stage of sleep. Mrs. Andrea does not need to wait to get this information from her physician.

D) Incorrect. There is no need to have the baby taken to the emergency department; this is a normal stage of sleep.

Type: MC Learning Outcome: 38-3 2) What is sleep?

A) Sleep is unconsciousness with perception of strong stimuli only.

B) Sleep is unconsciousness with heightened perception of external stimuli.

C) Sleep is a state with no response to stimuli.

D) Sleep is an altered state of consciousness with decreased responses to stimuli.

Answer: D Explanation: A) Incorrect. Sleep is not an unconscious state. An unconscious person has no purposeful response to stimuli. A sleeping person has decreased but present responses to stimuli.

B) Incorrect. Sleep is not an unconscious state.

C) Incorrect. During sleep, there is a decreased response to stimuli, but it is not absent.

D) Correct. Sleep is considered to be an altered state of consciousness in which the individual's perception of and response to the environment are decreased. Sleep is not a state of unconsciousness.

Type: MC Learning Outcome: 38-1

1 .

3) Mrs. Perry is teaching a class on the importance of sleep and rest to her first-year nursing students. How would she explain the purpose of the RAS system?

A) The RAS suppresses the brain centres.

B) The RAS controls the body biorhythm.

C) The RAS maintains wakefulness in the cerebral cortex.

D) The RAS sends stimuli from the cerebral cortex to the body.

Answer: C Explanation: A) Incorrect. The RAS does not suppress the brain centres; these are influenced by neurotransmitters.

B) Incorrect. The body's biorhythms are influenced by melatonin and cortisol, not by the RAS. C) Correct. In the sleep-wake cycle, the RAS maintains wakefulness in the cerebral cortex.

Darkness and the reduced mental and physical activity associated with sleep preparation cause a decrease in stimulation of the RAS. D) Incorrect. Information does not flow from the cortex to the body. Neurons within the reticular formation, located in the brain stem, integrate sensory information from the peripheral nervous system and relay the information to the cerebral cortex.

Type: MC Learning Outcome: 38-1 4) While doing an admission history on 30-year-old Mrs. Janeese, you learn that she has frequent sleepless nights and, as a result, has many questions about sleep. "Some nights I don't feel like I have slept at all, even the slightest of noises will awaken me." What stage of sleep is Mrs. Janeese describing?

A) Rapid-eye-movement (REM) sleep B) Non-rapid-eye-movement (NREM) sleep, stage I C) Non-rapid-eye-movement (NREM) sleep, stage II D) Non-rapid-eye-movement (NREM) sleep, stage III Answer: B Explanation: A) Incorrect. Mrs. Janeese is experiencing the lightest stage of sleep, NREM I. The sleeper may not be aware that they have been sleeping. REM sleep lasts for a longer period of time and is a deeper sleep. The person may be difficult to arouse from REM sleep.

B) Correct. Mrs. Janeese is describing NREM, stage I sleep which lasts only a few minutes.

During this stage, the person feels drowsy and relaxed, the eyes roll from side to side, and the heart and respiratory rates drop slightly. The sleeper may be easily awakened and may deny being asleep.

C) Incorrect. Stage II is also a light stage of sleep but requires more intense stimuli than stage I for the person to be awakened.

D) Incorrect. This is one of two deepest stages of sleep. The person is difficult to arouse and skeletal muscles are very relaxed.

Type: MC Learning Outcome: 38-2

2 .

5) A student in Mrs. Perry's class asks her when in the sleep cycle dreaming occurs. What is the correct answer?

A) During REM sleep B) In all stages of sleep C) During stage I REM sleep D) Within 10 minutes of falling asleep Answer: A Explanation: A) Correct. Most dreams occur during REM sleep but usually are not remembered unless the person arouses briefly at the end of the REM stage.

B) Incorrect. Dreaming does not occur in all stages of sleep.

C) Incorrect. There is no stage I of REM sleep.

D) Incorrect. Within 10 minutes of falling asleep, the person would be in either NREM stage I or NREM stage II. Dreaming does not occur in either of these stages.

Type: MC Learning Outcome: 38-2 6) Mrs. Janeese sleeps poorly during the 6 days she is hospitalized. After being discharged, she is very tired on her first night home. How would you to expect this to affect her sleep cycle?

A) Dreams will be prolonged.

B) REM sleep will predominate.

C) Stage IV NREM sleep will last 30 minutes during each cycle.

D) REM sleep cycles will be shorter than usual.

Answer: D Explanation: A) Incorrect. Dreams occur during REM sleep which is shortened when someone is very tired. Dreams would not be prolonged.

B) Incorrect. REM sleep is still evident, but it is not as long when someone is very tired.

C) Incorrect. There is no exact time that any one stage lasts. It varies throughout the night.

D) Correct. Mrs. Janeese will be very tired due to not sleeping well in hospital. REM cycles are often short when the person is very tired.

Type: MC Learning Outcome: 38-2

3 .

7) Mrs. Hughes has brought her 2-month-old son in for his first vaccination. She asks the nurse why his sleep patterns are so sporadic. How would the nurse respond?

A) Once REM sleep develops, by 6-9 months of age, an infant's sleep pattern will regularize.

B) Sleep is partially regulated by circadian rhythms that are not developed until 3-6 months of age.

C) NREM sleep is not fully developed in infants, so they do not fall into the deepest stages (III and IV).

D) The activating system for melatonin release is not mature until 6-8 months of age.

Answer: B Explanation: A) Incorrect. REM (active sleep in the newborn) is present right at birth, and infants go directly into REM as soon as they fall asleep. This does not affect the regularity of sleep patterns.

B) Correct. Circadian regularity begins to develop by the sixth week of life, and by 3 to 6 months, most infants have a regular sleep-wake cycle.

C) Incorrect. The only thing that differentiates the actual sleep cycles between an infant and an adult is that infants go directly into REM sleep and each cycle lasts about an hour as opposed to 90 minutes in the adult. NREM sleep does occur in infants, and it is referred to as quiet sleep.

D) Incorrect. There is no evidence that the release of melatonin is not as effective in the newborn/infant.

Type: MC Learning Outcome: 38-2 8) Mrs. Hughes has brought her 2-month-old son in for his first vaccination. She asks the nurse how she can promote good sleep for her infant at night. How would the nurse respond?

A) At night, feed baby in a dimly lit room.

B) Try and keep baby awake during daylight.

C) Put baby to bed with a familiar blanket or stuffed toy.

D) Infants benefit from consistent bedtime rituals.

Answer: A Explanation: A) Correct. Performing nighttime feeds and changes quietly and with lowered lights can also help establish day and night rhythms in babies.

B) Incorrect. Infants at this age need approximately 16-18 hours of sleep a day. It would not be appropriate to try and keep them awake during daylight hours.

C) Incorrect. This would be an appropriate action to take for a toddler who is resistant on going to bed.

D) Incorrect. Infants need to establish day and nighttime rhythms. Because of the number of hours they sleep during the day, establishing different routines for day and night is important.

Type: MC Learning Outcome: 38-3

4 .

9) The parents of 6-month-old Timmy tell the nurse that they are exhausted because their baby wakes up several times every night. What advice should the nurse give these parents?

A) Be certain that the baby is truly awake before picking him up for feeding B) Let the baby "cry it out" for a few nights until he can sleep through the night C) Continue to respond to the baby anytime he is restless during the night D) Bring the baby in for a sleep study to check for possible sleeping disorders Answer: A Explanation: A) Correct. Babies often move and make noises while sleeping that do not indicate wakefulness. The parents should be certain Timmy is awake before picking him up to feed, change, or comfort him.

B) Incorrect. Letting the baby "cry it out" is not appropriate if he really needs care.

C) Incorrect. Continuing to respond to the baby anytime he is restless during the night is not necessary and may result in parental exhaustion.

D) Incorrect. There is no indication of any need for a sleep study for Timmy. This is a normal sleep pattern for an infant.

Type: MC Learning Outcome: 38-3 10) Seventy-year-old Mr. Markson tells the nurse, "I can go to sleep without a problem, but then I wake up in a couple of hours and can't go back to sleep." What nursing action would help promote rest and sleep in this client?

A) Have Mr. Markson develop a bedtime ritual of quiet music and a glass of wine B) Encourage Mr. Markson to avoid taking pain medication prior to sleep C) Evaluate if Mr. Markson perceives sleeplessness to be a serious problem D) Have Mr. Markson perform moderate exercises before bedtime Answer: C Explanation: A) Incorrect. Alcohol and exercise can interfere with sleep.

B) Incorrect. If the client has pain, the nurse should not encourage avoidance of medication.

C) Correct. The first intervention is to determine what the pattern of sleeplessness means to the client. Many older clients will "nap" off and on throughout the day and night and spend wakeful times engaged in activity, even if the active times are not during traditional active hours.

D) Incorrect. Exercise late in the evening can interfere with sleep.

Type: MC Learning Outcome: 38-3

5 .

11) Jamie, a 5-year-old, has recurrent night terrors. What nursing intervention would the nurse plan to help alleviate this problem?

A) Walk Jamie around in the room when the night terrors occur B) Briefly wake and resettle Jamie 15 to 20 minutes before usual onset C) Give Jamie a cup of hot chocolate before bedtime D) Have Jamie empty his bladder prior to going to bed Answer: D Explanation: A) Incorrect. Walking Jamie around the room will not promote good sleep patterns for Jamie.

B) Incorrect. Waking and resettling Jamie before the usual onset may only delay its occurrence.

C) Incorrect. Hot chocolate has caffeine in it and may keep the child awake.

D) Correct. Night terrors are partial awakenings that are sometimes related to excessive tiredness or a full bladder. Having Jamie empty the bladder before going to bed might be helpful.

Type: MC Learning Outcome: 38-3 12) Cohen, a 6-year-old, has enlarged tonsils from frequent streptococcal infections. How might these enlarged tonsils affect his sleep?

A) Cause sleep apnea B) Increase REM sleep C) Precipitate narcolepsy D) Decrease stage IV NREM sleep Answer: A Explanation: A) Correct. Cohen's enlarged tonsils predispose him to obstructive sleep apnea.

Obstructive sleep apnea occurs when the structures of the pharynx or oral cavity block the flow of air.

B) Incorrect. Enlarged tonsils do not increase REM sleep.

C) Incorrect. Narcolepsy is manifested by excessive daytime sleepiness and the sleep at night usually begins with a sleep onset REM period. Enlarged tonsils would not cause narcolepsy.

D) Incorrect. Cohen's enlarged tonsils would not decrease stage IV NREM sleep.

Type: MC Learning Outcome: 38-5

6 .

13) During a corporate health fair, Mr. Mitchell states that he "just can't stay awake" during the daytime, although he "sleeps just fine at night." What advice should the nurse offer Mr. Mitchell?

A) Go to your physician for a physical examination B) Increase intake of caffeinated beverages in the daytime C) Use an over-the-counter sleep aid to deepen nighttime sleep D) Have a mental health screening for depression Answer: A Explanation: A) Correct. Daytime hypersomnia is often due to medical conditions such as kidney, liver, or metabolic disturbances.

B) Incorrect. Caffeinated beverages may increase daytime wakefulness, but will not help any underlying problem that may be present.

C) Incorrect. An over-the-counter sleep aid is not a good choice as Mr. Mitchell already sleeps well at night and sleep aids can sometimes cause future sleep disturbances.

D) Incorrect. There is no indication that Mr. Mitchell is depressed. Depression usually causes insomnia, and Mr. Mitchell states he is sleeping well at night.

Type: MC Learning Outcome: 38-5 14) Thirty-five-year-old Mr. Samson is being treated with a nasal continuous positive airway pressure device (CPAP) for sleep apnea. What finding would indicate to the nurse that this treatment has been effective for Mr. Samson?

A) Mr. Samson has lost 7 pounds since initiating treatment.

B) Mr. Samson sleeps so soundly that he snores.

C) Mr. Samson's diabetes is now under control.

D) Mr. Samson reports a decrease in morning headache.

Answer: D Explanation: A) Incorrect. Weight loss is not a direct result of CPAP therapy.

B) Incorrect. Snoring is a sign of apnea, not sound sleeping.

C) Incorrect. Successful treatment for sleep apnea will not help control diabetes.

D) Correct. The fact that Mr. Samson experiences a decrease in morning headache indicates that he is sleeping better.

Type: MC Learning Outcome: 38-7

7 .

15) The nurse is working with Mr. Elinore, an air traffic controller. He states that he has significant life stressors at this time, is sleeping poorly, and it is affecting his ability to function.

After developing a plan with Mr. Elinore that includes strategies to promote adequate rest and sleep, what would he and the nurse determine is an expected outcome?

A) Sleep at least 8 hours each night B) List three positive coping mechanisms for anxiety relief C) Report getting sufficient sleep to provide energy for daily activities D) Manifest less anxiety after taking prescribed medications Answer: C Explanation: A) Incorrect. Mr. Elinore may require more or less than 8 hours of sleep to feel rested and have sufficient energy.

B) Incorrect. Mr. Elinore has stated that his lack of sleep is contributing to him being unable to sleep. Listing possible ways to cope with anxiety will not guarantee that this will help him sleep.

C) Correct. The best outcome statement for Mr. Elinore is to report getting sufficient sleep to provide energy for daily activities. Mr. Elinore may require more than 8 hours of sleep to feel rested and have sufficient energy.

D) Incorrect. Antianxiety medications are probably not the most important factor for Mr. Elinore and it does not deal directly with the problem that Mr. Elinore is seeing the nurse for.

Type: MC Learning Outcome: 38-7 16) Mr. Bryant is a client being seen at the sleep clinic who is experiencing difficulty falling asleep. What suggestions regarding sleep times would the nurse make?

A) Maintain a regular bedtime and wake-up time for all days of the week.

B) If bedtime is delayed on one night, go to bed that much earlier the next night.

C) If daytime drowsiness occurs, go to bed earlier that night.

D) Sleep at least 1 hour later on mornings you don't have to go to work.

Answer: A Explanation: A) Correct. The best intervention is to have Mr. Bryant establish and maintain a regular bedtime and wake-up time for all days of the week.

B) Incorrect. Moving bedtimes to play catch up for a previous night's lost sleep does not promote a sleep routine.

C) Incorrect. Once a sleep pattern is established, daytime drowsiness should diminish. The routine needs to be established first.

D) Incorrect. Moving bedtimes and awakening times according to drowsiness, delayed bedtime, or work schedules does not promote a sleep routine.

Type: MC Learning Outcome: 38-7

8 .

17) Mr. Bryant, who reports having difficulty sleeping, asks if there are any environmental changes that he should make. Which recommendation would be appropriate?

A) Listen to story audiotapes B) Keep a television on in the bedroom C) Provide white noise with a fan D) Play a talk radio station Answer: C Explanation: A) Incorrect. Audiotapes may stimulate rather than provide a restful quiet environment.

B) Incorrect. Noise should be kept to a minimum. Television is not recommended for the same reason as audiotapes and talk radio. It promotes a stimulating environment which may keep a person awake rather than a quiet restful environment.

C) Correct. Noise should be kept to a minimum. Extraneous noise can be blocked by white noise from a fan, air conditioner, or white noise machine.

D) Incorrect. Talk radio is not recommended because it can be interesting enough to promote wakefulness.

Type: MC Learning Outcome: 38-8 18) Mr. Bryant also reports awakening several times during the night. What intervention should the nurse recommend for Mr. Bryant when he is unable to sleep?

A) Get out of bed, go into another room, and pursue some relaxing activity until drowsy B) Get out of bed, go into another room, and exercise until tired before trying to go back to sleep C) Sit in bed and watch the bedroom television until drowsy D) Stay in bed with eyes closed and do some mental arithmetic until sleepy Answer: A Explanation: A) Correct. The bed should be used only for sleep or sexual activity, so it is associated with sleep. Mr. Bryant should get up, go into a different room, and pursue some relaxing activity until drowsiness returns.

B) Incorrect. Exercise within 2 hours of attempting to sleep may cause wakefulness.

C) Incorrect. The bed should be used only for sleep or sexual activity, so it is associated with sleep. Lying awake in bed or sitting in the bed while watching television will strengthen the association between wakefulness and bed.

D) Incorrect. Lying awake in bed or sitting in the bed while doing mental arithmetic will strengthen the association between wakefulness and bed.

Type: MC Learning Outcome: 38-8

9 .

19) Mr. Bryan requests a bedtime snack. Which food should the nurse offer Mr. Bryan? A) Hot chocolate B) Tea and crackers C) Cereal with milk D) Chips and salsa Answer: C Explanation: A) Incorrect. Hot chocolate and tea contain caffeine which can cause wakefulness and nocturia. B) Incorrect. Hot chocolate and tea may contain caffeine which can cause wakefulness and nocturia. C) Correct. The nurse should offer Mr. Bryan a light carbohydrate (cereal) and milk. L- tryptophan, found in cheese and milk, may induce sleep, a fact that might explain why warm milk helps some people get to sleep. D) Incorrect. Chips and spicy salsa at bedtime may cause gastrointestinal upset. Type: MC Learning Outcome: 38-8 20) This is Mrs. Brophy's first night in hospital and she is having difficulty falling asleep. What is the first nursing intervention the nurse should use to help Mrs. Brophy sleep?

A) Give her the sleeping pill that has been ordered B) Offer her a back massage and talk calmly with her C) Offer her a cup of hot tea and a cookie D) Open the curtains to allow street light to shine through Answer: B Explanation: A) Incorrect. Sleeping pills often have daytime drowsiness and a hangover effect. B) Correct. By offering Mrs. Brophy a back massage the nurse is using nonpharmacological measures to induce and maintain sleep. C) Incorrect. Tea contains caffeine that may interfere with sleep. D) Incorrect. Closing, not opening, the curtains reduces light and promotes sleep. Type: MC Learning Outcome: 38-8

10 .

21) Mr. Jose is admitted for back surgery and brings his CPAP unit with him. What should the nurse's response be? A) Assist him to use it as he would at home B) Have his wife take it home so it won't get lost C) Explain that he can't use it in the hospital because of safety regulations D) Tell him that he won't need it because the physician will order him a sleeping pill Answer: A Explanation: A) Correct. The nurse should assist him to use it as he would at home. Sleep apnea is characterized by frequent periodic cessation of breathing during sleep.

It may be due to a defect in the respiratory centre of the brain, or due to an obstruction that occurs when structures of the pharynx or oral cavity block the flow of air. The CPAP unit will help maintain an open airway. B) Incorrect. It is necessary for Mr. Jose to continue using his CPAP. Sleep is essential to the healing process maintaining his use of the CPAP device will help Mr. Jose maintain an open airway and promote a better night's rest. C) Incorrect.

There are no safety reasons why he cannot use his device. There would be safety risks for Mr. Jose if he was not able to use this device while in hospital. D) Incorrect. A sleeping pill may promote sleep, but it will not maintain an open airway during sleep like the CPAP device will.

Type: MC Learning Outcome: 38-7 22) Mrs. Ellen has begun a fitness program in an effort to lose weight and achieve a healthier lifestyle. Since doing so, she has had difficulty falling asleep. What suggestions could the nurse offer Mrs. Ellen that may improve her sleep and rest patterns? A) Wear dark, wrap-around sunglasses when she exercises B) Have a small glass of wine and some cheese before bed C) Exercise moderately in the morning or early afternoon D) Exercise vigorously late in the evening Answer: C Explanation: A) Incorrect.

Dark, wrap-around sunglasses are useful for night-shift workers and may decrease the alerting effects of exposure to daylight. B) Incorrect. Wine is a stimulant and can cause a REM sleep disturbance if taken in large amounts. C) Correct. Moderate exercise in the morning or early afternoon is conducive to sleep. D) Incorrect. Vigorous exercise late in the day can delay sleep onset. Type: MC Learning Outcome: 38-8

11 .

23) Mr. Wesley has been receiving morphine around the clock for post-operative pain. What is the effect of opioids on sleep?

A) They increase REM sleep.

B) They increase NREM sleep.

C) They decrease REM sleep.

D) They decrease NREM sleep.

Answer: C Explanation: A) Incorrect. Opioids, like morphine and meperidine hydrochloride, do not increase REM sleep.

B) Incorrect. Opioids do not affect NREM sleep.

C) Correct. Opioids, like morphine and meperidine hydrochloride (Demerol), are known to suppress REM sleep and to cause frequent awakenings and drowsiness.

D) Incorrect. They do not affect NREM sleep.

Type: MC Learning Outcome: 38-4 24) Ms. Ayres is attending a sleep clinic for the first time. She has complaints of fatigue and inability to sleep at night. Which of the following tools would be used early in the assessment of Ms. Ayres sleep and rest patterns?

A) Electrooculogram B) Sleep diary C) Polysomnography D) Electroencephalogram Answer: B Explanation: A) Incorrect. An electrooculogram is part of the diagnostic test involved with a polysomnography test. It would not be the first test done on a client.

B) Correct. By keeping a sleep diary, Ms. Ayres can provide more precise information of her sleep pattern and habits associated with sleep. A sleep diary should be kept for at least one week and may include such things as the total number of sleep hours per night, length and timing of naps, activities performed 2 to 3 hours before bedtime, and bedtime rituals.

C) Incorrect. Polysomnography is a diagnostic test that measures sleep objectively. It measures electroencephalogram and electrooculogram waves simultaneously, and thus is able to record REM and NREM sleep. It is more invasive, and therefore would not be the first assessment done on Ms. Ayres.

D) Incorrect. An electroencephalogram is also part of a polysomnography test and would not be the first assessment done on a client visiting the sleep centre for the first time.

Type: MC Learning Outcome: 38-6

12 .

25) Ms. Ayres is to have some diagnostic tests related to sleep. Which diagnostic test will provide the health care team with the best information?

A) Multiple Sleep Latency Test B) Accelerometer C) Electrocardiogram (ECG) D) Polysomnography Answer: D Explanation: A) Incorrect. This is a test for narcolepsy. Ms. Ayres does not have the manifestations of narcolepsy.

B) Incorrect. An accelerometer is a watch-sized motion sensor worn to measure rest and activity.

It will not provide the health care team with as much information as a polysomnography.

C) Incorrect. An ECG may be a part of the polysomnography test, but alone it will not provide meaningful information about Ms. Ayres sleep disorder.

D) Correct. Polysomnography will provide objective information and include a number of tests, such as an electroencephalogram (EEG), electromyogram (EMG), and electrooculogram (EOG), all recorded simultaneously. This simultaneous recording divides sleep into REM and NREM sleep.

Type: MC Learning Outcome: 38-6 26) During her sleep diagnostics, Ms. Ayres was noted to have two periods of apnea within the first hour, lasting around 10 seconds. Based on this finding, what would the nurse's actions include?

A) Initiate CPAP treatment B) Prepare her for a polysomnography C) Have emergency airway equipment on standby D) Continue to monitor her Answer: D Explanation: A) Incorrect. Ms. Ayres does not have the manifestations of sleep apnea which CPAP would be considered a treatment for.

B) Incorrect. A polysomnography test is the sleep diagnostic test that she is currently having that would provide the information about the apnea.

C) Incorrect. This is not an emergent situation; short, infrequent periods of apnea are normal in most people.

D) Correct. There would be no recommendation based on this finding. All people have some episodes of apnea; they should not number more than five per hour, or last greater than 10 seconds. The nurse would continue to monitor Ms. Ayres.

Type: MC Learning Outcome: 38-6

13 .

27) Mrs. Blakely is an occupational health nurse who is employed by the local health authority.

She is heading a special project on reducing environmental stimuli in hospitals to promote rest and sleep for patients. She is visiting all the hospitals to check on the progress policy changes have made. Which of the following findings would indicate to Mrs. Blakely that an organization may need further guidance on policy changes?

A) Overhead lighting evident in all corridors and rooms B) Volume on paging system decreased after 9 PM C) All staff required to wear rubber soled shoes D) Shift report should be away from nursing stations Answer: A Explanation: A) Correct. The use of overhead lighting can impact clients' sleep, especially in rooms where there is more than one client. Lights should be ample enough to provide for safety but overbed lights in the care room and a nightlight in the bathroom will provide ample light without adding additional environmental stimuli for the patients.

B) Incorrect. In order to create a restful environment, the volume of an overhead paging system should be decreased, or the paging system should not be used after a certain time.

C) Incorrect. The use of rubber soled shoes will decrease the noise caused by all staff as they move through the hallways.

D) Incorrect. Staff should be advised to keep voices quiet outside clients' rooms, and to move away from common areas for report.

Type: MC Learning Outcome: 38-7 28) Mrs. Flacco takes the occasional sleeping aid to help her get the rest she needs. She has taken something twice in the last month. Which of the following should Mrs. Flacco consider before taking a sleeping aid tonight?

A) She is driving a school bus first thing in the morning.

B) She is at risk for developing dependence on the drug.

C) She is at risk for rebound insomnia.

D) She will dream more when taking these sleep aids.

Answer: A Explanation: A) Correct. Some medication effects can last many hours beyond the time that the client is asleep and daytime drowsiness and impaired psychomotor skills can result. Clients need to be cautioned about such effects and about driving or handling machinery while the drug is in their system.

B) Incorrect. Mrs. Flacco is only an occasional user of sleep aids, so she is not at risk for dependence.

C) Incorrect. Rebound insomnia usually occurs when regular use of sleep aids is abruptly stopped.

D) Incorrect. Most sleep aids affect REM more than NREM. It is possible after discontinuation of these sleep aids that she will dream more.

Type: MC Learning Outcome: 38-7

14 .

Fundamentals of Canadian Nursing, 4e(Kozier) Chapter 39 Activity and Exercise 1) Mr. Neil, a community health nurse, is organizing a wellness project to educate teenagers about keeping their bodies healthy. Which information about diet and exercise should be included?

A) Diet is the most important predictor of health.

B) Diet and activity together are important factors for maintaining health.

C) Exercise is sufficient to manage healthy weight.

D) Obese women who remain active have a low mortality rate.

Answer: B Explanation: A) Incorrect. Although diet is an important predictor of health, activity level appears to be more predictive of future health.

B) Correct. Research shows that diet and activity are the most important factors for maintaining health. People who follow a sedentary lifestyle have an increased chance of becoming overweight as well as developing a number of chronic diseases.

C) Incorrect. Increase in exercise without change in diet will not be sufficient to manage weight gain and is considered an unhealthy trend in today's society.

D) Incorrect. While obese women who are active are generally healthier than their sedentary counterparts, they still have a higher mortality rate than women who are lean and active.

Type: MC Learning Outcome: 39-1 2) Mr. Neil, a community health nurse, is speaking to families about the benefits of an active lifestyle. What activity levels does he recommend as appropriate for children ages 5-11?

A) 30 minutes minimum of moderate to vigorous activity daily B) 60 minutes of moderate to vigorous activity daily C) 30 minutes of moderate activity daily, and 30 minutes of vigorous activity 3 times a week D) 60 minutes of moderate activity 3 times a week.

Answer: B Explanation: A) Incorrect. This is below the minimum daily limit recommended in the Canadian activity guidelines.

B) Correct. The Canadian physical activity guidelines recommend that children 5-11 and youth 12-17 include a minimum of 60 minutes of moderate to vigorous intensity physical activity daily, and vigorous intensity activities at least 3 days per week.

C) Incorrect. This is below the minimum daily limit recommended in the Canadian physical activity guidelines.

D) Incorrect. This is below the minimum daily limit recommended in the Canadian physical activity guidelines.

Type: MC Learning Outcome: 39-1

1 .

3) Which of the following elements necessary for normal body movement will impact optimal lung expansion?

A) Proper body alignment B) Joint mobility C) Base of support D) Coordinated movement Answer: A Explanation: A) Correct. Proper body alignment enhances lung expansion and promotes efficient circulatory, respiratory, renal, and gastrointestinal functions.

B) Incorrect. Joints are the functional units of the musculoskeletal system. The bones of the skeleton articulate at the joints and most of the skeletal muscles attach to the bones at the joint.

While they are an element involved in body movement, they have no impact on lung expansion.

C) Incorrect. Base of support is a factor in balance. While balance is in itself an element necessary for movement, it does not impact lung expansion.

D) Incorrect. Balanced, smooth, purposeful movement is the result of proper functioning of the cerebral cortex, cerebellum, and basal ganglia. While this is necessary for normal body movement, it does not impact lung expansion.

Type: MC Learning Outcome: 39-2 4) Circumduction is a term that refers to the movement of a bone around its central axis.

Answer: FALSE Explanation: Circumduction refers to the movement of the distal part of a bone in a circle while the proximal end remains fixed. For example, move each leg backward, up, to the side, and down in a circle.

Type: TF Learning Outcome: 39-2 5) Supination refers to the movement of the sole of the foot inward by moving the ankle joint.

Answer: FALSE Explanation: Supination refers to moving the bones of the forearm so that the palm of the hand faces upward when held in front. Inversion refers to the movement of the sole of the foot inward by moving the ankle joint.

Type: TF Learning Outcome: 39-2

2 .

6) Which of the following physiological alterations is frequently a result of immobility? A) Bradycardia B) Venous pooling C) Diuresis D) Increased vital capacity Answer: B Explanation: A) Incorrect. Prolonged immobility does not result in bradycardia. B) Correct.

Prolonged immobility causes the cardiovascular system to show signs of deconditioning resulting in venous pooling. C) Incorrect. Prolonged immobility does not cause diuresis. D) Incorrect. Prolonged immobility causes a decrease in vital capacity, not an increase. Type: MC Learning Outcome: 39-4 7) Mr. Frederick, 80 years old, is confined to bed with multiple injuries following a motor vehicle accident. Which of the following observations would allow the nurse to conclude that his psychoneurological system is intact following his injuries?

A) Mr. Frederick's self-esteem has decreased over the last three weeks.

B) Mr. Frederick is withdrawn and does not initiate conversation.

C) Mr. Frederick is explaining to his wife how to solve a problem with the furnace.

D) Mr. Frederick becomes frustrated when he tries to perform activities of daily living.

Answer: C Explanation: A) Incorrect. A change in Mr. Frederick's self-esteem would be evidence that his psychoneurological system has been affected by his inactivity.

B) Incorrect. Frustration, a decrease in self-esteem, and withdrawal and regression may be effects of immobility on the psychoneurological system.

C) Correct. Two effects of immobility on the psychoneurological system are lowered selfesteem and decreased cognitive skills. Mr. Frederick's ability to work with his wife to solve a problem with the furnace shows that his problem-solving ability has not declined during his time in bed and in hospital.

D) Incorrect. Frustration, a decrease in self-esteem, and withdrawal and regression may be effects of immobility on the psychoneurological system.

Type: MC Learning Outcome: 39-4

3 .

8) Mr. Frederick, 80 years old, is confined to bed with multiple injuries following a motor vehicle accident. The nurse is instructing him on how to perform isometric exercises. How will these exercises affect Mr. Frederick? A) Decrease heart rate B) Prevent contractures C) Maintain muscle strength D) Improve cardiorespiratory function Answer: C Explanation: A) Incorrect. Aerobic exercises improve cardiorespiratory function and over time will result in a decreased heart rate. B) Incorrect. ROM exercises are required to prevent contractures. C) Correct. Isometric exercises result in a change in muscle tension without a change in joint or muscle movement. Isometric exercises are useful for strengthening muscles. D) Incorrect.

Aerobic exercises improve cardiorespiratory function. Type: MC Learning Outcome: 39-3 9) Ms. Peters is a student nurse working with a home care nurse. They visit an elderly client who has contractures. Miss Peters asks the nurse, "What is the physiological reason for contractures?"

How will the nurse respond?

A) Flexor muscles are stronger than extensor muscles B) Muscle mass loss affects only extensor muscles C) Hyperextension of the joints of the arms and legs D) Repetitive flexor and ulnar adduction Answer: A Explanation: A) Correct. The flexor muscles are stronger than the extensor muscles. Thus, when a person is inactive, the joints are pulled into a flexed position.

B) Incorrect. During periods of immobility, muscle mass loss is not confined to only the extensor muscles.

C) Incorrect. Hyperextension of the joints of the arms and legs is a normal movement and will not cause contractures.

D) Incorrect. Although repetitive movements are known to cause some injuries, contractures are not caused by this movement.

Type: MC Learning Outcome: 39-4

4 .

10) Mrs. Cara is attending her first prenatal visit. What information would the nurse offer her regarding exercise?

A) She can exercise if exercise was a part of her pre-pregnancy routine.

B) Exercise should be limited to no more than 15 minutes per day.

C) Healthy pregnant women should exercise at least 30 minutes per day.

D) She should increase her normal exercise pattern from pre-pregnancy routine.

Answer: C Explanation: A) Incorrect. Exercise can help pregnant women avoid excess weight gain, thus preventing long-term obesity after delivery. There are no contraindications to starting an exercise program during pregnancy.

B) Incorrect. 30 minutes of exercise daily is recommended.

C) Correct. Healthy pregnant women should exercise at least 30 minutes on most, if not all, days.

Exercise can help pregnant women avoid excess weight gain, thus preventing long-term obesity after delivery. Leaner babies may also be at a lower risk for obesity later in life.

D) Incorrect. There is no data to suggest that exercise should be increased over the usual prepregnancy routine.

Type: MC Learning Outcome: 39-4 11) What benefits of exercise for elderly clients may result in a decreased risk of falls?

A) Improved balance B) Strengthened muscles C) Increased range of motion D) Improved cardiovascular function Answer: A Explanation: A) Correct. Improved balance is a benefit of exercise and can result in a decreased risk of falls in the elderly.

B) Incorrect. Strengthened muscles are a benefit of exercise, but will not necessarily decrease the risk of falls in the elderly.

C) Incorrect. While range of motion is increased as a result of exercise, it will not necessarily decrease the risk of falls.

D) Incorrect. Exercise will improve cardiovascular function, but will not impact a risk for falls.

Type: MC Learning Outcome: 39-1

5 .

12) Mrs. Farron is a 65-year-old who has recently been diagnosed with depression. What explanation can the nurse provide her about how exercise can improve long-term symptoms of depression? A) Increases levels of endorphins B) Creates a diversion from reason for depression C) Limits endogenous opioids D) Decreases harmful effects of serotonin Answer: A Explanation: A) Correct. Exercise is thought to increase endogenous opioids which in turn increases levels of endorphins. B) Incorrect. While this may be a benefit, it is a temporary effect compared to the release of opioids and the benefit they have on mood regulation. C) Incorrect. Exercise is actually thought to increase the release of endogenous opioids, thus increasing levels of endorphins. D) Incorrect. Serotonin is necessary for mood regulation.

Exercise is thought to increase metabolites necessary for neurotransmitters (serotonin). Type: MC Learning Outcome: 39-1 13) Seventy-five-year-old Mrs. Bertram has been admitted to hospital with right-sided paralysis as a result of a cerebrovascular accident. What is the rationale for maintaining her in good body alignment while she is in bed?

A) It increases body strength and muscle mass.

B) Proper body alignment will alleviate pain.

C) It reduces the musculoskeletal strain and enhances lung expansion.

D) It minimizes the workload of the heart by preventing the valsalva manoeuvre.

Answer: C Explanation: A) Incorrect. Good body alignment does not improve body strength and muscle mass.

B) Incorrect. While good body alignment will promote comfort for the client while in bed, it may not necessarily alleviate pain that the client is experiencing.

C) Correct. When the body is well aligned, strain on the joints, muscles, tendons, and ligaments is minimized and the internal structures and organs are supported. Proper body alignment enhances lung expansion and promotes efficient circulatory, respiratory, renal, and gastrointestinal function.

D) Incorrect. Good body alignment does not minimize the workload of the heart, or prevent the valsalva manoeuvre.

Type: MC Learning Outcome: 39-2

6 .

14) Seventy-five-year-old Mrs. Bertram has been admitted to hospital with right-sided paralysis as a result of a left-sided cerebrovascular accident. She has a diagnosis of impaired mobility related to paralysis. She is to have passive range of motion (ROM) exercises performed on the right side of her body. Which of the following accurately reflects how ROM should be performed?

A) Weekly as long as paralysis is evident B) To the point of discomfort C) To the point of slight resistance D) To both arms and legs Answer: C Explanation: A) Incorrect. While ROM exercises would be continued until the client was able to exercise on her own, they should be done much more frequently, not weekly.

B) Incorrect. Passive ROM exercises should never be done to the point of discomfort.

C) Correct. Passive ROM exercises should be performed to the point of slight resistance, never to the point of discomfort.

D) Incorrect. Passive ROM exercises should be performed on the affected side. Mrs. Bertram should be encouraged to do active ROM exercises to the limbs on the opposite side of her body.

Type: MC Learning Outcome: 39-2 15) The nurse is caring for 50-year-old Mrs. Lucas, who has been recently diagnosed with early osteoporosis. Which interventions should be planned for this client?

A) During exacerbations, protect her bones with strict bed rest B) Develop an exercise plan that includes weight-bearing activities C) Increase vitamin D in her diet to enhance absorption of calcium D) Passive range of motion exercises twice daily Answer: B Explanation: A) Incorrect. Osteoporosis is not known to have exacerbations. Strict bed rest may well make the osteoporosis worse because there is no weight-bearing activity.

B) Correct. Osteoporosis is a demineralization of the bone in which calcium leaves the bone matrix. One causative factor is lack of weight-bearing activity. Weight bearing helps to move calcium back into the bones, thereby strengthening them. A standard intervention for those attempting to prevent or reverse osteoporosis is beginning an exercise plan that includes weightbearing activities.

C) Incorrect. Additional calcium in the diet after osteoporosis has begun is not thought to be effective.

D) Incorrect. Assisted range of motion exercises are not weight bearing and do not help delay or reverse osteoporosis.

Type: MC Learning Outcome: 39-4

7 .

16) Mr. Pearson, a newly admitted client, has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care?

A) Flexor-strengthening exercises B) Frequent position changes C) Weight-bearing activities.

D) Range of motion exercises Answer: D Explanation: A) Incorrect. The contracture occurs because the flexor muscles are stronger than the extensor muscles. This imbalance in strength pulls the inactive joint into a flexed position, and a permanent shortening of the muscle occurs. Strengthening the flexor muscles would compound the problem.

B) Incorrect. Frequent position changes will not reverse contractures, nor will weight-bearing activities. Contractures occur when the muscle is shortened permanently. Only surgery can reverse a contracture.

C) Incorrect. Weight-bearing activities would require the client to be able to extend arms or legs.

This is not possible because the contracture permanently shortens the muscles. Weight-bearing activities will not impact his contractures.

D) Correct. Once contractures occur they are irreversible except by surgical intervention. The best nursing intervention is to keep the contractures from getting tighter (or worse) by providing range of motion exercises.

Type: MC Learning Outcome: 39-6 17) The nurse educator is working on a hospital committee focused on preventing back injuries in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed?

A) Nurses must use transfer belts when moving clients.

B) No independent lifting of clients is permitted in the facility.

C) In order to prevent injury, nurses must strive to become physically fit.

D) All nursing personnel must attend annual body mechanics education.

Answer: B Explanation: A) Incorrect. While the use of belts can assist with moving clients, the most effective strategy in reducing back injuries to nurses is a policy that prohibits moving clients alone.

B) Correct. Research has shown that the only option that has any influence on the frequency of back injury is a policy prohibiting lifting clients without assistive devices or other personnel.

C) Incorrect. Good physical fitness level of the nurse will not impact back injuries as much as preventing solo lifting of clients.

D) Incorrect. Annual reinforcement of good body mechanics does not have the same effect as a policy that prevents solo lifting.

Type: MC Learning Outcome: 39-8

8 .

18) The nurse educator is working on a hospital committee focused on preventing back injuries in nurses. When completing rounds on one of the inpatient units, what observations would indicate to her that further education is necessary?

A) Two nurses are pulling a client up in bed. They are standing toward the head of the bed, feet apart and facing towards the centre of the bed.

B) Two nurses are pulling a client up in bed using a sliding sheet. Their palms are facing up grasping the sheet.

C) Two nurses are pulling a client up in bed. The bed is in Trendelenburg position.

D) Two nurses are repositioning a client from one side to the other. The nurse pulling the client towards her rocks from her front foot to her back foot.

Answer: A Explanation: A) Correct. The nurses should be facing in the direction of the move in order to reduce the chances of a lumbar twist, a move that could result in back injury to the nurse.

B) Incorrect. This is the correct position of hands when using a draw sheet or slider sheet.

C) Incorrect. Trendelenburg eases the repositioning of a client by the use of gravity.

D) Incorrect. When pushing or pulling a client in bed, one foot should be in front of the other.

The nurse should rock in the direction of the movement, onto the front foot if pushing, onto the back foot if pulling.

Type: MC Learning Outcome: 39-8 19) How should the nurse position Mr. Joseph, a 75-year-old client with chronic obstructive pulmonary disease (COPD) who is complaining of dyspnea?

A) Semi-Fowler's position with two pillows B) Orthopneic position across the overbed table C) Fowler's position with two pillows behind the head D) High Fowler's position with two pillows behind the head Answer: B Explanation: A) Incorrect. Semi-Fowler's and high Fowler's positions should not be used with more than one pillow or with overly large pillows as they will not allow for maximum chest expansion.

B) Correct. The orthopneic position across the overbed table facilitates respiration by allowing maximum chest expansion.

C) Incorrect. Fowler's, semi-Fowler's, and high Fowler's positions should not be used with more than one pillow or with overly large pillows as they will not allow for maximum chest expansion.

D) Incorrect. High Fowler's position does not allow for maximum chest expansion.

Type: MC Learning Outcome: 39-8

9 .

20) Mr. Granger is a 65-year-old client hospitalized with multiple fractures suffered in a motor vehicle accident. He calls the nurse and complains of pain and burning in the right calf area.

What action should be taken by the nurse?

A) Percuss over the area for change in tone B) Deeply palpate the area for rebound tenderness C) Measure the calf and compare to the opposite calf D) Medicate the client for pain and reassess in 30 minutes Answer: C Explanation: A) Incorrect. Palpating or percussing the area is contraindicated because injury to the vein may induce a thrombus. If a thrombus is present, these actions might embolize it.

B) Incorrect. Palpating or percussing the area is contraindicated because injury to the vein may induce a thrombus. If a thrombus is present, these actions might embolize it.

C) Correct. Among other assessment activities, the nurse should measure the calf and compare it to the opposite calf. Mr. Granger may be developing a deep vein thrombosis or thrombophlebitis.

D) Incorrect. Medicating Mr. Granger and reassessing him in 30 minutes does not address the reason for the pain and may cause a deterioration in his condition.

Type: MC Learning Outcome: 39-6 21) The nurse is assisting Mrs. Nesbitt, 40 years old, to dangle at the side of the bed. After raising the head of the bed, how should the nurse position herself?

A) Facing directly toward the client B) Facing toward the side of the bed C) Facing toward the far corner of the foot of the bed D) Facing toward the nearest corner of the head of the bed Answer: C Explanation: A) Incorrect. The nurse should face the direction that movement will occur. Facing away from this direction will require twisting movement of the nurse's trunk and may cause back injury.

B) Incorrect. The nurse should face the direction that movement will occur. Facing away from this direction will require twisting movement of the nurse's trunk and may cause back injury.

C) Correct. The nurse should face the far corner of the foot of the bed because this is the direction in which movement will occur.

D) Incorrect. The nurse should face the direction that movement will occur. Facing away from this direction will require twisting movement of the nurse's trunk and may cause back injury.

Type: MC Learning Outcome: 39-8

10 .

22) What is a priority safety action of the nurse prior to assisting a client's move from a bed to a wheelchair? A) Lock the brakes on the bed and chair B) Transfer with a friction-reducing device C) Place the head of the bed flat D) Place the wheelchair perpendicular to the bed.

Answer: A Explanation: A) Correct. Locking the wheels on the bed is an important safety measure. If the wheels are not locked and the bed moves out from under the client, none of the other safety actions will likely prevent a fall or a near fall, and this puts both the client and nurse at risk for injury. B) Incorrect. A friction-reducing device is normally used for repositioning a client in bed, or moving a client to another device. It would not contribute to the safe movement of a client from a bed to a chair. C) Incorrect. The position of the head of the bed would not necessarily contribute to a safe move. D) Incorrect. The wheelchair is normally placed either parallel or at a 45 degree angle. Placing it perpendicular would place both the client and the nurse at risk for injury. Type: MC Learning Outcome: 39-8 23) The nurse is preparing to transfer 40-year-old Mr. Noel from the bed to a stretcher. The bed should be placed parallel to the stretcher and in which of the following positions?

A) Slightly lower B) Slightly higher C) At the same height D) At least 2 inches lower Answer: B Explanation: A) Incorrect. By positioning the bed lower, the nurse would be required to pull the client up to the new surface, and could place herself at risk for injury.

B) Correct. It is easier to move a client down slightly to the new surface than to pull them up higher.

C) the Incorrect. When transferring a client from bed to stretcher, the bed should be parallel to stretcher and slightly higher. It is easier for the client to move down a slant to the new surface than to move up to a higher surface or to an even surface.

D) Incorrect. When transferring a client from bed to stretcher, the bed should be parallel to the stretcher and slightly higher. It is easier for the client to move down to the new surface than to move up to a higher surface or to an even surface.

Type: MC Learning Outcome: 39-8

11 .

24) Twelve hours post delivery of her first child, the nurse is assisting Mrs. Joseph to ambulate to the bathroom. Mrs. Joseph complains of light-headedness and begins to faint. What is the nurse's most important action?

A) Call for immediate assistance B) Ensure the client's modesty C) Prevent the client from hitting her head D) Check vital signs Answer: C Explanation: A) Incorrect. The nurse's priority should be prevention of injury as the client falls.

After the client has been assisted to the floor, the nurse should call for assistance.

B) Incorrect. The client's modesty at this time is important but would not be addressed until she is safely on the floor.

C) Correct. Clients are at risk for injury when they are feeling faint. The priority is ensuring the client does not strike her head on anything as she falls.

D) Incorrect. Vital signs would be checked once the client was safely on the floor and help had been called for.

Type: MC Learning Outcome: 39-8 25) Mr. Erikson, 32 years old, is learning to use crutches after fracturing his left ankle. The nurse is teaching him to transfer from a standing position to a chair. Mr. Erikson has positioned himself in front of the chair, with the back of his right leg against the chair. What direction should the nurse provide to Mr. Erikson as the next step to transfer safely?

A) Transfer the crutch on the right side to the left B) Reach behind and grasp the arm on the right side of the chair C) Lean forward, flex the knees and hips, and lower into the chair D) Stand perpendicular to the chair, and pivot from the right Answer: A Explanation: A) Correct. This is the correct option that gives Mr. Erikson the most support before lowering himself into the chair. During transfer, the body weight is placed on the crutches and the hand on the armrest of the chair.

B) Incorrect. Before Mr. Erikson can safely reach for the back of the chair, he must transfer the crutch to the affected side.

C) Incorrect. This would be the last action that would take place. The client needs to first move the crutch to the affected side, and reach for the back of the chair for optimum balance while transferring.

D) Incorrect. It would be awkward and unsafe to try to pivot into a chair while standing with crutches.

Type: MC Learning Outcome: 39-10

12 .

26) Mr. Rourke's activity is limited to a wheelchair until he is taught how to use crutches. Which of the following actions by the nurse demonstrates wheelchair safety?

A) The chair is positioned ahead of her when going down a ramp.

B) Mr. Rourke is pushed face-forward ahead of the nurse into the elevator.

C) Mr. Rourke is positioned as far forward as possible on the wheelchair seat.

D) The footplates are raised before Mr. Rourke is transferred into the wheelchair.

Answer: D Explanation: A) Incorrect. The nurse should keep his or her body between the client and the bottom of an incline or ramp.

B) Incorrect. The nurse should also back the client into an elevator.

C) Incorrect. The nurse should position the client well back on the wheelchair seat.

D) Correct. The nurse should remove or raise the footplates of a wheelchair before transferring Mr. Rourke into it. This will prevent him from injuring himself on the footplates or tipping the wheelchair over.

Type: MC Learning Outcome: 39-8 27) Mr. Neil is a community health nurse conducting a wellness seminar. He is asked by a participant what kind of exercises walking, swimming, and cycling are. What is the correct answer?

A) Anaerobic B) Isokinetic C) Isometric D) Isotonic Answer: D Explanation: A) Incorrect. Anaerobic exercise involves activity in which the muscles cannot draw out enough oxygen from the bloodstream, and anaerobic pathways are used to provide additional energy for a short time. Anaerobic exercises include weight lifting or sprinting.

B) Incorrect. Isokinetic exercises involve muscle contraction or tension against resistance.

C) Incorrect. Isometric exercises result in a change in muscle tension without change in joint or muscle movement. Isometric exercises are useful for strengthening muscles.

D) Correct. Most physical conditioning exercises, like walking, swimming, running, and cycling, are isotonic exercises. Activities of daily living and active range of motion (ROM) exercises are also isotonic exercises.

Type: MC Learning Outcome: 39-3

13 .

28) Mrs. Joyce is a 78-year-old woman who has had a cerebral vascular accident. She has leftsided weakness. Which of the following can be prevented by the use of supportive devices when positioning her on her right side?

A) Skin breakdown B) Hyperextension of lumbar curvature C) Internal rotation and adduction of shoulder D) Plantar flexion Answer: C Explanation: A) Incorrect. Repositioning on a regular basis will prevent skin breakdown; the use of supportive devices increases comfort but does not in itself promote skin integrity.

B) Incorrect. A client lying in the lateral position is not at risk for hyperextension of the lumbar curvature. This would be a risk if positioned unsupported in the prone position.

C) Correct. The purpose of using supportive devices in this situation is specifically to prevent internal rotation and adduction of the shoulder. This is accomplished by placing a pillow under the upper arm when a client is in the side lying (lateral) position.

D) Incorrect. The client is not at risk for plantar flexion when positioned on her side. She would be at risk for plantar flexion if she were positioned in the prone position.

Type: MC Learning Outcome: 39-8

14 .

Fundamentals of Canadian Nursing, 4e(Kozier) Chapter 40 Nutrition 1) On her first checkup after the birth of her son, Mrs. Magee reports that her newborn wakes every 2 hours and takes only about 2 ounces of formula before going back to sleep. What information should the nurse offer Mrs. Magee?

A) Offer the baby less formula to prevent waste B) Make the baby wait at least 3 hours between feedings C) Continue to feed the baby with this "on demand" schedule D) During feeding, tap his feet to encourage wakefulness Answer: C Explanation: A) Incorrect. The infant should be fed until they show signs of satisfaction, either sucking that slows or until they fall asleep. Offering them less formula may not meet their nutritional needs.

B) Incorrect. The infant should feed when they demonstrate signs of hunger. Infants lose fluid faster than adults due to a higher metabolic rate, and fluid loss through their skin and lungs.

Making the infant wait does not meet their nutritional needs.

C) Correct. This is a normal feeding pattern for a newborn. Their stomach will not hold much more than 2-3 ounces of formula at a time. Waking and trying to feed more than this amount may promote regurgitation of the feeds. Newborns are often fed following an "on demand" schedule which may include feeding as often as every 2 hours.

D) Incorrect. Falling asleep is a sign that the infant is satisfied after feeding.

Type: MC Learning Outcome: 40-6 2) Mrs. Jenner brings her 2-month-old infant to the clinic because she is concerned that he is spitting up too much after he feeds. What criteria will the nurse use to determine if an infant's regurgitation should be further investigated?

A) How often the baby spits up B) How much the baby spits up at a time C) The infant's weight gain D) The consistency of the regurgitated matter Answer: C Explanation: A) Incorrect. The only criteria which would prompt further investigation would be an infant that was not gaining weight.

B) Incorrect. The only criteria which would prompt further investigation would be an infant that was not gaining weight.

C) Correct. As long as the baby continues to gain weight as expected, it would not need to be further investigated. If the infant was not gaining weight, there would need to be additional assessments completed.

D) Incorrect. The consistency of the regurgitated material may be thin (just consumed) or curdled (has been partially digested) and either case is normal. The only criteria which would prompt further investigation would be an infant that was not gaining weight.

Type: MC Learning Outcome: 40-6

1 .

3) Mrs. Marcs brings her 7-month-old son, Dylan, to the clinic for a checkup. She has started offering solid foods to him as previously discussed with the nurse. Dylan is tolerating rice cereal, apple sauce, and other fruits. Which food should the nurse recommend to be introduced next?

A) Strained beef B) Squash C) Green beans D) Strained chicken Answer: B Explanation: A) Incorrect. Meats, whether it is poultry or other, are usually introduced after cereals, fruits, and vegetables.

B) Correct. Most experts recommend introducing foods in the order of which they are easily digested or tolerated. Most recommend introducing cereals, fruits, and then yellow vegetables.

C) Incorrect. Green beans would normally be introduced after yellow vegetables.

D) Incorrect. Meats, whether it is poultry or other, are usually introduced after cereals, fruits, and vegetables.

Type: MC Learning Outcome: 40-6 4) Which of the following foods is an example of both a soluble and non-soluble fibre?

A) Broccoli B) White rice C) Lentils D) Oats Answer: A Explanation: A) Correct. Insoluble fibre acts as roughage and draws water into the colon, preventing constipation. An example of insoluble fibre is broccoli. Soluble fibre breaks down and forms a gel that is thought to reduce the amount of cholesterol that is absorbed. Broccoli is an example of both soluble and insoluble fibre.

B) Incorrect. White rice is a soluble fibre only C) Incorrect. Lentils are a soluble fibre only.

D) Incorrect. Oats are a soluble fibre only.

Type: MC Learning Outcome: 40-1

2 .

5) Mr. Johansen, 75 years old, is admitted with a hip fracture. The nurse has noticed that he is very thin and assesses him for signs of malnutrition. Which of the following are signs suggestive of malnutrition?

A) Shiny hair and brittle nails B) Lethargy and bruised, dry skin C) Underdeveloped arm muscles D) Moist mucous membranes Answer: B Explanation: A) Incorrect. Shiny hair is not a clinical sign of malnutrition.

B) Correct. Mr. Johansen's tired appearance and dry skin with the presence of bruising are clinical signs suggestive of malnutrition. To confirm malnutrition, clinical findings need to be substantiated with laboratory tests and dietary data.

C) Incorrect. Underdeveloped arm muscles by itself is not indicative of malnutrition.

D) Incorrect. Moist mucous membranes are not signs suggestive of malnutrition.

Type: MC Learning Outcome: 40-10 6) The nurse does a dietary assessment and learns that Mr. Johansen lives alone, does not enjoy cooking, and tends to consume a lot of tea and toast. Which of the following laboratory tests may indicate a long-term protein deficiency?

A) C-reactive protein B) Transferrin C) Hemoglobin D) Albumin Answer: D Explanation: A) Incorrect. C-reactive protein is a diagnostic test indicating inflammation. It does not indicate protein deficiency.

B) Incorrect. Transferrin responds more quickly to protein deficiencies, thus would not necessarily reflect a long-term protein deficiency.

C) Incorrect. Hemoglobin level can be an indicator of iron-deficiency anemia if hemorrhage or other abnormal blood loss is ruled out. It is not a reflection of long-term protein deficiency.

D) Correct. Albumin level is an indicator of a long-term protein deficiency. Because there is so much albumin in the body and because it is not broken down very quickly, albumin concentrations change slowly. Thus, a low serum albumin level is a useful indicator of prolonged protein depletion rather than acute or short-term changes in nutritional status.

Type: MC Learning Outcome: 40-10

3 .

7) Seventy-five-year-old Mr. Johansen fractured his right hip. His laboratory results and examination indicate he has malnutrition. He has an order for a high protein diet. Which of the following foods will provide Mr. Johansen with complete proteins?

A) Corn B) Beans C) Eggs D) Peanut butter Answer: C Explanation: A) Incorrect. Corn, beans, and peanut butter are incomplete proteins and must be eaten in combination with other complementary foods or with a small amount of animal protein to provide a complete protein.

B) Incorrect. Corn, beans, and peanut butter are incomplete proteins and must be eaten in combination with other complementary foods or with a small amount of animal protein to provide a complete protein.

C) Correct. Eggs will provide Mr. Johansen with complete proteins.

D) Incorrect. Corn, beans, and peanut butter are incomplete proteins and must be eaten in combination with other complementary foods or with a small amount of animal protein to provide a complete protein.

Type: MC Learning Outcome: 40-1 8) Mr. Johansen is recovering from a hip replacement. Considering a diagnosis of protein deficient malnutrition, what is Mr. Johansen at risk for?

A) Abnormal bleeding B) Poor wound healing C) Deep vein thrombosis D) Atelectasis Answer: B Explanation: A) Incorrect. Abnormal bleeding would be indicative of a vitamin K deficiency.

B) Correct. Considering his recent surgery for a hip replacement and that he has protein deficiency malnutrition, Mr. Johansen is at risk for poor wound healing. Proteins are necessary for the growth, maintenance, and repair of all cells.

C) Incorrect. Mr. Johansen would be at risk for deep vein thrombosis if he were immobile. This would not be a risk because of protein deficiency.

D) Incorrect. Immobility may contribute to atelectasis and would not be caused by protein deficiency.

Type: MC Learning Outcome: 40-10

4 .

9) Mr. Spirou is 57 years old and has recently been diagnosed with diabetes type 2. He has been trying to lose weight by watching his caloric intake but has had little success. He visits the Diabetic Health Centre to get information on using glycemic index to guide his food choices.

What information can the nurse provide Mr. Spirou about glycemic index?

A) Glycemic index can be altered by how a food is prepared.

B) Foods with a high glycemic index will help promote weight loss.

C) Eating low glycemic index foods may lead to metabolic syndrome.

D) Glycemic index refers to the amount of glucose in the blood.

Answer: A Explanation: A) Correct. The preparation of foods can affect their glycemic index. For example, a potato boiled with the skin on has a lower index than a potato without the skin, or one that is mashed.

B) Incorrect. It is foods with a low glycemic index that will promote weight loss, not high index.

C) Incorrect. Metabolic syndrome is a condition in clients who are obese, have hyperlipidemia, hypertension, and insulin resistance. Eating foods with a low glycemic index would be recommended for this population of patients.

D) Incorrect. The amount of glucose in the blood is referred to as glycemic level, not glycemic index.

Type: MC Learning Outcome: 40-9 10) Mr. Spirou has decided to follow the glycemic index when making food selections rather than calorie counting. Which of the following selections for lunch would provide him with the best choice for weight loss?

A) Sandwich on pumpernickel bread B) Rice cakes C) Sandwich on a white bagel D) Serving of basmati rice Answer: A Explanation: A) Correct. A sandwich made of pumpernickel would have a lower glycemic index than the other choices. Pumpernickel has a glycemic index of 55 or less.

B) Incorrect. Rice cakes are actually the higher of the choices; they have a glycemic index of greater than 70.

C) Incorrect. A sandwich on a white bagel would have a glycemic index greater than 70 D) Incorrect. A serving of basmati rice has a medium-high glycemic index, usually between 5659.

Type: MC Learning Outcome: 40-9

5 .

11) Mrs. Angelou, 48 years old, is being seen at her physician's office for her annual physical examination. Her nutritional assessment includes the following data: BMI-31, Waist circumference of 92 cm, elevated low density lipoprotein, and a BP of 155/90. She has been informed that she is insulin resistant. Considering all of these findings, what is Mrs. Angelou at risk for?

A) Metabolic syndrome B) Cardiovascular disease C) Osteoarthritis D) Hyperlipidemia Answer: A Explanation: A) Correct. Mrs. Angelou has metabolic syndrome, a constellation of central obesity, dyslipidemia, hypertension, and insulin resistance, leading to increased risk of type 2 diabetes mellitus.

B) Incorrect. Mrs. Angelou has hypertension which alone would place her at risk for cardiovascular disease (CVD). Insulin resistance would not in itself place her at risk for CVD. C) Incorrect. While her obesity definitely places her at risk for osteoarthritis, the other findings would not necessarily contribute to this diagnosis.

D) Incorrect. Mrs. Angelou's elevated low density lipoprotein indicates that she has hyperlipidemia; she is not merely at risk for hyperlipidemia.

Type: MC Learning Outcome: 40-10 12) Mr. Reddy, an overweight construction worker, is following a 2,000-calorie diet as a strategy to promote weight loss. While shopping, he is learning to pay closer attention to food labels when making choices. Besides the caloric intake, what other information on the food labels should he be considering in order to succeed at his weight loss goal?

A) Lighter or reduced calorie foods B) The letter "L" located in the lower right corner C) The recommended serving size D) A fat content of less than 11% Answer: C Explanation: A) Incorrect. The words "lighter" or "reduced calories" only mean that this version of the food is lower in calories than a previous version, but the food can still be very high in calories.

B) Incorrect. There is no special label letter that indicates foods that are lighter in calories.

C) Correct. The recommended serving size is very important to consider when making choices.

For example, when choosing a cereal for breakfast, a lower count cereal may include a calorie count of 100 per serving size of 1/2 cup. If a client consumes 1-1 1/2 cups, the calorie intake has increased considerably.

D) Incorrect. Choosing a fat content of a food of less than 11% is very high. If Mr. Reddy is attempting to lose weight, a wiser choice would be a fat content less than 5%.

Type: MC Learning Outcome: 40-7

6 .

13) Mrs. Lee reports that her teenager has started a vegan diet. Which of the following foods should the nurse recommend to Mrs. Lee to ensure that this teenager does not become iron deficient?

A) Tofu, soybean milk, and orange juice B) Soybean milk, Brewer's yeast, and apples C) Brewer's yeast, apples, and strawberries D) Orange juice, apples, and peas Answer: A Explanation: A) Correct. The foods that would best prevent iron deficiency are tofu, soybean milk, and orange juice.

B) Incorrect. Brewer's yeast is a good source of vitamin B12, which is often low in vegan diets but it is not a source of iron. Strawberries, apples, and peas are not a source of iron.

C) Incorrect. Brewer's yeast is a good source of vitamin B12, which is often low in vegan diets but it is not a source of iron. Strawberries, apples, and peas are not a source of iron.

D) Incorrect. Strawberries, apples, and peas are not a source of iron.

Type: MC Learning Outcome: 40-1 14) Clients who consume large amounts of alcohol on a daily basis are at risk for vitamin C deficiency.

Answer: FALSE Explanation: This statement is false. Alcohol requires vitamin B for metabolism, so people who consume large amounts of alcohol daily are more at risk for vitamin B deficiency.

Type: TF Learning Outcome: 40-5 15) The nurse is caring for 16-year-old Jody who has been admitted to hospital with severe anorexia nervosa. Jody is to have an enteral feeding tube inserted. As the feeding tube is passed into the oropharynx, Jody begins to gag and cough. Which is the appropriate nursing action for the nurse to take?

A) Remove the tube and attempt reinsertion B) Give Jody a few sips of water to drink C) Use firm pressure to pass the tube through the glottis D) Have the client tilt the head back to open the passage Answer: B Explanation: A) Incorrect. This is a common response to the presence of a tube in the oropharynx, so removal of the tube is not necessary.

B) Correct. Swallowing water may help calm the gag reflex and also facilitate the "swallowing" of the tube.

C) Incorrect. The nurse should not use pressure to pass the tube as it may cause trauma to the tissues.

D) Incorrect. The client's head should be tilted forward at this point to facilitate the insertion into the esophagus.

Type: MC Learning Outcome: 40-12

7 .

16) The nurse notices that 16-year-old Jody's continuous open system tube-feeding set is almost empty. What action should the nurse take?

A) Add tube feeding to the set B) Discontinue the feeding and hang a closed system bag C) Wash out the set and add new feeding D) Flush the set with clear carbonated soda and discontinue Answer: C Explanation: A) Incorrect. Feeding is not added to that which has already been hanging.

B) Incorrect. There is no indication to change the type of feeding to a closed system.

C) Correct. The open set should be taken down, washed well, and rehung with new feeding.

D) Incorrect. There is no indication that the tube needs to be flushed or irrigated. Carbonated soda should not be used to irrigate the tube as it can lead to occlusion.

Type: MC Learning Outcome: 40-12 17) How would the nurse prepare to aspirate stomach contents from Jody's soft bore feeding tube?

A) Attach to wall suction set to continuous low suction B) Use a small syringe (10 mL) to maintain positive pressure C) Use a large syringe (30 mL) to create less negative pressure D) Use a small syringe (10 mL) to decrease the possibility of collapsing the tube Answer: D Explanation: A) Incorrect. Continuous low suction may damage the mucous membrane by causing the tube to adhere to the stomach.

B) Incorrect. It is not possible to avoid creating negative pressure, but a smaller syringe will create less negative pressure than a larger syringe without collapsing the tube.

C) Incorrect. A 30 mL syringe will very likely collapse a small bore feeding tube because it creates a negative pressure that is too great for small bore tubes.

D) Correct. The nurse should use a 10 mL syringe because it will decrease the possibility of collapsing the feeding tube by decreasing the amount of negative pressure.

Type: MC Learning Outcome: 40-12

8 .

18) Mr. Dubrovnik has enteral feeds infusing into a soft bore feeding tube. The feeding is running at the prescribed rate. On early morning assessment, the nurse observes that Mr. Dubrovnik's breathing is shallow and his colour is dusky. What is the nurse's priority action?

A) Place Mr. Dubrovnik in high Fowler's position B) Turn off the tube feeding C) Assess Mr. Dubrovnik's lung sounds D) Assess Mr. Dubrovnik's bowel sounds Answer: B Explanation: A) Incorrect. The client is exhibiting signs of aspiration, and the nurse must take action to prevent further aspiration. High Fowler's position does not do anything to address the possibility of aspiration. B) Correct. Shallow breathing and a dusky colour indicates possible aspiration of the feeding. The priority action is to discontinue the feeding to eliminate any further feeds from entering his lungs. C) Incorrect. Lung assessments are necessary to determine whether the client has aspirated, and would be completed after the tube feeds are shut off. D) Incorrect. Assessing bowel sounds will not provide any information necessary to determine whether the client has aspirated. Type: MC Learning Outcome: 40-12 19) The nurse is removing 16-year-old Jody's nasogastric tube. What instruction does the nurse give Jody as the nasogastric tube is removed? A) Exhale during the removal B) Breathe in and out slowly C) Hold her breath D) Lay in a supine position Answer: C Explanation: A) Incorrect.

Exhaling during the removal puts Jody at risk for aspiration. B) Incorrect. Breathing in during the removal puts Jody at risk for aspiration. C) Correct. Holding the breath closes the glottis, thereby reducing the possibility of aspiration as the tube is removed. D) Incorrect.

Lying in a supine position would place Jody at risk for aspiration. Type: MC Learning Outcome: 40-12

9 .

20) Aaron, 16 years old, is being seen for a routine physical. He has a body mass index (BMI) of 27. Assuming that a full nutritional assessment has been completed, what recommendations should be made to Aaron in regards to energy balance? A) Maintain his current level of activity and nutritional intake B) Decrease caloric intake, and increase physical activity C) Increase his caloric intake and maintain activity levels D) Suggest a program in behaviour modification Answer: B Explanation: A) Incorrect. Aaron's BMI of 27 falls within the category of being overweight. Aaron should be advised to follow the recommendations of the Canadian food guide, decrease caloric intake, and increase his activity level. B) Correct. Aaron's BMI of 27 falls within the category of being overweight.

Aaron should be advised to follow the recommendations of the Canadian food guide, decrease caloric intake, and increase his activity level. C) Incorrect. Aaron's BMI of 27 falls within the category of being overweight. He needs to decrease his caloric intake, not increase it. D) Incorrect. This would not be the first suggestion made. There is no indication that Aaron has experienced difficulty in losing weight. This might be considered in the future if changes in his nutritional intake and activity levels failed at producing the desired effects.

Type: MC Learning Outcome: 40-3 21) Mrs. Porter is being seen at the health clinic to have a complete nutritional assessment completed. She has recently been informed that she has metabolic syndrome. Which of the following assessments might be recommended at this time to get a clear understanding of the influences on her current weight? A) Anthropometric measurements B) Food diary C) Food frequency record D) Dietary history Answer: D Explanation: A) Incorrect. These would have been completed in support of her diagnosis of metabolic syndrome. B) Incorrect. A food diary will only provide information on what she has eaten over a 5-7 day time period. C) Incorrect. A food frequency record will only provide information on how often particular foods are ingested. D) Correct. A dietary history includes data about the client's usual eating patterns and habits, allergies and food intolerances, as well as cultural influences or religious factors that may influence nutrition. It is the most comprehensive assessment choice of those listed. Type: MC Learning Outcome: 40-8

10 .

22) Over the past year, Mrs. Porter has demonstrated a commitment to improving her health. Her BMI has decreased, and her waist circumference (WC) is now at 80 cm as a result of changes to her eating patterns and an increase in physical activity. Her blood pressure is presently 128/76, and her glucose levels have stabilized. Which of the following findings indicate that she is no longer considered to have metabolic syndrome?

A) Normal cholesterol B) WC less than 90 cm C) BMI of 32 D) BP less than 150/80 Answer: A Explanation: A) Correct. Along with the weight loss, the stabilization of her blood glucose level, and the decrease in Mrs. Porter's blood pressure, a normal cholesterol level would indicate that she is no longer considered to have metabolic syndrome.

B) Incorrect. A WC of greater than 88 cm still indicates abdominal obesity.

C) Incorrect. A BMI of 32, even if it is lower than what her original BMI was, is still too high and places her in the obese category. She would still be considered at least at risk for metabolic syndrome with a BMI in that range.

D) Incorrect. A blood pressure of less than 150/80 is still considered to be hypertensive. BP should ideally be less than 140/80.

Type: MC Learning Outcome: 40-10 23) What nursing diagnosis is the most important for the nurse to include in the care plan of Mrs. Everly who has just been started on total parenteral nutrition (TPN) therapy?

A) Risk for infection B) Imbalanced nutrition: less than body requirements C) Activity intolerance D) Fluid volume deficit Answer: A Explanation: A) Correct. TPN is delivered via a venous catheter and is very high in glucose.

There is a very high risk for infection.

B) Incorrect. Mrs. Everly already has imbalanced nutrition, so while that nursing diagnosis would be included, it is not as important as the risk for infection.

C) Incorrect. While she may have an activity intolerance, the risk for infection is the priority as it relates to TPN because of the high glucose content.

D) Incorrect. Mrs. Everly is now at more risk of fluid volume overload from the additional TPN fluid.

Type: MC Learning Outcome: 40-9

11 .

24) The nurse at a community clinic is teaching Harry about essential nutrients and their use by the body. Which nutrient provides the main source of energy for the body?

A) Fats B) Proteins C) Vitamins D) Carbohydrates Answer: D Explanation: A) Incorrect. Fats are stored in the liver, adipose tissue, and muscle tissue for release when needed for energy. They are not used as readily as carbohydrates.

B) Incorrect. Some amino acids are used by the liver to provide the body with plasma proteins, while others are stored throughout the body where they are used to make protein for cell structure.

C) Incorrect. Vitamins are needed to catalyze the metabolic process, but are not in themselves a source of energy.

D) Correct. Carbohydrates provide the main and most important source of readily available energy.

Type: MC Learning Outcome: 40-2 25) The nurse at a community clinic is teaching Harry about essential nutrients and their use by the body. Carbohydrates that are not needed for energy are stored as glycogen and what other body substance?

A) Fat B) Muscle C) Glucose D) Pyruvic acid Answer: A Explanation: A) Correct. Carbohydrates that are not needed for energy are stored as glycogen and fat.

B) Incorrect. Carbohydrates not needed for energy are not stored as muscle.

C) Incorrect. Carbohydrates not needed for energy are not stored as glucose.

D) Incorrect. Carbohydrates that are not needed for energy are stored as glycogen and fat, not pyruvic acid.

Type: MC Learning Outcome: 40-2

12 .

26) Mrs. Babcock has been advised to avoid saturated fatty acids in her diet. How can she accomplish this?

A) By using only animal fat B) By avoiding all fats and fatty foods C) By using fats that are liquid at room temperature D) By reducing her fat intake to 30% of total calories Answer: C Explanation: A) Incorrect. Mrs. Babcock should be avoiding fats from animals and any that are solid at room temperature.

B) Incorrect. Mrs. Babcock does not need to avoid all fats and fatty foods because some may be required for energy and protection of body tissues and organs.

C) Correct. Mrs. Babcock can avoid saturated fatty acids by using fats that are liquid at room temperature: fats that are derived from plants, such as olives and avocadoes. Saturated fats are from animals and are solid at room temperature.

D) Incorrect. Reducing her ingestion of fat to 30% of total calories is recommended, but she needs to ensure that the fats she is ingesting are unsaturated.

Type: MC Learning Outcome: 40-1 27) When talking with Mr. Mario, the nurse is asked to explain what she means by "energy balance." Which is the best response by the nurse?

A) Eating 15% more calories than our body uses for energy B) Eating 15% fewer calories than our body uses for energy C) Maintaining a balance between the blood glucose level and the insulin level D) Maintaining extra insulin in the blood for utilization when needed Answer: C Explanation: A) Incorrect. Eating more calories than what is required will lead to weight gain.

B) Incorrect. Eating fewer calories than we need may lead to malnutrition.

C) Correct. Maintaining a balance between the blood glucose level and the insulin level is the correct response.

D) Incorrect. Extra insulin in the blood indicates a state of hyperinsulinemia. This excess of insulin may develop into insulin resistance in which the cell's sensitivity to insulin is diminished.

Type: MC Learning Outcome: 40-3

13 .

28) Student nurses from the local community college are presenting a program to families at primary schools entitled, "Preventing Childhood Obesity." Which of the following recommendations by the Childhood Obesity Foundation are included in their presentation?

A) Less than 2 hours of screen time per day B) Three servings of vegetables per day C) A maximum of 2-3 juice drinks per day D) A minimum of 30 minutes of physical activity daily Answer: A Explanation: A) Correct. Because most screen time is sedentary, limiting it to less than 2 hours per day and providing other activities that promote movement is recommended.

B) Incorrect. It is actually recommended that children have at least 5 servings of fruit and vegetables daily.

C) Incorrect. Children should eat their fruits and vegetables in their original form. Juices can be high in sugar.

D) Incorrect. Children in this age range should have a minimum of 60 minutes of physical activity daily.

Type: MC Learning Outcome: 40-11

14 .

Fundamentals of Canadian Nursing, 4e(Kozier) Chapter 41 Fecal Elimination 1) Mrs. Smith asks the nurse why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which of the following is the best response?

A) Sitting on the toilet decreases the contractions of the muscles of the pelvic floor.

B) Sitting on the toilet increases the downward pressure on the rectum.

C) Sitting on the toilet increases the pressure within the abdomen.

D) Sitting on the toilet contracts the internal oblique muscles.

Answer: B Explanation: A) Incorrect. Contraction of the muscles of the pelvic floor is increased, not decreased.

B) Correct. The sitting position increases the downward pressure on the rectum, assisting one to pass stool.

C) Incorrect. Thigh flexion will increase the pressure within the abdomen; sitting on the toilet alone will not accomplish this.

D) Incorrect. Contraction of the internal obliques does not happen when sitting on the toilet.

Type: MC Learning Outcome: 41-1 2) Students in an anatomy and physiology class learn that there are three distinct types of movement in the large intestine. What do they learn is the reason for Haustral churning?

A) It aids in the absorption of water from the intestinal contents.

B) It is responsible for the promotion of peristalsis.

C) It regulates the flow of chyme into the large intestine.

D) It prevents the back flow of intestinal contents into the ileum.

Answer: A Explanation: A) Correct. Haustral churning involves the movement of chyme back and forth in the large intestine. Its purpose is to mix the contents and aids in the absorption of water.

B) Incorrect. Haustral churning is not responsible for the promotion of peristalsis. Peristalsis is another distinct movement of the colon.

C) Incorrect. The ileocecal valve is responsible for regulating the flow of chyme into the large intestine.

D) Incorrect. The ileocecal valve is also responsible for ensuring that there is no back-up of chyme into the ileum.

Type: MC Learning Outcome: 41-1

1 .

3) Which of the following clients is at greatest risk for developing constipation?

A) An adult who is on bed rest B) An infant who is breast-fed C) A school-age child at recess D) A 2-year-old toddler Answer: A Explanation: A) Correct. Adults who are on bed rest are at greatest risk for developing constipation because they are unable to get the exercise required to promote peristalsis.

B) Incorrect. Infants that are breast-fed pass stools frequently, usually after each feeding, because the intestine is immature and water is not well absorbed.

C) Incorrect. School-age children may delay defecation because of play, but their activity still promotes regular bowel movements.

D) Incorrect. Toddlers normally do not have problems with constipation because of their activity level.

Type: MC Learning Outcome: 41-2 4) The nurse is taking care of Mr. Alexander, who states that he ignores the urge to defecate when he is at work. What information can the nurse provide him about this practice?

A) If you continue to ignore the urge to defecate, the urge is ultimately lost.

B) It is best to suppress the urge than suffer embarrassment at work.

C) This is a common practice, and it will help strengthen the reflex.

D) The internal anal sphincter responds by stopping feces from progressing into the rectum.

Answer: A Explanation: A) Correct. When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be progressively weakened. Ignoring the urge repeatedly will eventually cause the urge to be lost.

B) Incorrect. When the urge to defecate is suppressed, water continues to be absorbed from the fecal matter making the feces hard and difficult to expel.

C) Incorrect. This practice will weaken, not strengthen, the reflex.

D) Incorrect. The internal anal sphincter is involuntary. The urge to defecate occurs because the internal anal sphincter has allowed feces to move into the anal canal.

Type: MC Learning Outcome: 41-1

2 .

5) What physiological changes occur that predispose the elderly to constipation?

A) Decreased control of the anal sphincter muscles B) Diminished innervation of the internal sphincter C) Inability to absorb fluid from the chyme in the colon D) Loss of tone in the smooth muscle of the colon Answer: D Explanation: A) Incorrect. Decreased control of the anal sphincter would cause lack of control of defecation (incontinence).

B) Incorrect. There is no evidence to support that innervation to the internal sphincter is affected by age.

C) Incorrect. An inability to absorb water from the chyme would not result in hard, dry stools.

D) Correct. The decreased tone of the colon plus poor abdominal muscle strength contribute to constipation.

Type: MC Learning Outcome: 41-2 6) Which of the following characteristics assessed by the nurse is considered normal for an adult's feces?

A) Black in colour B) Cylindrical in shape C) Pungent in odour D) Yellow in colour Answer: B Explanation: A) Incorrect. Black is abnormal and may indicate the presence of blood in the stools.

B) Correct. Cylindrical in contour is a normal characteristic of feces because it takes the shape of the rectum.

C) Incorrect. Pungent is abnormal, but aromatic odour is normal.

D) Incorrect. Yellow is the normal colour of an infant's feces, not an adult's.

Type: MC Learning Outcome: 41-3

3 .

7) Mrs. Jackson asks the nurse what she can do about her frequent bouts of diarrhea. Which of the following is the best response by the nurse?

A) Change her daily routine B) Decrease fluid consumption C) Increase fibre in the diet D) Note the precipitating event Answer: D Explanation: A) Incorrect. Before the daily routines are changed, it is important to determine whether there are events in her routine that are precipitating the diarrhea.

B) Incorrect. Decreasing fluid consumption may lead to either dehydration or constipation.

C) Incorrect. Increasing fibre in the diet, especially insoluble fibre, will make the diarrhea worse because it draws water into the colon.

D) Correct. Medications, food allergies, and psychological stress such as anxiety can cause diarrhea. Noting the event can help identify the cause and strategies to deal with them.

Type: MC Learning Outcome: 41-4 8) The nurse is called to Mr. Martinez's room to assess his first bowel movement after surgery.

While he has indicated feelings of urgency over the last few days, he has not had a bowel movement in 6 days. Upon investigation, the nurse finds a very small amount of liquid stool.

What would the nurse conclude?

A) Mr. Martinez is constipated.

B) Mr. Martinez has fecal impaction.

C) Mr. Martinez has diarrhea.

D) Mr. Martinez has fecal incontinence.

Answer: B Explanation: A) Incorrect. Constipation would normally result in the passage of hard, dry, formed stool.

B) Correct. While further investigation would be necessary to conclude, fecal impaction should be considered a possibility. A person who has fecal impaction can experience the passage of liquid fecal seepage that can be misconstrued as diarrhea. The liquid portion of the feces seeps out around the impacted mass. A digital exam of the rectum would be necessary to confirm.

C) Incorrect. Diarrhea refers to the passage of three or more loose (mushy) or watery feces per day, or more frequently than is usual for that person. The fact that he has felt the urgency to defecate over the last few days helps discriminate the liquid stools from diarrhea.

D) Incorrect. Incontinence refers to loss of voluntary ability to control fecal discharges through the anal sphincter.

Type: MC Learning Outcome: 41-5

4 .

9) Forty-five year-old Ms. Allison has had multiple sclerosis for 20 years and has been confined to a wheelchair in an extended care unit for 5 years. Which of the following nursing diagnoses would be most appropriate for her?

A) Bowel incontinence B) Constipation C) Diarrhea D) Grieving Answer: B Explanation: A) Incorrect. Lack of sphincter control contributes to bowel incontinence, not bed rest.

B) Correct. Lack of activity, like being confined to a wheelchair, is a major contributor to constipation. Lack of activity slows bowel movements.

C) Incorrect. Diarrhea would come from a GI upset triggered by diseases, medication, or diet.

D) Incorrect. Grieving is not likely a problem unless she has just been confined to a wheelchair or newly admitted to the extended care unit.

Type: MC Learning Outcome: 41-6 10) Twenty-five year-old Mr. James has diarrhea. Which of the following goals would be appropriate for him?

A) He will have bowel movements regularly.

B) He will increase the amount of sugar in the diet.

C) He will limit fluid intake.

D) He will regain normal stool consistency.

Answer: D Explanation: A) Incorrect. Defecating regularly once the diarrhea has subsided can be a goal, but the immediate goal needs to be to regain normal consistency of stool. The problem needs to be corrected first.

B) Incorrect. Increasing the amount of sugar in the diet will just add to the diarrhea.

C) Incorrect. Since Mr. James is experiencing diarrhea, which can dehydrate him and promote electrolyte loss, limiting fluids would not be appropriate.

D) Correct. Since Mr. James is experiencing diarrhea, the goal would be to regain normal stool consistency which would be less water in the stool and more formed consistency.

Type: MC Learning Outcome: 41-7

5 .

11) Thirty-year-old Mrs. Shelley was diagnosed with cancer of the colon requiring a bowel resection and formation of a colostomy. Which of the following instructions will assist her in taking care of her colostomy?

A) Change the drainage pouch daily B) Loose clothing will be needed now that a pouch is worn C) Stick a pin into the drainage pouch to relieve any gas buildup D) Secure the faceplate to the drainage pouch so no skin around the stoma is exposed Answer: D Explanation: A) Incorrect. The drainage pouches are expensive, and they can be used for up to a week before being changed. Just daily rinsing and cleaning is necessary.

B) Incorrect. No special clothing has to be worn with a colostomy pouch. The client can wear the same clothes she had prior to surgery.

C) Incorrect. Sticking a pin into the pouch may cause leakage and irritation of the skin around the pouch.

D) Correct. The skin around a stoma is very susceptible to irritation and breakdown. To avoid skin irritation, the faceplate to the drainage pouch needs to fit close enough to the stoma so as not to expose any other skin.

Type: MC Learning Outcome: 41-10 12) Which of the following assessment skills would the RN perform first when examining Beatrice for fecal elimination problems?

A) Auscultation B) Inspection C) Palpation D) Percussion Answer: A Explanation: A) Correct. Auscultation precedes palpation because palpation can alter peristalsis.

B) Incorrect. Examination of the rectum and anus includes inspection and palpation.

Auscultation should be first because palpation alters peristalsis.

C) Incorrect. Examination of the rectum and anus includes inspection and palpation.

Auscultation should be first because palpation alters peristalsis.

D) Incorrect. Auscultation precedes percussion because percussion can alter peristalsis.

Type: MC Learning Outcome: 41-4

6 .

13) Mrs. Beatty has been hospitalized to determine the cause of her right-sided epigastric pain.

Which of the following assessment data would indicate compromised gastrointestinal function?

A) Bowel sounds active in all four quadrants B) Clay colour stool C) Increased appetite D) Semisolid and moist stool Answer: B Explanation: A) Incorrect. Bowel sounds active in all four quadrants is indicative of normal bowel activity.

B) Correct. Clay colour stools would be an indication of a problem in the GI tract. Clay colour is a sign of the absence of bile pigment (bile obstruction).

C) Incorrect. If the GI tract were compromised, Mrs. Beatty would have a decrease in appetite, not an increase.

D) Incorrect. A semisolid and moist stool indicates normal bowel function.

Type: MC Learning Outcome: 41-3 14) Which of the following suggestions by the nurse would assist Mr. Adamson to maintain a normal fecal elimination pattern?

A) Drink two to four glasses of water daily B) Include more spicy foods and sugar in the diet C) Include more whole grains in the diet D) Use enemas as necessary Answer: C Explanation: A) Incorrect. Two to four glasses of water daily is not adequate; for regular elimination, six to eight glasses of water should be consumed daily.

B) Incorrect. Increasing the consumption of spicy foods and sugar will cause diarrhea, which is not a normal fecal pattern.

C) Correct. Eating more whole grains will increase fibre in the diet, which increases bulk and volume.

D) Incorrect. The regular use of enemas and laxatives will promote dependence.

Type: MC Learning Outcome: 41-8

7 .

15) Mr. Adamson is booked for a colonoscopy and requires a cleansing enema. What information does the nurse provide Mr. Adamson before administering the enema? A) Hold the solution for a short time B) Lie in the left lateral position C) Lie in the right lateral position D) Take quick breaths in through the nose Answer: B Explanation: A) Incorrect.

Once the enema is given, Mr. Adamson should hold the solution as long as possible for the best results. B) Correct. Mr. Adamson should lie in the left lateral position. This position facilitates the flow of solution by gravity into the sigmoid and descending colon. C) Incorrect.

The left lateral position is appropriate for administering an enema due to the anatomy of the sigmoid colon. The right lateral position is not appropriate to administer an enema. D) Incorrect. Mr. Adamson should take slow deep breaths in through the mouth. This will enable the client to hold the solution being given. Type: MC Learning Outcome: 41-11 16) Mrs. Ramone has a problem with constipation and requires a cleansing enema. What action is expected of a hypertonic solution enema like sodium phosphate? A) It exerts osmotic pressure and draws fluid from the interstitial space into the colon. B) It exerts a lower osmotic pressure than the surrounding interstitial fluid. C) It exerts the same osmotic pressure as the interstitial fluid surrounding the colon. D) It stimulates peristalsis by increasing the volume in the colon and irritating the colon. Answer: A Explanation: A) Correct. A hypertonic solution exerts osmotic pressure and draws fluid from the interstitial space into the colon. B) Incorrect.

A hypotonic solution (tap water) exerts a lower osmotic pressure than the surrounding interstitial fluid causing water to move from the colon into the interstitial space. Before the water moves from the colon, it stimulates peristalsis and defecation. C) Incorrect. Isotonic solutions (e.g., physiological [normal] saline) are considered the safest enema solutions to use.

They exert the same osmotic pressure as the interstitial fluid surrounding the colon.

Therefore, there is no fluid movement into or out of the colon. The instilled volume of saline in the colon stimulates peristalsis. D) Incorrect. This would be true of a soapsuds enema (cleansing). Soapsuds stimulate peristalsis by increasing the volume in the colon and irritating the colon. Type: MC Learning Outcome: 41-8

8 .

17) Which of the following findings is indicative of fecal impaction?

A) Loss of desire to defecate B) Constipation with liquid fecal seepage C) Absence of stool upon digital rectal exam D) Alternating patterns of normal stool and diarrhea Answer: B Explanation: A) Incorrect. The desire to defecate occurs frequently but is nonproductive or productive only of the liquid stool.

B) Correct. Fecal impaction is a collection of hardened feces in the folds of the rectum. It is recognized by the passage of liquid fecal seepage and no normal stool. The liquid portion of the feces seeps out around the impacted mass. The desire to defecate occurs frequently but is nonproductive or productive only of the liquid stool.

C) Incorrect. The absence of stool is inconsistent with fecal impaction. Stool can be felt in the rectum upon digital rectal exam.

D) Incorrect. An alternating pattern of normal stool and diarrhea is not consistent with fecal impaction.

Type: MC Learning Outcome: 41-5 18) The nurse is collecting a stool specimen from a bedpan. Which of the following actions are indicated?

A) Wear sterile gloves and use a sterile specimen cup B) Take the specimen to the laboratory at the end of the shift C) Avoid contaminating the outside of the container with feces D) Wear gloves, use a paper towel to remove and transfer the feces to the specimen cup Answer: C Explanation: A) Incorrect. Wearing sterile gloves and using a sterile specimen cup are not necessary. The nurse would use aseptic technique, not sterile.

B) Incorrect. The stool specimen should be sent to the laboratory immediately because a fresh specimen provides the most accurate results.

C) Correct. The nurse should avoid contaminating the outside of the container with feces.

D) Incorrect. A paper towel should not be used to transfer the specimen to the specimen container because contents from the paper towel can affect the laboratory analysis.

Type: MC Learning Outcome: 41-4

9 .

19) The nurse has taught Mr. Johnson about measures to relieve his constipation. Which of the following outcome criteria is most appropriate for Mr. Johnson?

A) He will remain free of flatulence.

B) He will remain free of perianal irritation.

C) He will use bisacodyl daily to manage his constipation.

D) He will eat a diet that includes fibre and 8 to 10 glasses of fluid daily.

Answer: D Explanation: A) Incorrect. Lack of flatulence and freedom from perianal irritation and odour are not related to constipation.

B) Incorrect. Freedom from perianal irritation and odour are not related to constipation.

C) Incorrect. Laxatives like bisacodyl should not be used because they weaken the bowel's natural responses to fecal distention, which worsens the constipation problem.

D) Correct. Mr. Johnson should eat a well-balanced diet that includes fibre and 8 to 10 glasses of fluid daily. These are actions known to relieve constipation.

Type: MC Learning Outcome: 41-12 20) Mrs. Beauvert comes to the clinic with her 1-month-old infant. She tells the nurse that she is going to have to stop breast-feeding her daughter because her baby's stools are yellow. What is the nurse's best response?

A) "You are correct. Let's discuss this problem with your doctor."

B) "You really don't need to worry. It is normal for the baby's stools to be that colour."

C) "Do you feel that because your baby's stools are yellow that you are not providing adequate nutrition for her?"

D) "Yellow stools are normal in infants. Is there any other reason you feel you should quit breast-feeding?"

Answer: D Explanation: A) Incorrect. Because the yellow stools are normal, there is no need to discuss this with the doctor.

B) Incorrect. Telling Mrs. Beauvert that she does not need to worry minimizes her concerns and may deter her from expressing any others.

C) Incorrect. This is a closed question that is presumptive and does not permit Mrs. Beauvert from communicating other concerns.

D) Correct. The best response by the nurse is to acknowledge that yellow stools are normal and to open the conversation to the exploration of other concerns related to breast-feeding.

Type: MC Learning Outcome: 41-2

10 .

21) Thirty-year-old Mrs. Shelley was diagnosed with cancer of the colon requiring a bowel resection and formation of a colostomy. When assessing Mrs. Shelley's stoma, the nurse notes that it is dark blue in colour. What should be the nurse's priority action?

A) Notify the physician immediately B) Apply an antibiotic powder to the stoma surface C) Use only hypoallergenic adhesive on the ostomy appliance D) Remove the old Karaya wafer and apply a new one to the stoma area Answer: A Explanation: A) Correct. The nurse's priority action should be to notify the surgeon immediately. The dark blue colour indicates impaired blood circulation to the stoma tissue.

B) Incorrect. Applying antibiotic powder to the stoma surface will not improve circulation to the stoma.

C) Incorrect. Using hypoallergenic adhesive and removing the Karaya wafer will not improve circulation to the stoma.

D) Incorrect. Removing the Karaya wafer will not improve circulation to the stoma.

Type: MC Learning Outcome: 41-10 22) Thirty-year-old Mrs. Shelley was diagnosed with cancer of the colon requiring a bowel resection and formation of a colostomy. Which of the following is a correct part of the procedure for changing Mrs. Shelley's ostomy appliance?

A) Don sterile gloves before removing the ostomy pouch B) Peel the bag off quickly to decrease the amount of pain C) Schedule the ostomy change for 30 to 45 minutes before meal time D) Empty the pouch into a bedpan before removing the ostomy appliance Answer: D Explanation: A) Incorrect. Clean, rather than sterile, gloves are required for changing Mrs. Shelley's ostomy appliance.

B) Incorrect. Removing the ostomy skin barrier and appliance should be done slowly while holding the skin taut to minimize discomfort and prevent abrasion to Mrs. Shelley's skin.

C) Incorrect. The ostomy change should not be done close to mealtimes because some clients find the procedure distasteful. It may decrease their desire to eat.

D) Correct. The nurse should empty the pouch into a bedpan before removing the ostomy appliance because it decreases the risk of spillage.

Type: MC Learning Outcome: 41-10

11 .

23) Mr. Jorgen has chronic constipation. What would be the first step in initiating a bowel training program for Mr. Jorgen?

A) Administer a suppository B) Increase the client's fluid intake C) Increase the fibre in Mr. Jorgen's diet D) Assess Mr. Jorgen's usual bowel habits Answer: D Explanation: A) Incorrect. Mr. Jorgen may not need a suppository; it should not be used because it can promote dependence.

B) Incorrect. Increasing fibre or fluids may not remedy his problem with constipation. The plan for bowel retraining must begin with an assessment.

C) Incorrect. Increasing fibre or fluids is premature until Mr. Jorgen's usual bowel habits are determined.

D) Correct. The nurse should assess Mr. Jorgen's bowel habits first in order to know what changes need to be made to them.

Type: MC Learning Outcome: 41-9 24) Mrs. McIsaac calls the health clinic for advice on how to care for her husband and 11-yearold son, who both have diarrhea. The nurse advises her to have her son and husband increase their fluid intake and limit their intake of whole wheat and whole grain breads and cereals. What is the most important reason for limiting the whole wheat and whole grain products?

A) These products will draw more water into the colon.

B) During bouts of diarrhea, dietary intake should be limited to fluids.

C) These products are not high enough in sodium and potassium to replace losses.

D) These products do not have a high enough probiotic content.

Answer: A Explanation: A) Correct. These foods are rich in insoluble fibre, so they will draw water into the colon and further irritate the colon.

B) Incorrect. Dietary management of diarrhea is usually limited to fluids and bland foods such as rice, oatmeal, and skinless potatoes. As well, products that have probiotic content have been shown to shorten the duration of diarrhea.

C) Incorrect. While they may not have high concentrations of sodium and potassium which should be replaced during episodes of diarrhea, this is not the most important reason for limiting them. These products are limited because they have the potential of making the diarrhea worse because of their fibre content.

D) Incorrect. Probiotic content is found in yogurts and some other dairy products, not whole wheat products.

Type: MC Learning Outcome: 41-9

12 .

25) Mrs. McIsaac calls the clinic at 4 pm to report that her 6-month-old daughter has had four loose stools in 3 hours. The infant is irritable and has a slight fever. What should the nurse advise Mrs. McIsaac to do?

A) Make an appointment for her to be seen in the clinic the following day B) The infant should be seen by a physician C) Have Mrs. McIsaac give her infant a yogurt drink with probiotics D) Restrict the infant's intake to clear fluids Answer: B Explanation: A) Incorrect. This option is not soon enough for the infant. She is at risk for dehydration and should be seen immediately.

B) Correct. The infant should be seen by a physician; she is at risk for dehydration.

C) Incorrect. Probiotic drinks would be appropriate for older children, not an infant.

D) Incorrect. Infants dehydrate quickly, and their condition can deteriorate rapidly. The infant needs to be seen by a physician for assessment.

Type: MC Learning Outcome: 41-9 26) The nurse has been teaching Mr. Georgson measures to prevent constipation. Which of the following changes implemented by Mr. Georgson would demonstrate the need for additional teaching?

A) He is using noncodeine-based analgesic for his arthritic pain.

B) He has increased intake of fruits and vegetables in his diet.

C) He swims 5 days a week for 1 hour.

D) He has increased his fluid intake to 1000 mL daily.

Answer: D Explanation: A) Incorrect. This would be an action you would expect Mr. Georgson to take, as codeine may cause constipation in some adults. Further instruction would not be necessary.

B) Incorrect. An increase of intake of fruits and vegetables would be a good decision by Mr. Georgson and would not require additional information.

C) Incorrect. Increased activity, like swimming, promotes gastric motility, which increases bowel function. No further teaching would be required.

D) Correct. Mr. Georgson's fluid intake is not adequate to help with his constipation; he should be further advised to increase his intake to a minimum of 1500 mL/day.

Type: MC Learning Outcome: 41-7

13 .

27) Ms. Percy is a student nurse who has just completed giving a tap water enema to her client. The client had a small bowel movement and states she stills feels full. What reason would the nurse give to Ms. Percy for why she wouldn't repeat the enema? A) The action of this hypotonic solution may cause circulatory overload. B) The action of this hypertonic solution may cause sodium retention. C) It may cause irritation and damage to the intestinal mucosa. D) Multiple enemas with isotonic solution may cause dehydration. Answer: A Explanation: A) Correct. A tap water enema is a hypotonic solution. The enema is instilled into the colon, and because it has a lower osmotic pressure than the surrounding interstitial tissues, it causes water to move out into these tissues. Before the water moves from the colon, it stimulates peristalsis and defecation. Because the water moves out of the colon, the tap water enema should not be repeated because of the danger of circulatory overload when the water moves from the interstitial space into the circulatory system. B) Incorrect. It is true that a hypertonic solution may contribute to sodium retention, but a tap water enema is not a hypertonic solution. C) Incorrect. A soapsuds enema may lead to irritation and damage to the intestinal mucosa. D) Incorrect. A tap water enema is not an isotonic solution, it is hypotonic.

Type: MC Learning Outcome: 41-9 28) Mrs. Ellinor is being administered an enema this morning. The nurse encounters resistance at the internal sphincter when inserting the enema tube into Mrs. Ellinor's rectum. What should the nurse do next? A) Have Mrs. Ellinor take a deep breath and run a small amount of fluid through the tube B) Raise the height of the container holding the solution to increase pressure C) Withdraw the tube right away and report the resistance to the charge nurse D) Withdraw the tube and re-insert it Answer: A Explanation: A) Correct. The nurse should instruct Mrs. Ellinor to take a deep breath while she runs a small amount of fluid through the tube. This manoeuvre will help relax the internal anal sphincter. B) Incorrect. Increasing pressure by raising the bag will not move the tube past the internal sphincter. Increasing the height of the bag will increase pressure resulting in the fluid flowing into the bed. C) Incorrect. It is a normal occurrence to meet a little resistance at the internal sphincter; this is not an urgent situation. D) Incorrect. It is not necessary to withdraw the tube, as it is normal to meet a little resistance at the internal sphincter. Type: MC Learning Outcome: 41-11

14 .

Fundamentals of Canadian Nursing, 4e(Kozier) Chapter 42 Urinary Elimination 1) Which of the following clients is at risk for difficulty in urinary elimination? A) Mr. Lincoln, who had bladder cancer and now has a newly created ileal conduit B) Ms. Joyce, a 25-year-old female client with low self-esteem C) Mr. Allen, an 80-year-old male reporting frequent urination at night D) Mrs. Ethier, who takes a diuretic every day for her blood pressure Answer: C Explanation: A) Incorrect. Bladder cancer, and the formation of an ileal conduit, will not impact the formation of urine and should not cause difficulty in elimination.

Continued urine production through the ileal conduit will need to be observed and assessed frequently. B) Incorrect. Low self-esteem will not influence or cause problems with voiding.

C) Correct. Mr. Allen's frequent urination at night may indicate problems with his prostate.

Older male adults experience urinary retention due to prostate enlargement causing an alteration in urinary elimination. D) Incorrect. Mrs. Ethier is taking diuretics as a means to decrease her blood pressure. It does not influence her ability to void. Type: MC Learning Outcome: 42-3 2) Effective management of secondary enuresis may include instigated waking and reward systems. Answer: TRUE Explanation: Secondary enuresis usually manifests itself in children who have achieved nighttime bladder control for at least 6 months, but have experienced a stressor or traumatic event which may cause periods of nocturnal enuresis.

While these management techniques may not be effective treatment for primary enuresis, they have been shown to be effective in those with secondary enuresis. Type: TF Learning Outcome: 42-3

1 .

3) Mr. Allenby, 77 years old, experiences frequent urination at night. Except for a diuretic he takes once per day for hypertension, he is otherwise healthy. How would the nurse explain the reason for his nocturia to Mr. Allenby?

A) Decrease in bladder capacity increases frequency of urination B) Expected effect of the diuretic C) Decrease in the number of nephrons D) Increase in cardiac output Answer: A Explanation: A) Correct. The capacity of the bladder and its ability to completely empty diminish with age. These factors explain the need for older adults to get up two or more times during the night to void.

B) Incorrect. If a diuretic is taken in the morning, its effect would not last into the night.

C) Incorrect. A decrease in the number of nephrons would in turn decrease the filtration rate, decreasing the overall production of urine.

D) Incorrect. While an increase in cardiac output would increase blood supply to the kidneys, and thus filtration rate, cardiac output does not increase with age.

Type: MC Learning Outcome: 42-3 4) Mrs. Carson, 30 years old, has had several bladder infections in the past year. Which of the following nursing interventions would help prevent future urinary tract infections?

A) After urinating, wipe the perineum from back to front B) Encourage the use of bubble baths C) Have the client increase sugar in the diet D) Instruct the client to empty the bladder completely Answer: D Explanation: A) Incorrect. Mrs. Carson should wipe from front to back. Wiping from back to front would encourage contamination from gastrointestinal bacteria.

B) Incorrect. Irritating soaps and bubble baths can contribute to infections and should be avoided. Showering is preferred over baths.

C) Incorrect. She should decrease the use of sugar in the diet because sugar promotes bacterial growth.

D) Correct. Completely emptying the bladder prevents stasis of urine. Stasis of urine (urine that remains in the bladder for extended periods of time) contributes to urinary tract infections.

Type: MC Learning Outcome: 42-11

2 .

5) Mrs. Rourke has returned from the operating room following surgery. She has a retention catheter in place. Which of the following nursing interventions is appropriate when providing perineal and catheter care for her?

A) Wear sterile gloves B) Retape the catheter to the thigh C) Deflate and inflate the balloon at least once a day D) Retract the labia majora away from the urinary meatus Answer: B Explanation: A) Incorrect. Sterile gloves are not necessary when providing perineal and catheter care.

B) Correct. Retaping the catheter to the thigh after care prevents trauma and pain from tension and pulling.

C) Incorrect. It is not necessary to deflate and re-inflate the balloon on the catheter; in fact, this action may risk dislodging the catheter.

D) Incorrect. When giving catheter care to a female, the labia minora, not the labia majora, is gently retracted away from the urinary meatus.

Type: MC Learning Outcome: 42-12 6) Mrs. Archer is a nurse on a busy surgical floor. She states that on some days she has gone 8 hours without emptying her bladder. What is Mrs. Archer at greater risk for?

A) Urinary tract infection (UTI) B) Formation of renal calculi C) Relaxation of urethral sphincter D) Chronic urinary retention Answer: A Explanation: A) Correct. Voluntarily suppressing urination because of perceived time pressures places the client at risk for a UTI. B) Incorrect. Suppressing the urge to void does not place a client at risk for renal calculi.

C) Incorrect. Relaxation of the sphincter would cause urinary incontinence. Prolonged suppression of the urge to void increases the risk of UTI, not incontinence.

D) Incorrect. Urinary retention refers to the inability to empty the bladder completely. Mrs. Archer is not at risk for retention.

Type: MC Learning Outcome: 42-2

3 .

7) Mrs. Lacroix was seen in the clinic 1 month ago with complaints of frequent urinary tract infections. After her last infection was treated, she was provided with information on how she could prevent further infections. Which of the following statements indicates to the nurse that further teaching is required?

A) She is wearing cotton undergarments instead of nylon.

B) Mrs. Lacroix has increased her coffee consumption.

C) She is drinking 6-8 glasses of water or cranberry juice per day.

D) She is taking showers instead of baths.

Answer: B Explanation: A) Incorrect. Wearing cotton undergarments is recommended for clients who have had frequent UTIs because the fabric breathes and does not cause urethral irritation.

B) Correct. Mrs. Lacroix may require additional teaching regarding her intake of coffee. Drinks high in caffeine, as well as alcohol, are thought to be irritating to the bladder.

C) Incorrect. Drinking 6-8 glasses of water per day is recommended.

D) Incorrect. Taking showers is a recommendation over baths because bacteria present in the bath water can enter the urethra.

Type: MC Learning Outcome: 42-11 8) Mr. Ravinder is rushed to the emergency department with what his health care provider suspects to be necrosis of the ileal conduit stoma. What evidence supports this diagnosis?

A) Stoma is black in colour.

B) Stoma is moist.

C) Stoma is pink and shiny.

D) There is slight bleeding from stoma.

Answer: A Explanation: A) Correct. A black stoma with sloughing is a sign indicative of necrosis and is a situation that requires immediate attention by health care professionals.

B) Incorrect. A healthy stoma should appear pink to red and look moist and shiny.

C) Incorrect. A healthy stoma should appear pink to red and look moist and shiny.

D) Incorrect. Slight bleeding might occur because the intestinal mucosa is very fragile.

Type: MC Learning Outcome: 42-12 9) A client brings in a specimen for a routine urinalysis. Which of the following findings are considered normal?

A) pH 6 and no glucose present B) Blood present and no ketones C) Specific gravity 1.035 D) Dark amber colour Answer: A Explanation: A) Correct. Normal pH is 4.5-8. Glucose is not a normal component of urine.

B) Incorrect. There should be no blood or ketones present in urine.

C) Incorrect. Normal specific gravity of urine is 1.010-1.025.

D) Incorrect. The urine should be a pale amber colour, not dark amber.

Type: MC Learning Outcome: 42-6

4 .

10) Mrs. Cabrera comes into the clinic with complaints of not being able to empty her bladder completely. Which of the following medications Mrs. Cabrera is taking may be contributing to her condition?

A) Glucosamine B) Levothyroxin C) Lasix D) Hydralazine Answer: D Explanation: A) Incorrect. Glucosamine, levothyroxin, and Lasix are not known to cause urinary retention.

B) Incorrect. Glucosamine, levothyroxin, and Lasix are not known to cause urinary retention.

C) Incorrect. Glucosamine, levothyroxin, and Lasix are not known to cause urinary retention.

D) Correct. Hydralazine is a medication that is thought to contribute to urinary retention.

Type: MC Learning Outcome: 42-4 11) Mrs. Gill has a 2 1/2-year-old son who she is attempting to toilet train. She asks the nurse at what age should she expect her son to gain daytime bladder control. How will the nurse respond?

A) 2 years old B) 3 years old C) 4 years old D) 5 years old Answer: B Explanation: A) Incorrect. Children usually become aware of bladder fullness between 18 and 24 months but do not gain daytime control until around 3 years of age.

B) Correct. Daytime control is usually achieved when the child is 3 years old.

C) Incorrect. Mrs. Gill can expect that the child may gain full control (day and nighttime) of his bladder by the time he is 4 or 5 years.

D) Incorrect. Mrs. Gill can expect that the child may gain full control (day and nighttime) of his bladder by the time he is 4 or 5 years.

Type: MC Learning Outcome: 42-2

5 .

12) Mrs. Armstrong has a chronic neurogenic bladder disorder. She is being taught how to complete a self-catheterization. Which of the following are important considerations?

A) Catheterization should be done when the bladder is full B) Wash the red rubber catheter between uses with soap and water C) Use a catheter with a 5-10 mL balloon D) Leave catheter in place for 15-20 minutes Answer: B Explanation: A) Incorrect. Mrs. Armstrong should attempt to void before catheterizing herself.

B) Correct. Catheters can be used more than once. Washing between uses with soap and water, and storing in a clean container is recommended. It should be replaced when it becomes difficult to clean.

C) Incorrect. Catheters for intermittent catheterizations do not have balloons; it would be appropriate to use a straight catheter.

D) Incorrect. The catheter is only left in place until the bladder is emptied.

Type: MC Learning Outcome: 42-10 13) Mr. Elliott has a three-way indwelling catheter after having a transurethral resection of the prostate (TURP). He tells the nurse he needs to void. What action should the nurse take?

A) Irrigate the catheter B) Reposition the catheter C) Retape the catheter to the abdomen D) Deflate and then re-inflate the balloon Answer: A Explanation: A) Correct. Blood clots give the client the sensation to urinate when they obstruct the urine outflow; therefore, irrigation is advised to clear the clots.

B) Incorrect. Repositioning the catheter would not be an option right after surgery, as the risk of dislodging it and causing trauma to the tissues is high.

C) Incorrect. The catheter is usually taped to the leg and should not be manipulated. It creates traction which is intended to help control bleeding.

D) Incorrect. Deflating and re-inflating the balloon is not an option. The balloons are inflated not only to keep the catheter in place but also to control bleeding after surgery.

Type: MC Learning Outcome: 42-12

6 .

14) What is the basic functioning unit of the renal system?

A) Bladder B) Glomerulus C) Nephron D) Loop of Henle Answer: C Explanation: A) Incorrect. The bladder is a reservoir for urine, not the functioning unit of the renal system.

B) Incorrect. The glomerulus is a part of the nephron, not the sole functioning unit of the renal system.

C) Correct. The functional units of the kidney are nephrons.

D) Incorrect. The loop of Henle is a component of the nephron responsible for sodium and potassium reabsorption.

Type: MC Learning Outcome: 42-1 15) Blood pressure within the renal capillaries is maintained at a slightly lower pressure than generally found in capillary structures in the body.

Answer: FALSE Explanation: The vascular structure in the kidneys ensures that the blood pressure within the renal capillaries is higher; this supports the filtration function.

Type: TF Learning Outcome: 42-1 16) Which two hormones are responsible for the regulation of sodium and water in the proximal convoluted tubule?

A) Cortisol and adrenocorticotropic B) Atrial natriuretic peptide and brain natriuretic peptide C) Secretin and cholecystokinin D) Aldolsterone and antidiuretic hormone Answer: B Explanation: A) Incorrect. Cortisol and adrenocorticotropic are hormones from the adrenal cortex but are not involved in the regulation of sodium and water.

B) Correct. Atrial natriuretic peptide and brain natriuretic peptide are responsible for decreasing the reabsorption of sodium ions and water in the proximal loop.

C) Incorrect. Secretin and cholecystokinin are hormones that neutralize the acid in the stomach.

D) Incorrect. Aldosterone and antidiuretic hormone are two hormones involved with the regulation of sodium and water in the distal convoluted tubule.

Type: MC Learning Outcome: 42-1

7 .

17) Lisa, 18, is being seen at the walk-in clinic about dysuria, urgency, and frequency. Which of the following conditions is a primary cause of these urinary alterations? A) Stress B) Pregnancy C) Diabetes mellitus D) Urinary tract infection Answer: D Explanation: A) Incorrect. Stress is more likely to cause urinary incontinence. These symptoms represent a UTI. B) Incorrect. Pregnancy in its early stages may cause frequency and possible urgency, but not dysuria. C) Incorrect. While diabetes may be responsible for frequency of urination, dysuria and urgency would not be symptoms. D) Correct. A urinary tract infection (UTI) can cause urinary frequency, urgency, and dysuria (pain on voiding). Type: MC Learning Outcome: 42-4 18) Impaired blood flow to the kidneys or impending renal failure result in an output of less than 500 mL daily. What is the term used to describe a urinary output of less than 500 mL per day? A) Diuresis B) Anuria C) Oliguria D) Polyuria Answer: C Explanation: A) Incorrect. The term diuresis is often used when medications are given to promote urine output. B) Incorrect. Anuria refers to a complete lack of urine production. C) Correct. Oliguria is the term used to describes a urinary output of less than 500 mL a day or 30 mL per hour in an adult. D) Incorrect. Polyuria refers to the production of abnormally large amounts of urine by the kidneys. Type: MC Learning Outcome: 42-3

8 .

19) Lisa, 18, is being seen at the walk-in clinic about dysuria and frequency. What kind of urine specimen will the nurse expect the health care provider to order?

A) Routine voided urine specimen B) Clean catch or midstream urine specimen C) Residual urine specimen D) 24-hour urine specimen Answer: B Explanation: A) Incorrect. A routine voided specimen provides the constituents in the urine, not the type of bacteria or their sensitivity.

B) Correct. The kind of urine specimen that the nurse will expect the health care provider to order is a clean catch or midstream urine specimen. This specimen will determine the presence of a UTI. C) Incorrect. A residual urine specimen is the urine collected after a client has voided and is catheterized to find the amount of urine remaining in the bladder.

D) Incorrect. A 24-hour urine specimen is one that is collected over a 24-hour period to determine concentrations of solutes and filtration rates.

Type: MC Learning Outcome: 42-7 20) The nurse is to collect a urine specimen from an indwelling catheter without a needleless port. There is no urine in the tubing. After collecting all required equipment, and preparing the client, what would the nurse do first?

A) Open the sterile container B) Insert a needle into the tubing C) Clamp the catheter tubing D) Clean the tubing with disinfectant swab Answer: C Explanation: A) Incorrect. It is too early to open the sterile container. It would be contaminated by the time the urine specimen is collected.

B) Incorrect. There is no urine in the tubing. The tubing needs to be clamped first to allow for a fresh collection of urine.

C) Correct. The first step would be to clamp the tubing for 15-20 minutes to allow fresh urine to collect in the tube.

D) Incorrect. It is premature to swab the tubing; it would not remain clean while the urine is collecting in the tube.

Type: MC Learning Outcome: 42-7

9 .

21) Mrs. Eglington has just had her catheter removed. What teaching would the nurse provide her that may help prevent a UTI? A) Practice frequent voiding (every 2 to 4 hours) B) Drink four 250 mL glasses of water each day C) Take daily bubble baths D) Caffeinated beverages are recommended Answer: A Explanation: A) Correct. Mrs. Eglington should void every 2 to 4 hours to flush bacteria through the urethra and prevent them from ascending into the bladder.

B) Incorrect. Mrs. Eglington should drink at least eight 250 mL glasses of water daily to flush bacteria out of the urinary system.

C) Incorrect. She should avoid using bubble baths or harsh soaps as they can be irritating to the urethra and encourage inflammation and bacterial infection.

D) Incorrect. Caffeinated beverages are not recommended as they can irritate the bladder.

Type: MC Learning Outcome: 42-10 22) Mr. Hornby is a 24-year-old quadriplegic with a urinary retention catheter. He has recently experienced frequent urinary tract infections (UTIs). What information can the home care nurse provide him about foods that may decrease his risk of UTI? A) Milk and milk products B) Whole grains and eggs C) Green, leafy vegetables and corn D) Legumes, rice Answer: B Explanation: A) Incorrect. Milk and milk products are not known to acidify the urine; they would not help prevent UTIs. B) Correct. The nurse should inform Mr. Hornby that foods that acidify the urine include eggs, cheese, meat, poultry, and whole grains. These foods are thought to help prevent UTIs by acidifying the urine.

C) Incorrect. These vegetables are not known to acidify the urine and will not prevent UTIs. D) Incorrect. Legumes and rice are not known to acidify the urine and will not prevent UTIs. Type: MC Learning Outcome: 42-11

10 .

23) Mrs. Eglington, a 54-year-old woman, is to have an indwelling urinary catheter inserted.

What is the correct technique for cleansing the female genitalia immediately prior to catheterization? A) Separating the labia and cleansing from back to front B) Separating the labia and cleansing from front to back C) Cleanse around the urinary meatus in a circular motion D) Cleansing the labia from back to front using alcohol Answer: B Explanation: A) Incorrect. Cleansing from back to front brings bacteria from the rectal area toward the urinary meatus. B) Correct. When cleansing the perineal area prior to catheterization, the nurse should separate the labia and cleanse from front to back. C) Incorrect. Cleaning the perineal area is always done from front to back, not in a circular motion around the meatus.

D) Incorrect. Alcohol would not be used to cleanse as it may irritate the mucous membranes; cleansing would always be from front to back. Type: MC Learning Outcome: 42-11 24) Mr. Wilson is having a heart valve replacement today. He is in preoperative hold being prepped for surgery. He has benign prostatic hypertrophy (BPH). Which of the following is an appropriate choice of urinary catheters for Mr. Wilson? A) Indwelling coude B) Straight C) Indwelling retention D) Three-way foley Answer: A Explanation: A) Correct. An indwelling coude catheter is the appropriate choice for Mr. Wilson because of his BPH. It is more rigid than other catheters and has a tapered, curved tip. This catheter may be used for men with prostatic hypertrophy as it is more easily controlled and less traumatic on insertion. B) Incorrect. A straight catheter has no balloon to hold it in place; it is usually used to check for residual urine and would not be appropriate for a catheter that will need to be in use for days.

C) Incorrect. An indwelling retention catheter would be the usual choice for most clients. It has a balloon on the end so is appropriate for prolonged use. It is not the appropriate catheter for Mr. Wilson because he has BPH. D) Incorrect. A three-way catheter is appropriate for use when bladder irrigations are part of the treatment plan. Type: MC Learning Outcome: 42-10

11 .

25) Mr. Wilson is 1 day post-operative from a mitral valve replacement. Which of the following would be reported to the physician as a significant finding? A) Urine output in the past 8 hours is 150 mL. B) Urine is very pale yellow. C) Urine output over the past 2 hours is 70 mL. D) Urine is dark amber in colour. Answer: A Explanation: A) Correct. Mr. Wilson's output is very low; this may be caused by a decrease in blood supply to the kidneys. It should be reported to the physician urgently. B) Incorrect. Very pale urine is not a significant finding. It is the amount of urine produced at this time that is the concern. C) Incorrect. Mr. Wilson's urine output is low but adequate at this time. D) Incorrect. His urine output is concentrated; there is no concern as long as he continues to produce around 30 mL per hour.

Type: MC Learning Outcome: 42-12 26) The nurse is planning to teach Mr. Ravinder about his ileal conduit. Which of the following should be incorporated into the teaching plan for him? A) Change the appliance every day B) Increase fluid intake C) Notify the physician if the stoma is deep pink and shiny D) Notify physician if strands of mucus appear in the urine Answer: B Explanation: A) Incorrect. The appliance should be changed every 5 to 7 days.

Changing the appliance daily is unnecessary and may irritate peri-stomal skin. B) Correct.

Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the stoma. C) Incorrect. A deep pink, shiny stoma is normal, and there's no need to notify the physician. D) Incorrect. This is a normal finding. Strands of mucus may appear in urine because of the mucus-producing cells of the ileum. Type: MC Learning Outcome: 42-12

12 .

27) Mrs. Stuart is a 54-year-old client with an indwelling catheter. What instructions should the nurse give to the X-ray technician who is accompanying Mrs. Stuart to the radiology department for an X-ray? A) The drainage bag should be kept below bladder level at all times.

B) Mrs. Stuart may feel some abdominal pressure while she is walking about. C) The drainage bag should be disconnected before leaving Mrs. Stuart's bedside. D) The drainage bag should be placed on the X-ray table beside Mrs. Stuart. Answer: A Explanation: A) Correct. The nurse should tell the X-ray technician that the drainage bag should be kept below the level of the bladder at all times in order to avoid a backflow of urine and bacteria into the bladder. B) Incorrect. Mrs. Stuart should not feel abdominal pressure when walking because the drainage bag should be kept below the bladder level and it will continue to drain the bladder. C) Incorrect. The drainage system should not be disconnected because it opens a closed system increasing the risk for bacteria to enter the bladder. D) Incorrect. Placing the drainage bag on the table with Mrs. Stuart would allow a backflow of urine. Type: MC Learning Outcome: 4211 28) Mr. Singh has a three-way foley catheter in place. He has been receiving intermittent bladder irrigations. When assessing Mr. Singh, the nurse notes that he has no urine output in his catheter bag. What should her first action be? A) Call the physician B) Check the tubing for kinks C) Run irrigating fluid into the bladder D) Remove catheter and reinsert Answer: B Explanation: A) Incorrect. Calling the physician is premature. No urine in the bag may be caused by a clamped or kinked tube. B) Correct. If the tubing has been left clamped after the bladder was last irrigated, or if the tubing is kinked, straightening the tube or unclamping it will allow the bladder to drain. The urine output needs to be reevaluated following. C) Incorrect. The tubing needs to be checked before irrigating the bladder. The client should be reassessed after the tubing is straightened. D) Incorrect. There is no need to remove the catheter; this action may increase risk of infection. Type: MC Learning Outcome: 42-12

13 .

Fundamentals of Canadian Nursing, 4e (Kozier) Chapter 43 Oxygenation and Circulation 1) Mr. Jacks is a 23-year-old with a respiratory rate of 36 breaths per minute. What term would the nurse use to document this in the electronic health record?

A) Eupnea B) Bradypnea C) Tachypnea D) Dyspnea Answer: C Explanation: A) Incorrect. Eupnea is normal breathing of 12 to 20 breaths per minute of quiet, rhythmic, and effortless breathing.

B) Incorrect. Bradypnea is an abnormally slow respiratory rate (less than 12 breaths per minute).

C) Correct. Mr. Jacks' breathing pattern would be described as tachypnea, an abnormally high respiratory rate.

D) Incorrect. This is a sensation of breathlessness or difficulty breathing.

Type: MC Learning Outcome: 43-5 2) Ms. Calloway is a student nurse who is teaching her client about the anatomy and physiology of the heart. What does she teach her client is the primary pacemaker of the heart?

A) SA node B) AV node C) Purkinje fibres D) Bundle of HIS Answer: A Explanation: A) Correct. The SA node is the primary pacemaker of the heart. Located at the junction of the right atrium and the vena cava, it fires at a rate of 60-100 bpm.

B) Incorrect. While the AV node may take over the pacemaker function as a compensatory mechanism, it is not considered the primary pacemaker.

C) Incorrect. The Purkinje fibres are part of the ventricular conduction system. Their intrinsic rate is between 20-30. The Purkinje fibres are not the primary pacemaker of the heart.

D) Incorrect. The bundle of HIS is not considered the primary pacemaker; they are part of the ventricular conduction system.

Type: MC Learning Outcome: 43-1

1 .

3) Mr. Bruce, 55 years old, has chronic obstructive lung disease and has oxygen ordered at 1.5 litres per minute via nasal cannula. Mr. Bruce complains of shortness of breath. What action should be taken by the nurse?

A) Increase the oxygen to 3 litres per minute via nasal cannula B) Lower the head of the client's bed to semi-Fowler's position C) Have Mr. Bruce breathe through pursed lips D) Increase oxygen to a partial non-rebreather mask Answer: C Explanation: A) Incorrect. Increasing Mr. Bruce's oxygen is not advisable because it may reduce his drive to breathe. In clients, like Mr. Bruce, with chronic obstructive lung disease, the stimulus to breathe is hypoxemia.

B) Incorrect. The client's head of the bed should be raised, not lowered.

C) Correct. Mr. Bruce should be taught to breathe out against pursed lips to increase the time it takes to exhale and to help keep airways open.

D) Incorrect. This high concentration of oxygen may reduce Mr. Bruce's drive to breathe.

Type: MC Learning Outcome: 43-7 4) Which of the following breathing patterns may be the result of metabolic acidosis?

A) Cheyne-Stokes B) Biot's C) Cluster D) Kussmaul's Answer: D Explanation: A) Incorrect. Cheyne-Stokes is characterized by intermittent shallow and deep respirations that also have periods of apnea. Heart failure and drug overdose may cause this type of respiration.

B) Incorrect. Biot's respirations are characterized by shallow breaths interrupted by apnea.

C) Incorrect. Cluster respirations is another term for Biot's respirations.

D) Correct. Kussmaul's respirations are a type of hyperventilation that accompanies metabolic acidosis. They represent the body's attempt to compensate for the acidosis by "blowing off" carbon dioxide.

Type: MC Learning Outcome: 43-3

2 .

5) Ten-year-old Kyle has cystic fibrosis. What is the best time to plan his twice-daily postural drainage?

A) 8 AM and 11 AM B) 12 PM and 6 PM C) 7 AM and 8 PM D) 9 AM and 9 PM Answer: C Explanation: A) Incorrect. Of the options offered, the one that takes into consideration the meal schedule and is most widely distributed is 7 AM and 8 PM. B) Incorrect. Of the options offered, the one that takes into consideration the meal schedule and is most widely distributed is 7 AM and 8 PM. C) Correct. Postural drainage should be scheduled to avoid hours shortly after meals because the treatment may induce vomiting and can be very tiring for the client. Since this client is getting the treatments only twice each day, the sessions should be separated as far as possible to allow for benefits across a longer time span.

D) Incorrect. Of the options offered, the one that takes into consideration the meal schedule and is most widely distributed is 7 AM and 8 PM. Type: MC Learning Outcome: 43-9 6) Mrs. Leonard is receiving oxygen by non-rebreather mask. Which of the following is a true statement regarding this type of oxygen delivery?

A) It is used only when humidity is necessary.

B) It delivers oxygen concentrations of 60-90%.

C) It does not interfere with eating or talking.

D) It delivers the highest concentration of oxygen next to mechanical ventilation.

Answer: D Explanation: A) Incorrect. Humidity is possible with other delivery methods such as cannula and venturi mask as well.

B) Incorrect. The non-rebreather delivers concentrations of 95-100%.

C) Incorrect. This would be true of a nasal cannula device.

D) Correct. The non-rebreather delivers concentrations of 95-100%, the highest possible without intubation or mechanical ventilation.

Type: MC Learning Outcome: 43-10

3 .

7) What action should the nurse take after inserting an oropharyngeal airway in Mr. Ahmed?

A) Tape the airway in place B) Suction the client C) Turn the client's head to the side D) Insert a nasal trumpet Answer: C Explanation: A) Incorrect. The airway should not be taped in place. An oral airway is used for clients who have an altered level of consciousness. Taping the airway would not allow the client to cough or gag the airway out when able.

B) Incorrect. Unless Mr. Ahmed is symptomatic, there is no need to suction him after inserting an airway. He should be suctioned when necessary.

C) Correct. The nurse should turn Mr. Ahmed's head to the side to allow drainage of oral secretions.

D) Incorrect. Insertion of a nasal trumpet or nasopharyngeal airway is not necessary when the oropharyngeal airway is in place.

Type: MC Learning Outcome: 43-10 8) Mr. Julian, a 60-year-old man, has a new tracheostomy. Upon arrival to the unit what is the priority nursing action?

A) Call respiratory care to attach the tracheotomy tube to the ventilator B) Remove the tracheotomy ties and replace them with an elastic bandage C) Remove the tracheotomy inner cannula D) Tape the tracheotomy obturator to the head of the bed Answer: D Explanation: A) Incorrect. There is no evidence the client needs to be ventilated. It is not always the case just because someone has an artificial airway.

B) Incorrect. The tracheotomy ties are only removed when they are soiled and need to be changed. Manipulating the apparatus more than it is necessary puts the nurse at risk for dislodging the trach.

C) Incorrect. The tracheotomy inner cannula is only removed for cleaning.

D) Correct. The obturator should be taped to the head of the bed so that it will be readily available if Mr. Julian's tracheotomy tube should become dislodged.

Type: MC Learning Outcome: 43-10

4 .

9) Mr. Julian is coughing up copious amounts of secretions. What actions would the nurse take to suction Mr. Julian's tracheostomy?

A) Turn the suction level up to 60 mm Hg prior to inserting the catheter B) Increase the oxygen flow to the client by 20% prior to suctioning C) Insert the catheter approximately 12.5 cm without applying suction D) Hyperventilate the lungs before suctioning Answer: C Explanation: A) Incorrect. This suction is not adequate. Wall suction should be turned up to 80 to 120 mm Hg. B) Incorrect. Oxygen would normally be increased to 100% pre-suctioning.

C) Correct. The nurse would insert the catheter approximately 12.5 cm for adults, less for children, without applying suction.

D) Incorrect. Hyperinflating Mr. Julian's lungs is not advised. He has copious secretions, and this practice may force the secretions deeper into his lungs.

Type: MC Learning Outcome: 43-10 10) Mr. Patterson is 73 years old and is being seen in the emergency room. He is having difficulty breathing, his respiratory rate is increased, and he is coughing up pinkish coloured frothy secretions. Considering his symptoms, what does this condition lead to initially?

A) Hypoxemia B) Hypoxia C) Apnea D) Tachypnea Answer: A Explanation: A) Correct. Mr. Patterson has pulmonary edema. It causes hypoxemia because of impaired diffusion at the alveolar-capillary level which causes reduced levels of O2 in the blood.

B) Incorrect. Hypoxia is insufficient O2 anywhere in the body. Hypoxia may be caused if the hypoxemia is severe. Hypoxemia may lead to hypoxia if the cardiovascular system is unable to compensate.

C) Incorrect. If Mr. Patterson's condition deteriorates, pulmonary edema could lead to respiratory arrest and apnea. He would show signs of hypoxemia initially.

D) Incorrect. Mr. Patterson already has tachypnea.

Type: MC Learning Outcome: 43-7

5 .

11) The nurse is preparing to assist with the removal of Mrs. Charles's chest tube. Which of the following actions following removal is appropriate considering there is no purse-string suture?

A) Apply an occlusive dressing to the site B) Leave the site open to air so the site can heal C) Provide suture material for the physician to use to close the site D) Apply a non-adherent gauze dressing Answer: A Explanation: A) Correct. Since this chest tube was put in without a purse-string suture, there is nothing to pull the tissue together once the tube is removed. In order to prevent leakage of air into the chest cavity, an occlusive dressing must be used.

B) Incorrect. The site would not be left open because this would allow air to enter into the chest.

C) Incorrect. A purse-string suture is used at times because it allows for quick closure of the opening once the tube is removed. Suturing after the tube is removed would allow air to enter the chest cavity.

D) Incorrect. The required dressing is an occlusive one that would not allow air to enter the chest after removal of the tube.

Type: MC Learning Outcome: 43-10 12) Mr. Bruce will be going home on oxygen therapy. What statement, made by Mr. Bruce, would indicate that he needs further discharge teaching instructions?

A) "I will replace my cotton blankets with wool ones."

B) "My son will not be able to smoke when I am around."

C) "I will have my electrical appliance checked for grounding."

D) "I will buy a fire extinguisher for my bedroom."

Answer: A Explanation: A) Correct. Wool blankets and fabrics tend to produce static electricity, which can cause sparks and can cause oxygen-saturated fabrics to burn more readily.

B) Incorrect. This is a hazard associated with oxygen use. Any family members in the home that smoke should do so outside or far away from where the oxygen is in use.

C) Incorrect. It is very important that electrical equipment is in good working order to prevent the occurrence of short circuit sparks.

D) Incorrect. A working fire extinguisher should be available for use in the home.

Type: MC Learning Outcome: 43-10

6 .

13) Mrs. Katerina has an endotracheal tube in place and is on a mechanical ventilator. She is restless and is pulling at the tube. How would the nurse assess if the tube is still in place?

A) Count the client's respirations B) Monitor an O2 saturation C) Auscultate for bilateral breath sounds D) Deflate the cuff and listen for air leak Answer: C Explanation: A) Incorrect. Because the client often breathes at a rate above which the ventilator is set at, counting the client's respirations will not give accurate information about where the tube is placed.

B) Incorrect. An O2 saturation will provide the nurse with information about the client's current oxygen levels, but will not provide her with any information about the placement of the tube.

C) Correct. The end of the endotracheal tube should sit in the trachea superior to the bifurcation of the bronchi. If the tube is in correct position, the nurse should be able to hear equal bilateral breath sounds.

D) Incorrect. Deflating the cuff and listening for minimal leak is a way to prevent damage to the trachea, but will not provide them with any information about the placement of the tube.

Type: MC Learning Outcome: 43-10 14) The ties on Mr. Julian's tracheostomy are very soiled. What is the safest method for changing these ties?

A) Remove the old ties, clean the area well, and then put on new ties B) Attach the new tape and tie with a square knot behind the client's neck C) Use two people, one to hold the trach, the other to change the ties D) Remove the outer cannula, replace the soiled ties, and reinsert Answer: C Explanation: A) Incorrect. Removing the ties without an assistant could allow the tracheostomy tube to become dislodged.

B) Incorrect. The knot for securing the tracheostomy tube should be tied at the side of the neck to prevent an area of pressure development.

C) Correct. The safest way to perform this intervention is to have an assistant hold the tracheostomy tube flange in place while the nurse removes the old ties and replaces them.

D) Incorrect. The outer cannula is not removed in a new tracheostomy and may place the client at risk for respiratory distress.

Type: MC Learning Outcome: 43-10

7 .

15) While suctioning Mr. Julian's tracheostomy, the nurse notes that Mr. Julian's heart rate has increased from 80 to 100 bpm. Based on this assessment, what action should the nurse take? A) Immediately discontinue suctioning B) Prepare to resuscitate the client C) Continue to suction until the airway is clear D) Complete the suctioning as quickly as possible Answer: D Explanation: A) Incorrect. There is no need to immediately discontinue suctioning. It would be advised to allow at least 2-3 minutes before repeating suctioning to allow him to recover. B) Incorrect. Mr. Julian does not need to be resuscitated. An increase to a heart rate to 100 is showing that the client is stressed by the suctioning but if the suctioning is completed quickly, his heart rate should return to its normal rate within minutes. C) Incorrect. He will likely not tolerate continuing the suctioning until the airway is clear. The nurse should allow Mr. Julian to rest and reassess whether a second episode of suctioning is indicated. D) Correct. An increase in heart rate from 80 to 100 is not an unusual finding during suctioning, but does indicate increased stress on Mr. Julian. The nurse should complete the suctioning as quickly as possible. Type: MC Learning Outcome: 43-10 16) Mrs. Headly, who is being mechanically ventilated, has copious amounts of secretions ranging from thick and tenacious to frothy. What should the nurse do in preparation for suctioning Mrs. Headly?

A) Hyperventilate Mrs. Headly pre-suctioning B) Increase oxygen delivery to 60-80% C) Instill normal saline into the endotracheal tube before suctioning D) Avoid hyperventilation before suctioning Answer: D Explanation: A) Incorrect. Mrs. Headly should not be hyperventilated because of the amount of her secretions. Hyperventilating may force these secretions further into the respiratory tract.

B) Incorrect. Oxygen should be increased to 100%.

C) a Incorrect. Instillation of saline is no longer a recommended practice as it is shown to have negative effect on oxygenation and dyspnea.

D) for Correct. The nurse should avoid hyperventilation and should increase the oxygen to 100% several breaths prior to initiating suction. Hyperventilating Mrs. Headly will likely serve to force secretions back into the respiratory tract.

Type: MC Learning Outcome: 43-10

8 .

17) As a part of preoperative teaching, the nurse is instructing Mr. Zuk on the use of a volumeoriented incentive spirometer. Which instruction should be included in this teaching?

A) Tilt the device slightly toward yourself while using B) Take a deep breath and cough several times before using the incentive spirometer C) Inhale a slow, deep breath to elevate the ball in the cylinder and hold for 2 seconds D) Blow out into the mouthpiece until the ball in the cylinder rises and hold it for 2 seconds Answer: C Explanation: A) Incorrect. The device should be kept level during its use.

B) Incorrect. Mr. Zuk should use the device first, which will help to open up airways, and then cough.

C) Correct. The volume-oriented incentive spirometer works best when the patient inhales slowly and deeply to raise the ball in the enclosed cylinder. Mr. Zuk should try to hold it there for 2 seconds initially, increasing to 6 seconds to keep the ball elevated.

D) Incorrect. Blowing into the device will not achieve the effects of deep breathing, opening the airways in the lungs that are at risk of deflating after general anaesthesia.

Type: MC Learning Outcome: 43-10 18) Mrs. Lois has a nursing diagnosis of ineffective airway clearance related to inadequate chest expansion and poor cough effort related to pain secondary to trauma. What is an appropriate nursing order to help her achieve the outcome of a patent airway?

A) Provide uninterrupted periods of sleep B) Teach the rationale for her clear fluid diet C) Assess for cyanosis and clubbing of the fingers D) Encourage and assist with frequent position changes Answer: D Explanation: A) Incorrect. Uninterrupted periods of sleep are necessary for healing to take place, but will not necessarily contribute to a patent airway.

B) Incorrect. A clear liquid diet is not part of a treatment plan for ineffective airway clearance and would not promote the achievement of a patent airway.

C) Incorrect. Cyanosis is a late sign of an airway problems and clubbing takes an extended period (months to years) to occur. Measures taken at this time are intended to prevent further respiratory complications.

D) Correct. Frequent position changes will promote taking bigger breaths. This will result in moving more secretions than she would if she were lying still.

Type: MC Learning Outcome: 43-9

9 .

19) Mrs. Lois has a nursing diagnosis of ineffective airway clearance related to inadequate chest expansion and poor cough effort related to pain secondary to trauma. One of her outcomes is a patent airway. How would the nurse determine whether Mrs. Lois has met this outcome?

A) Auscultate her lungs B) Assess her oxygen saturations C) Measure her vital capacity D) Measure her tidal volume Answer: A Explanation: A) Correct. Auscultating Mrs. Lois's lungs will inform the nurse of the movement of air in the lungs and any secretions or bronchoconstriction present.

B) Incorrect. Assessing her saturations will only provide information about oxygen delivery.

While someone with a poor cough effort may have low saturations, this information would not be the most accurate in determining whether her airway is free from secretions.

C) Incorrect. Measuring her vital capacity will only provide information about how much air is exhaled after maximal inspiration. It will not provide data about whether Mrs. Lois's airway is clear.

D) Incorrect. Mrs. Lois's tidal volume will provide information on her ability to move air in and out of her lungs, not whether her chest is clear.

Type: MC Learning Outcome: 43-12 20) Which diagnostic test measures the normal volume of air inspired and expired with each breath?

A) Tidal volume B) Vital capacity C) Total lung capacity D) Inspiratory reserve volume Answer: A Explanation: A) Correct. Tidal volume is the normal volume of air inspired and expired with each breath.

B) Incorrect. Vital capacity is the total volume of air that can be exhaled after a maximal inspiration.

C) Incorrect. The total lung capacity is the total volume of the lungs at maximum inflation.

D) Incorrect. Inspiratory reserve volume is the maximum amount of air that can be inhaled over and above a normal breath.

Type: MC Learning Outcome: 43-2

10 .

21) Mrs. Kafi has just delivered a premature infant at 33 weeks gestation. After careful examination, it is determined that his only complication is respiratory distress syndrome (RDS).

What does the nurse tell Mrs. Kafi is the reason why her infant son requires mechanical ventilation?

A) His alveolar walls are too thin for adequate air exchange.

B) He cannot produce an adequate supply of a protein necessary for lung expansion.

C) He has limited blood supply to his lungs due to constricted blood vessels.

D) He has a condition known as bronchopulmonary dysplasia (BPD).

Answer: B Explanation: A) Incorrect. Alveolar walls are usually thin with good blood supply to allow air exchange to take place. A premature infant's alveolar walls are usually thick and have poor circulation.

B) Correct. Premature lungs cannot produce an adequate supply of surfactant which is necessary for normal expansion of the lungs.

C) Incorrect. This is true of fetal circulation and is usually not evident after birth.

D) Incorrect. A child is not born with BPD. It is something that develops as a consequence of prematurity and progressive lung inflammation from mechanical ventilation.

Type: MC Learning Outcome: 43-3 22) Normal breathing is dependant on which of the following factors?

A) Positive intrapleural pressure B) Negative intrapleural pressure C) Absence of intrapulmonic pressure D) Equal intrapleural and intrapulmonic pressures Answer: B Explanation: A) Incorrect. The intrapleural pressure (the pressure in the pleural cavity surrounding the lungs) is always slightly negative, not positive.

B) Correct. The intrapleural pressure is always slightly negative in relation to atmospheric pressure. This negative pressure is essential because it creates the suction that holds the two pleural layers together as the chest cage expands and contracts.

C) Incorrect. Intrapulmonic pressure (pressure within the lungs) equalizes with atmospheric pressure. If there were no pressure, air would not be able to move in and out of the lungs.

D) Incorrect. The intrapleural and intrapulmonic pressures need to be different in order for ventilation to occur.

Type: MC Learning Outcome: 43-2

11 .

23) Priscilla is a 1-day-old infant born at 36 weeks gestation. She is in the neonatal intensive care unit for monitoring. Which of the following would be considered a normal finding?

A) Irregularly irregular heart rate of 200 B) Irregular heart rate increasing and decreasing with each breath C) Regular heart rate of 70 to 120 beats per minute D) Heart rate of 60 to 100 beats per minute Answer: B Explanation: A) Incorrect. An irregularly irregular heart rate would be consistent with atrial fibrillation and would not be considered a normal finding.

B) Correct. A newborn can have an irregular heart rate that increases and decreases with breathing. This is called sinus arrhythmia and is considered a normal finding.

C) Incorrect. A heart rate of 80-200 is considered within normal range for a newborn.

D) Incorrect. A heart rate range of 60-100 would be considered low for a newborn.

Type: MC Learning Outcome: 43-3 24) Mr. Grant has a 20-year history of chronic obstructive lung disease. What changes in Mr. Grant may be indicative of chronic hypoxemia?

A) Bradycardia B) Shortening of the nail beds C) Fatigue and lethargy D) Peripheral edema Answer: C Explanation: A) Incorrect. Bradycardia would not be a sign of chronic hypoxemia; tachycardia may be a compensatory mechanism that would be evident.

B) Incorrect. Shortening of the nail beds does not occur. The base of the nail becomes swollen and the ends of the fingers increase in size. This is a condition known as clubbing.

C) Correct. Fatigue and lethargy is a result of chronically reduced levels of oxygen to the body, specifically in this case, to the brain.

D) Incorrect. This would be a sign of heart failure not chronic hypoxemia.

Type: MC Learning Outcome: 43-4

12 .

25) Mrs. Patrick brings her husband into the clinic with respiratory difficulties. Which of the following findings indicate a partial upper airway obstruction?

A) Hyperventilation B) Hypoventilation C) Oxygen saturation of 92% on room air D) Low-pitched snoring sound during inhalation Answer: D Explanation: A) Incorrect. Hyperventilation is an increased movement of air into and out of the lungs and would not in itself indicate an upper airway obstruction.

B) Incorrect. Hypoventilation is inadequate alveolar ventilation, and it may eventually occur in someone that has an upper airway obstruction.

C) Incorrect. While it would be important to monitor oxygen saturation, it would not give the nurse the evidence to support a partial obstruction. Assessing the chest sounds will confirm the obstruction.

D) Correct. A low-pitched snoring sound during inhalation is an indication of partial obstruction of the upper airway.

Type: MC Learning Outcome: 43-6 26) Mr. Gunstensen is to have a sputum specimen collected for acid-fast bacillus. How would the nurse go about collecting this specimen?

A) Early evening weekly for 3 weeks B) Early evening specimen daily for 3 days C) Early morning specimen daily for 3 days D) Immediately after a warm drink times three specimens Answer: C Explanation: A) Incorrect. Morning is the ideal time to collect a sputum specimen. Normally they are collected for 3 consecutive days, not weeks.

B) Incorrect. Early evening will not produce an adequate specimen; the nurse should wait till the morning after the sputum has accumulated.

C) Correct. Sputum specimens are collected in the morning because the person can cough up the secretions that have accumulated during the night. AFB specimens are usually collected for 3 days in a row.

D) Incorrect. The morning is the best time to get an adequate specimen because the sputum will have accumulated overnight. Drinking a warm drink will not ensure the ability to produce adequate sputum.

Type: MC Learning Outcome: 43-8

13 .

27) Mr. Van Denamstel is suspected of having arterial vascular disease. He is in the clinic to have an ankle-brachial index (ABI) done. What is the first information the nurse is required to collect? A) Take blood pressure in both arms B) Take brachial pulse and the post tibial pulse C) Take systolic pressure using dorsalis pedis D) Take brachial pulse and dorsalis pedis Answer: A Explanation: A) Correct. An ankle-brachial index requires taking blood pressure in both arms, and then comparing the higher of the two pressures to the higher of the systolic dorsalis pedis or posterior tib. The index is calculated by dividing the higher of the dorsalis pedis/posterior tib by the higher of the brachial systolic pressures. A normal ankle-brachial index is between 0.91-1.3 and indicates the absence of arterial disease. B) Incorrect. An ABI is determined by comparing systolic blood pressures in the arms and legs. Taking pulses would not give the required information to determine an ABI. C) Incorrect. Taking a dorsalis pedis pulse would not provide complete information to determine an ABI. D) Incorrect. An ABI is determined by comparing systolic blood pressures in the arms and legs. Taking pulses would not give the required information to determine an ABI. Type: MC Learning Outcome: 43-8 28) What is the reason why American Heart Association has advocated a C-A-B approach to cardiopulmonary resuscitation instead of the longstanding A-B-C? A) Airway is easier to maintain open after compressions B) Compressions are more effective without airway or respirations C) Reduces time to first compressions D) Allows for more accurate landmarking for compressions Answer: C Explanation: A) Incorrect. An airway is not easier to maintain after compressions are started.

B) Incorrect. Compressions first have been shown to improve outcomes in some adult victims; maintaining an airway and respirations are still important to improve overall survival rates.

C) Correct. The highest survival rates in adult-onset cardiac arrest occur in witnessed arrests and have has a rhythm of either pulseless ventricular tachycardia or ventricular fibrillation. Research determined that early compressions and defibrillation have contributed to this group having higher survival rates.

D) Incorrect. This is not a benefit of C-A-B. One of the barriers for A-B-C is a delay of initiating CPR while the responder retrieves a barrier device. C-A-B provides victims with immediate compressions which have been shown in witnessed arrests to improve outcomes.

Type: MC Learning Outcome: 43-11

14 .

Fundamentals of Canadian Nursing, 4e (Kozier) Chapter 44 Fluid, Electrolyte, and AcidBase Balance 1) Mr. Isaac is a 24-year-old client who has had vomiting and diarrhea for 4 days due to a viral infection. The nurse is assessing his acid-base balance. Which statement correctly reflects the attempt by Mr. Isaac's body to restore acid-base balance? A) Respiratory regulation is slow, but very efficient. B) Primary regulation is through GI system losses. C) Kidney regulation is powerfully effective. D) Cardiovascular system is the major buffer. Answer: C Explanation: A) Incorrect. The opposite is true. The respiratory system is the first to respond to alterations in the acid-base system. It is quick, but temporary. B) Incorrect. Acid-base is not regulated through the GI system. C) Correct. The major buffering systems are the respiratory system and the renal system. Both systems are actively involved in maintaining the narrow pH range necessary for optimal function. Respiratory regulation is rapid, but temporary. Renal regulation is slower, but powerfully effective. D) Incorrect. The cardiovascular system is not one of the body's buffering systems. Type: MC Learning Outcome: 44-2 2) Mr. Isaac, a 24-year-old client, has had vomiting and diarrhea for 4 days due to a viral infection. The nurse is assessing Mr. Isaac's acid-base balance. When blood levels of carbonic acid and carbon dioxide rise, how does the respiratory system respond? A) The rate and depth of respirations increase and carbon dioxide is exhaled. B) The rate and depth of respirations decrease and carbon dioxide is exhaled. C) The rate and depth of respirations increase and carbon dioxide is retained. D) The rate and depth of respirations decrease and carbon dioxide is retained. Answer: A Explanation: A) Correct. When blood levels of carbonic acid and carbon dioxide rise, the rate and depth of respirations increase, allowing carbon dioxide to be exhaled, causing carbonic acid levels to fall. B) Incorrect.

When rate and depth of respirations decrease, less carbon dioxide would be exhaled, leading to a decrease in pH. C) Incorrect. Carbon dioxide is not retained when the rate and depth of respirations is increased. D) Incorrect. A decrease in the rate and depth of respirations and carbon dioxide retention would not be desirable if a patient already had elevated carbon dioxide levels. Type: MC Learning Outcome: 44-2

1 .

3) Mr. Isaac, a 24-year-old client, has had vomiting and diarrhea for 4 days due to a viral infection. Which electrolyte imbalance is the nurse most likely to see as a result of Mr. Isaac's vomiting and diarrhea?

A) Hypocalcemia B) Hypophosphatemia C) Hypermagnesemia D) Hypokalemia Answer: D Explanation: A) Incorrect. Risk factors for hypocalcemia are parathyroid removal, hypoparathyroid, acute pancreatitis, hyperphosphatemia, thyroid carcinoma, malabsorption, hypomagnesemia, alkalosis, sepsis, and alcohol abuse.

B) Incorrect. Risk factors for hypophosphatemia include alcohol withdrawal, and the use of antacids that bind with phosphates.

C) Incorrect. Hypermagnesium risk factors include abnormal retention of magnesium, as in renal failure and adrenal insufficiency, and treatment with magnesium salts.

D) Correct. The electrolyte imbalance that the nurse is most likely to see as a result of Mr. Isaac's vomiting and diarrhea is hypokalemia. Vomiting, gastric suction, diarrhea, and heavy perspiration are risk factors for low potassium levels.

Type: MC Learning Outcome: 44-4 4) Mr. Isaac, a 24-year-old client, has had vomiting and diarrhea for 4 days due to a viral infection. The nurse is assessing Mr. Isaac's fluid balance. What physical assessment criteria would support a nursing diagnosis of fluid volume deficit?

A) Distended neck veins B) Full bounding pulse C) Increased blood pressure D) Dry mucous membranes Answer: D Explanation: A) Incorrect. Distended neck veins may be indicative of fluid volume overload.

B) Incorrect. A weak pulse, not a bounding one, would be indicative of fluid volume deficit.

C) Incorrect. An increase in blood pressure may be indicative of fluid volume overload.

D) Correct. Dry mucous membranes would be one of the signs to support the nursing diagnosis of fluid volume deficit. Other signs may include decreased salivation, weak pulse, and a decrease in blood pressure.

Type: MC Learning Outcome: 44-6

2 .

5) The nurse is caring for Mrs. Lyall, a 30-year-old engineer, who is 3 days post-operative.

Which intervention should the nurse implement to decrease Mrs. Lyall's possibility of developing hypercalcemia?

A) Measure vital signs every 4 hours B) Ambulate Mrs. Lyall at least three times daily C) Irrigate her nasogastric tube every 2 hours D) Assist the client to turn, cough, and deep breathe every 2 hours Answer: B Explanation: A) Incorrect. Checking Mrs. Lyall's vital signs will not prevent hypercalcemia from taking place.

B) Correct. Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum.

C) Incorrect. Irrigating her nasogastric tube will have no effect on developing hypercalcemia.

D) Incorrect. These actions will help to prevent atelectasis and pneumonia, but will not prevent hypercalcemia.

Type: MC Learning Outcome: 44-4 6) Mrs. Lyall asks why it has been necessary to measure her urine each time she voids. Which response about urine output should the nurse make?

A) Output should be lower than her fluid intake.

B) Output should be higher than her fluid intake.

C) Output should be approximately the same as her fluid intake.

D) Output over 24 hours will determine a urinary tract infection.

Answer: C Explanation: A) Incorrect. Urinary output that is lower than intake may lead to fluid volume excess.

B) Incorrect. Urinary output that is higher than intake could lead to dehydration.

C) Correct. Urinary output in a well or healthy state should be approximately the same as the fluid intake.

D) Incorrect. Urinary output itself is not an indication of a UTI, although the characteristics of the urine voided and the voiding pattern may indicate the presence of an infection.

Type: MC Learning Outcome: 44-1

3 .

7) Mr. Abraham is in the emergency room in renal failure. His potassium is 6.0 mmol/L. Which of the following nursing interventions is a priority?

A) Place patient on an electrocardiograph monitor (ECG) B) Prepare patient for renal dialysis C) Encourage foods rich in potassium D) Measure and strain all urine Answer: A Explanation: A) Correct. The nursing priority for Mr. Abraham is to monitor closely his cardiac status. His potassium is very high and if left untreated may lead to cardiac arrest.

B) Incorrect. While this option may be a treatment necessary for Mr. Abraham, it is not as much a priority as placing him on an ECG monitor so that his cardiac status can be monitored closely.

C) Incorrect. Mr. Abraham's potassium is high; foods rich in potassium would be contraindicated.

D) Incorrect. Monitoring any urine output would be included in his care plan but is not the immediate priority.

Type: MC Learning Outcome: 44-4 8) The mother of 1-month-old Kelsey calls the nurse who works in the health clinic. The mother is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infant's mother?

A) Bring the infant to the clinic for evaluation B) Give the infant at least 2 ounces of juice every 2 hours C) Measure the infant's urine output for 24 hours D) Provide the infant with 50 mL of glucose water Answer: A Explanation: A) Correct. Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group.

B) Incorrect. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status. In the early stages of vomiting an electrolyte replacement like Pedialyte may be appropriate, but juice and glucose drinks would not be the appropriate choice.

C) Incorrect. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated. This is an urgent situation considering the infant has already had the vomiting and diarrhea for 2 days.

D) Incorrect. This is an urgent situation that requires the infant be evaluated immediately. Simply trying to provide an infant who is vomiting with fluids delays treatment and promotes more rapid dehydration.

Type: MC Learning Outcome: 44-4

4 .

9) Kelsey, a 1-month-old infant, was hospitalized with a gastroenteritis. She weighs 6.4 kg.

Before discharging her home with her mother, what would the nurse advise is the minimum daily fluid intake for Kelsey?

A) 1640 mL/day B) 640 mL/day C) 1320 mL/day D) 130 mL/day Answer: B Explanation: A) Incorrect. Minimum daily fluid intake is determined by multiplying the infant's body weight by 100 mL. B) Correct. Minimum daily fluid intake for infants weighing between 1-10 kg is 100 mL/kg of body weight. 6.4 kg × 100 mL = 640 mL/day C) Incorrect. The formula for infants greater than 10 kg is: 1000 mL + 50 mL/kg of body weight.

Kelsey is only 6.4 kg, so this would not be the correct formula to use for her.

D) Incorrect. This would not be an adequate fluid intake according to Kelsey's weight.

Type: MC Learning Outcome: 44-3 10) Mrs. Belker has just had a subclavian central venous catheter inserted. Which of the following signs may indicate complications from the placement?

A) Presence of bibasilar crackles B) Sudden onset of shortness of breath C) Bradycardia D) Severe temporal headache Answer: B Explanation: A) Incorrect. Bibasilar crackles may develop secondary to fluid overload or to the disease process, but would not be particularly evident just after placement of the subclavian catheter.

B) Correct. Insertion of a subclavian central venous catheter may result in a pneumothorax, causing sudden onset of shortness of breath. Tachycardia, chest pain, cough, and hypotension are other signs she may exhibit.

C) Incorrect. Bradycardia is not indicative of complications; tachycardia might be though.

D) Incorrect. A sudden onset of a headache would not be a sign indicative of complications related to the insertion of a subclavian line.

Type: MC Learning Outcome: 44-5

5 .

11) A nurse is caring for Mr. Hammitz who is receiving intravenous fluids that are not regulated on an electronic controller. Where should the nurse look for the number of drops per millilitre of fluid the tubing delivers?

A) On the tubing package B) The documentation when the infusion started C) In the drug monograph D) On the roller clamp of the tubing Answer: A Explanation: A) Correct. The drop factor (number of drops per millilitre of fluid) of tubing is located on the tubing packaging.

B) Incorrect. The drop factor would not be in the documentation.

C) Incorrect. Drug monographs would include information on how a drug should be administered, and who can administer them. The drop factor would not be included.

D) Incorrect. The roller clamp does not indicate drop factors.

Type: MC Learning Outcome: 44-8 12) The physician has ordered that Mr. Hammitz receive 50 mL of an IV solution to infuse over 20 minutes. In order to accurately infuse this solution, the electronic controller should be set to deliver how many mL/hr?

A) 50 mL/hr B) 100 mL/hr C) 150 mL/hr D) 200 mL/hr Answer: C Explanation: A) Incorrect. This rate on the electronic controller would deliver the volume of fluid in one hour, not 20 minutes.

B) Incorrect. This rate on the electronic controller would deliver the volume in 30 minutes, not 20 minutes.

C) Correct. This is the correct rate. 150 mL/hr = 50 mL/20 minutes.

D) Incorrect. This rate would deliver the volume of fluid in 15 minutes, not 20.

Type: MC Learning Outcome: 44-8

6 .

13) The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes to Chelsey who is 3 years old. The tubing has a drop factor of 20. How many drops per minute should the nurse set the controller to deliver? A) 25 drops per minute B) 50 drops per minute C) 75 drops per minute D) 100 drops per minute Answer: B Explanation: A) Incorrect. 25 drops per minute would infuse the volume in 60 minutes. B) Correct. Total infusion volume × drop factor / minutes to infuse. 75 mL × 20 drops/30 minutes = 50 drops per minute. C) Incorrect. 75 drops per minute would infuse the volume too quickly. D) Incorrect. 100 drops per minute would infuse the volume in 15 minutes. Type: MC Learning Outcome: 44-8 14) The nurse is caring for Kimberly, a 3-month-old infant, who is receiving IV therapy at a rate of 10 mL/hour. The 500-mL IV bag was hung at 9 AM Monday morning when the IV catheter was initiated. It is now 9 AM on Tuesday morning. What nursing action should be taken?

A) Change the bag and tubing B) Infuse the remaining IV fluid before hanging a new bag C) Discard the remaining IV fluid and hang a new bag D) Discontinue the IV site and restart an IV in the opposite hand Answer: C Explanation: A) Incorrect. It is not necessary after only 24 hours to change the IV tubing.

B) Incorrect. The remaining IV fluid should be discarded, not infused and a new bag hung.

C) Correct. The remaining IV fluid should be discarded and a new bag hung. IV fluid should be changed every 24 hours, regardless of how much solution remains. This helps to minimize the risk of contamination.

D) willIncorrect. It is not necessary to start a new site; simply changing the bag every 24 hours reduce the risk of contamination and possible complications.

Type: MC Learning Outcome: 44-8

7 .

15) Mr. Armando has just been started on a diuretic that is potassium wasting. Which of the following foods would the nurse encourage Mr. Armando to include in his diet?

A) Bananas and oranges B) Lentils and peanuts C) Dairy products D) Apples and grapes Answer: A Explanation: A) Correct. Foods rich in potassium include oranges, bananas, and green leafy vegetables. A diuretic that is potassium wasting will cause the client to lose potassium daily.

Including sources rich in potassium in his diet is one way that this loss can be replaced.

B) Incorrect. Nuts and legumes are not foods rich in potassium.

C) Incorrect. Dairy products are not a rich source of potassium.

D) Incorrect. Apples and grapes are not a rich source of potassium.

Type: MC Learning Outcome: 44-7 16) Skye, a 16-year-old high school student, is brought to the emergency department after passing out in a local department store. Skye reports dieting by fasting for the last 5 days. Which acid-base imbalance would Skye be at risk for?

A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic acidosis D) Metabolic alkalosis Answer: C Explanation: A) Incorrect. Skye's fasting would not place her at risk for respiratory acidosis.

B) Incorrect. Skye's fasting would not place her at risk for respiratory alkalosis C) Correct. A person who is fasting is at risk for development of metabolic acidosis. Metabolic acidosis develops during starvation by the breakdown of fats for energy which produces ketones.

D) Incorrect. Skye's fasting would not place her at risk for metabolic alkalosis.

Type: MC Learning Outcome: 44-3

8 .

17) Mr. Isaac, a 24-year-old client, has had vomiting and diarrhea for 4 days due to a viral infection. Which arterial blood gas results would the nurse expect to find in this client?

A) pH 7.30; PaCO2 50; HCO3 27 B) pH 7.47; PaCO2 43; HCO3 28 C) pH 7.43; PaCO2 50; HCO3 28 D) pH 7.47; PaCO2 30; HCO3 23 Answer: B Explanation: A) Incorrect. These results indicate a respiratory acidosis with partial compensation. B) Correct. The nurse would expect that this client is alkalotic because stomach acids have been lost. In metabolic alkalosis the pH would be above 7.45, the HCO3 would be high (above 26), and the PaCO2 is normal indicating no compensation.

C) Incorrect. These results indicate respiratory acidosis with full compensation.

D) Incorrect. These results would indicate respiratory alkalosis.

Type: MC Learning Outcome: 44-3 18) Ms. Ellsmere, 23, is in the emergency room after an opiate overdose. What are expected blood gas results?

A) pH 7.30; PaCO2 54; HCO3 24 B) pH 7.47; PaCO2 43; HCO3 28 C) pH 7.30; PaCO2 43; HCO3 18 D) pH 7.50; PaCO2 32; HCO3 24 Answer: A Explanation: A) Correct. Since opiates act to decrease or suppress respirations, Ms. Ellsmere will retain carbon dioxide and levels of H2CO3 will increase. The expected acid-base imbalance would be respiratory acidosis.

B) Incorrect. These results reflect metabolic alkalosis, which would be present in clients with gastric suction.

C) Incorrect. These results reflect metabolic acidosis, which may be evident in clients with diabetes or renal impairment.

D) Incorrect. These results would reflect respiratory alkalosis, which may be evident in clients with hypoxia or extreme anxiety.

Type: MC Learning Outcome: 44-3

9 .

19) Ten minutes after the transfusion of a unit of packed red blood cells was initiated, Mr. Ericson complained of a headache. The nurse assesses that Mr. Ericson has slight shortness of breath and feels warm to the touch. What action by the nurse is the priority?

A) Notify the physician B) Discontinue the transfusion C) Slow the rate of the transfusion D) Prepare to resuscitate the client Answer: B Explanation: A) Incorrect. The nurse would contact the physician, but this action should be after the transfusion is discontinued.

B) Correct. The priority intervention is to discontinue the transfusion. If Mr. Ericson is having a transfusion reaction, it is best to limit the amount of blood transfused.

C) Incorrect. Slowing the rate of the transfusion allows additional blood to be infused.

D) Incorrect. At this point, there is no need to prepare for resuscitation.

Type: MC Learning Outcome: 44-8 20) Mr. Lee complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse?

A) Call the physician for direction B) Place a cool pack over the IV site and vein C) Discontinue the IV and place a warm pack on the area D) Slow the IV infusion and reassess the area in 15 minutes Answer: C Explanation: A) Incorrect. This assessment and evaluation are within the scope of nursing practice; at this point, collaboration with the physician is not necessary.

B) Incorrect. A cool pack over the IV site will not prevent additional damage to the vein.

C) Correct. This assessment likely indicates the beginning of phlebitis. The nurse should discontinue the IV and place a warm pack on the area.

D) Incorrect. Slowing the IV will not prevent further damage to the vein and will also alter the amount of IV fluid and medication the client is receiving.

Type: MC Learning Outcome: 44-8

10 .

21) Mrs. Charlson has an IV with an intermittent infusion lock in place for twice daily antibiotic infusions. She is requesting a shower. What action should be taken by the nurse?

A) Discontinue the lock B) Cover the lock with an occlusive dressing C) Place a piece of cloth tape under the lock, wrapping the top in a U shape D) Encourage a bed bath until the IV is discontinued Answer: B Explanation: A) Incorrect. Discontinuing the lock is not appropriate if the client still requires intermittent IV medications.

B) Correct. The client can shower if the lock is covered with an occlusive dressing.

C) Incorrect. The dressing over the IV must be kept dry, and the use of cloth tape will not keep the site dry.

D) Incorrect. A bed bath is not necessary as long as the site is covered and remains dry.

Type: MC Learning Outcome: 44-8 22) The nurse is collecting equipment to administer a unit of packed red blood cells to Mr. Ericson. Which IV fluid should be used to initiate the IV for this transfusion?

A) 1000 mL of lactated Ringer's solution B) 250 mL of normal saline C) 500 mL of 5% dextrose and water D) 100 mL of 5% dextrose and 1/2 normal saline Answer: B Explanation: A) Incorrect. Blood and blood products should only be administered with normal saline. Dextrose, lactated Ringer's, or combinations of saline with dextrose may cause damage to the blood cells.

B) Correct. Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered.

C) Incorrect. Blood and blood products should only be administered with normal saline.

Dextrose, lactated Ringer's, or combinations of saline with dextrose may cause damage to the blood cells.

D) Incorrect. Blood and blood products should only be administered with normal saline.

Dextrose, lactated Ringer's, or combinations of saline with dextrose may cause damage to the blood cells.

Type: MC Learning Outcome: 44-8

11 .

23) The nurse has obtained a unit of packed red blood cells from the laboratory blood bank to administer to Mr. Ericson. Upon returning to Mr. Ericson's room, the nurse discovers that he has been taken for an emergency CT scan and is expected to be gone from the unit for approximately 45 minutes. What action should the nurse take?

A) Place the blood in the unit refrigerator until Mr. Ericson returns B) Return the blood to the laboratory blood bank until Mr. Ericson returns C) Set up the blood with the IV fluid and y-tubing in his room and initiate immediately after the client returns D) Set up the blood with the IV fluid and y-tubing and place it in the unit medication room until he returns Answer: B Explanation: A) Incorrect. The unit refrigerator is not climate controlled for blood storage.

B) Correct. Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated.

C) Incorrect. Setting up the blood either in the client's room or in the medication room is wrong on two counts. First, for safety reasons, the blood would not be set up before completing all ABO, patient, and product identifiers. Second, blood needs to be kept chilled until it is transfused. The nurse does not have any idea at this time how long Mr. Ericson will be off the unit.

D) Incorrect. Setting up the blood either in the client's room or in the medication room is wrong on two counts. First, for safety reasons, the blood would not be set up before completing all ABO, patient, and product identifers. Second, blood needs to be kept chilled until it is transfused.

The nurse does not have any idea at this time how long Mr. Ericson will be off the unit.

Type: MC Learning Outcome: 44-8 24) The nurse has initiated Mr. Ericson's blood transfusion. Which action is now a priority?

A) Assign an appropriate health care provider to sit with Mr. Ericson for 15 minutes B) Return to the room and take a set of vital signs in 15 minutes C) Stay with Mr. Ericson and closely observe him for the first 5 to 15 minutes of the transfusion D) Advise Mr. Ericson to notify the nurse if he experiences any chilling, nausea, or rapid heart rate Answer: C Explanation: A) Incorrect. The nurse cannot delegate this assessment to another health care provider.

B) Incorrect. While it is true that vital signs should be checked in 15 minutes, by not monitoring him in that time, a reaction may already be underway.

C) Correct. The nurse should stay with Mr. Ericson and closely observe him for the first 5 to 15 minutes of the transfusion. The earlier a transfusion reaction occurs, the more severe it tends to be. Identifying such reactions early may minimize the consequences.

D) Incorrect. These instructions would be given to Mr. Ericson after the nurse completes the first 10-minute assessment.

Type: MC Learning Outcome: 44-8

12 .

25) Mrs. Ami has been placed on a 1200 mL oral fluid restriction. How should the nurse plan for this restriction?

A) Offer Mrs. Ami softer, cold foods such as sherbet and custard B) Remove fluids from diet trays and offer them only between meals C) Plan for 600 mL from 7-3, 400 mL from 3-11, and 200 mL from 11-7 D) Place 1200 mL of fluid at her bedside every 24 hours Answer: C Explanation: A) Incorrect. Sherbet and custard are counted as liquids and should be avoided.

B) Incorrect. Mrs. Ami should be given a choice regarding consumption of fluids at mealtime.

C) Correct. The amount of fluid allowed should be divided between the three major time-frames of the day (7-3, 3-11, 11-7). This helps by taking into consideration meals and medication administration times.

D) Incorrect. Mrs. Ami should be given a choice regarding types of fluid consumed and when to consume them.

Type: MC Learning Outcome: 44-7 26) Mrs. Hislop, 80 years old, has a diagnosis of heart failure. She has pitting edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client?

A) Heart failure related to edema, as evidenced by confusion B) Fluid volume deficit related to loss of fluids as evidenced by edema C) Excess fluid volume related to retention of fluids as evidenced by edema and orthopnea D) Hyperosmolar fluid imbalance related to congestive heart failure as evidenced by edema and confusion Answer: C Explanation: A) Incorrect. Heart failure is a medical diagnosis, not a nursing diagnosis.

B) Incorrect. Fluid volume deficit is not associated with heart failure; she is exhibiting signs of fluid volume overload.

C) Correct. Edema and orthopnea are assessment findings associated with excess fluid volume.

D) Incorrect. Hyperosmolar fluid imbalance occurs when water is lost from the body, and is not congruent with the signs Mrs. Hislop is experiencing.

Type: MC Learning Outcome: 44-6

13 .

27) The nurse is caring for Mr. Richards, who presented to the emergency department with fever, chills, nausea, and loss of appetite. How would the nurse test Mr. Richards for orthostatic hypotension?

A) Raise his legs above heart level and measure his blood pressure B) Measure his blood pressure in both the sitting and standing position C) Measure his blood pressure before and after a normal saline fluid challenge D) Assess him for dependent edema and then reassess while supine Answer: B Explanation: A) Incorrect. This not the correct way of assessing for orthostatic hypotension.

B) Correct. The nurse should measure the client's blood pressure and heart rate in the sitting position and then again in the standing position. The presence of orthostatic hypotension may be a sign of fluid volume deficit.

C) Incorrect. Normal saline challenges are often administered to clients who are dehydrated, but they are not part of assessment of orthostatic hypotension.

D) Incorrect. Assessing for orthostatic hypotension does not involve checking for the presence of edema.

Type: MC Learning Outcome: 44-5 28) The nurse is caring for Mrs. Emmet, an elderly patient, who has been receiving intravenous fluids at 175 mL/hr. The nurse assesses that Mrs. Emmet has crackles, shortness of breath, and distended neck veins. The nurse would recognize these findings as which complication of IV fluid therapy?

A) Third space syndrome B) Fluid volume excess C) Pulmonary embolism D) Allergic reaction to the antibiotics Answer: B Explanation: A) Incorrect. Third space syndrome occurs when fluid from circulating volume shifts into areas where it is not accessible (like the bowel or interstitial spaces). There is no evidence this has occurred to Mrs. Emmet.

B) Correct. Fluid volume excess may occur if clients, especially the very young or elderly, receive IV fluid rapidly. Solution administered too quickly can cause a significant increase in circulating volume.

C) Incorrect. Her signs do not support a diagnosis of pulmonary embolus.

D) Incorrect. There is no mention in the scenario of antibiotic infusion.

Type: MC Learning Outcome: 44-9

14 .

29) Mr. Singh has been admitted to hospital after a work explosion left him with third degree burns to 30% of his body. Considering his fluid loss, which of the following solutions may be considered for administration to him?

A) Albumin B) Autologous transfusion C) Dextrose and water D) Fresh frozen plasma Answer: A Explanation: A) Correct. Mr. Singh has lost large volumes of fluids to the burn sites. Albumin is a volume expander and a protein that would be considered for infusion.

B) Incorrect. An autologous transfusion is used when blood is collected from a client weeks prior to surgery to use for blood replacement in the client's scheduled surgery.

C) Incorrect. Dextrose and water become hypotonic in plasma, therefore expanding extracellular fluid volume.

D) Incorrect. Fresh frozen plasma is administered for administration of clotting factors.

Type: MC Learning Outcome: 44-8

15 .

Fundamentals of Canadian Nursing, 4e(Kozier) Chapter 45 Sexuality 1) During discussion of family, the client speaks about an adult son who is a homosexual. The client expresses concern about his son, stating: "I am so worried about him. I know he is going to hell." What is the most important fact for the nurse to consider in formulating a response to this client's concern?

A) Normal sexuality is described as whatever behaviours give pleasure and satisfaction to those adults involved.

B) Since alternative lifestyles are now so well accepted in society, this parent should not feel so much concern.

C) What constitutes normal sexual expression varies among cultures and religions.

D) Sexual development is genetically determined and not affected by environment.

Answer: C Explanation: A) Incorrect. Even though many consider whatever activity gives pleasure and satisfaction to the involved adults to be normal, some cultures and religions do not hold that belief.

B) Incorrect. While alternative lifestyles are well accepted in some cultures, it is apparent that this is not a belief held by this individual.

C) Correct. This nurse should remember that culture and religion have a big impact upon what a person believes to be normal sexual behaviour.

D) Incorrect. Sexual development has both genetic and environmental components.

Type: MC Learning Outcome: 45-3 2) The parents of a 17-month-old boy are very concerned because the baby touches his genital area during diaper changes. What information should the nurse share with the parents?

A) At his age, this touching is not a sexual experience.

B) Masturbation to orgasm is common and normal at this age.

C) Genital stimulation should not be occurring until the age of 2 1/2 or 3.

D) Babies are sexual beings, but this activity should be discouraged.

Answer: A Explanation: A) Correct. At this age, exploration and touching of the genital area is no different than exploration and touching of fingers and toes. This touching is not considered a sexual experience.

B) Incorrect. Masturbation to orgasm can occur as early as age 3, although no ejaculation occurs until after puberty.

C) Incorrect. At around age 2 1/2 or 3 the child begins to understand genital differences and to identify as a male or female.

D) Incorrect. There is no need to discourage genital exploration at 17 months.

Type: MC Learning Outcome: 45-1

1 .

3) Which statement, made by a postmenopausal woman may indicate the need for further assessment by the nurse?

A) "For some reason, I have more sexual desire than ever."

B) "I use water-soluble lubricant to treat my vaginal dryness."

C) "I am so glad that I don't need to worry about sex anymore."

D) "Sex certainly takes longer than it used to, but I'm getting used to that."

Answer: C Explanation: A) Incorrect. This is a true statement about postmenopausal sexual relationships; there is no need for the nurse to follow up on this statement.

B) Incorrect. This is also a healthy intervention for treating vaginal dryness associated with postmenopausal changes.

C) Correct. The nurse would further assess the client who made the statement, "I am so glad that I don't need to worry about sex anymore." This statement is unclear. Does it mean that the client is glad not to have to engage in sex anymore or does it mean that she will not have to worry about getting pregnant anymore?

D) Incorrect. This is also a normal change after menopause, and reflects a healthy response to those changes.

Type: MC Learning Outcome: 45-4 4) A 45-year-old client reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How does the nurse interpret these assessment data?

A) The husband may be seeking sexual satisfaction outside the marriage.

B) The woman's lack of sexual desire has resulted in impotence in her husband.

C) If both partners share the same lack of desire, there is no problem.

D) This situation is so unnatural that some dysfunction is present.

Answer: C Explanation: A) Incorrect. There is no indication that the husband is seeking satisfaction outside the marriage.

B) Incorrect. There is no evidence that the wife's lack of desire has resulted in sexual impotence in her husband, but further assessment might be in order.

C) Correct. If both members of a couple have the same lack of desire and they are comfortable, there is likely no problem with the couple's sexual relationship. Couples may experience other forms of sexual pleasure that do not necessarily include intercourse.

D) Incorrect. This situation may be considered unnatural in the predominant North American culture, but if both members of the couple are comfortable with the relationship, no dysfunction is present.

Type: MC Learning Outcome: 45-4

2 .

5) The nurse is preparing for pelvic physical examination of a woman who has been medically diagnosed with vaginismus. What equipment should the nurse obtain for this examination?

A) Culture swabs to assess expected vaginal infection B) Gloves and a vaginal suppository C) Smaller than normal vaginal speculums D) Equipment for pre-examination douche Answer: C Explanation: A) Incorrect. Swabs for culture are not necessary for a client with vaginismus.

B) Incorrect. While gloves will be used for a vaginal exam, a vaginal suppository will not be used for a client with vaginismus.

C) Correct. Clients with vaginismus experience involuntary spasm of the outer one-third of the vaginal muscles. This spasm makes internal examination, tampon use, and intercourse difficult.

Use of smaller than normal vaginal speculums may make examination easier.

D) Incorrect. There is no requirement for a pre-examination douche.

Type: MC Learning Outcome: 45-8 6) Mrs. Cape is a 56-year-old woman who had a right-sided mastectomy last year for breast cancer. She is currently cancer free, and is in the health clinic to speak with the nurse about her sexual relationship with her husband of 30 years. She tells the nurse that while she still has sexual desires, her body does not respond the same way it used to. She notes that she does not get the same level of excitement that she used to. In developing a plan of care, what nursing diagnosis is appropriate for Mrs. Cape?

A) Anxiety related to loss of sexual desire B) Deficient knowledge C) Disturbed body image D) Ineffective sexuality pattern Answer: D Explanation: A) Incorrect. Mrs. Cape does not have a loss of desire; she is unable to obtain the same level of sexual excitement that she used to achieve before her mastectomy.

B) Incorrect. This would be the case when someone was unclear about how to prevent pregnancy, or normal changes over the life span.

C) Incorrect. This would be correct if Mrs. Cape felt that her mastectomy led to perceived rejection by her spouse.

D) Correct. Ineffective sexuality pattern occurs when an individual experiences changes in sexual function during one of the phases of sexual response (desire, excitation, orgasm) which is viewed as unsatisfying, unrewarding, or inadequate.

Type: MC Learning Outcome: 45-8

3 .

7) A recently married couple is trying to conceive a child. The husband is a college athlete and his coach forbids sexual activity for 2 days prior to a game because it weakens the individual.

The wife asks the nurse if abstinence before the game is necessary. What is the best response?

A) As long as intercourse is not involved, there is no reason to avoid sexual activity.

B) Some residual physical weakness is common for up to 18 hours after sex.

C) This is a common myth among athletes, but there is no basis in fact.

D) Sexual activity before intense physical exercise increases stamina and endurance.

Answer: C Explanation: A) Incorrect. There is no evidence that avoiding intercourse is necessary.

B) Incorrect. The idea that sexual activity weakens the person physically is a common misconception among athletes, but there is no evidence to support this idea.

C) Correct. The idea that sexual activity weakens the person physically is a common misconception among athletes, but there is no evidence to support this idea.

D) Incorrect. There is no evidence that sexual activity before intense exercise affects stamina or endurance.

Type: MC Learning Outcome: 45-1 8) A 15-year-old female tells the nurse that she makes her boyfriend stop intercourse before she has an orgasm so she will not get pregnant. What should the nurse do first?

A) Inform her about sexually transmitted infections with unprotected sex B) Explore any sexual myths the young woman might believe C) Advise her that she can still get pregnant before an orgasm occurs D) Advise that conception is unlikely as long as ejaculation happens outside the vagina Answer: C Explanation: A) Incorrect. While this is important, it may be done after assessment of the client's knowledge base is complete and after dispelling the myth or misinformation that client has initially shared with the nurse.

B) Incorrect. A more in-depth assessment of the client's knowledge base is important, however the nurse should first dispel the myth that has already been identified.

C) Correct. The first thing the nurse should do is to dispel the current myth the client has shared with her. Conceiving is not related to experiencing orgasm.

D) Incorrect. The seminal fluid expelled prior to ejaculation also contains sperm and can result in pregnancy even if the male ejaculates outside the vagina.

Type: MC Learning Outcome: 45-1

4 .

9) A high school student tells the school nurse that during biology the class learned that alcohol is associated with erectile dysfunction. The student wonders why so many girls get pregnant during evenings when alcohol is consumed. The nurse plans a response based upon which concept?

A) Alcohol is a central nervous system depressant which affects judgment.

B) Erectile dysfunction only occurs after years of alcohol abuse.

C) Alcohol is a sexual stimulant.

D) Erectile dysfunction occurs only in men older than 50.

Answer: A Explanation: A) Correct. Alcohol is implicated in behaviours leading to undesired pregnancy because it is a central nervous system depressant and affects judgment.

B) Incorrect. Situational erectile dysfunction often occurs when the male partner is drunk.

Chronic erectile dysfunction is more common in older men, and alcohol abuse is associated with this problem.

C) Incorrect. Alcohol is implicated in behaviours leading to undesired pregnancy because it is a central nervous system depressant and affects judgment. It is not a sexual stimulant.

D) Incorrect. Chronic erectile dysfunction is more common in older men, and alcohol abuse is associated with this problem.

Type: MC Learning Outcome: 45-6 10) A female client has experienced recurrent candidiasis with intense vaginal itching and excoriation. After treatment, the client is reexamined, and the nurse practitioner finds presence of a white, cheesy discharge. What recommendation is necessary?

A) Referral to a surgeon for excision of infected tissue B) Examination and treatment of sexual partner C) Treatment with a stronger oral antibiotic D) Routine douches with a topical antibiotic solution Answer: B Explanation: A) Incorrect. There is no need for tissue excision.

B) Correct. Candidiasis is a sexually transmitted infection. It may be that this woman's sexual partner is also infected with candidiasis and that the couple is transmitting the infection between them.

C) Incorrect. Candidiasis is a yeast infection. Antibiotic therapy is not indicated and may, in fact, complicate treatment.

D) Incorrect. Antibiotic therapy is not indicated and may, in fact, complicate treatment.

Type: MC Learning Outcome: 45-8

5 .

11) The nurse enters the room and finds the adult client masturbating. What action should the nurse take?

A) Tell the client that masturbation is harmful to sexual well-being B) Say "excuse me" and leave the room C) Request that the client stop so that care can be provided D) Ask the client if there are any sexual concerns that should be discussed Answer: B Explanation: A) Incorrect. Masturbation is not harmful to sexual well-being and does not indicate sexual concerns that should be discussed.

B) Correct. In this situation, the nurse should quickly and politely leave the room.

C) Incorrect. It is inappropriate to ask the client to stop so that care can be provided.

D) Incorrect. Masturbation is not harmful to sexual well-being and does not indicate sexual concerns that should be discussed.

Type: MC Learning Outcome: 45-2 12) The nurse who is teaching a client about breast awareness describes inspection of the breasts before a mirror. Which findings should the nurse tell the client should be evaluated by a health care provider? (Select all that apply.)

1. puckering of the skin 2. scaling on a nipple 3. free movement of the breast over the chest wall 4. symmetry of the nipples 5. change in shape Answer: 1, 2, 5 Explanation: The client should be taught to observe for change in size or shape, lumps or thickenings, rashes or skin irritations, dimpled or puckered skin, and discharge or change in nipples. The nipples should be symmetrical and the breasts should have free movement over the chest wall.

Type: SA Learning Outcome: 45-9

6 .

13) After client teaching on testicular self-exam, Mr. Williams is restating to the nurse the steps of the procedure. What facts stated by Mr. Williams indicate a need for clarification of information? (Select all that apply.)

1. Exam should be completed daily in the shower 2. Roll testicle between thumb and fingers 3. Check for lumps, thickening, or hardening 4. Palpate the epididymis on the bottom and front of the testicle 5. The epididymis should feel smooth as the testicle 6. Report any lumps to the health care provider Answer: 1, 4, and 5 Explanation: Mr. Williams needs clarification of the following information. The self exam should be performed monthly, not daily. The epididymis is palpated at the top and back of the testicle, and it will not feel as smooth as the testicle. The other information is accurate and demonstrates an understanding of the health teaching provided.

Type: SA Learning Outcome: 45-9 14) A nurse colleague is outraged that a grandchild's daycare centre is planning a class on sexuality for 3- and 4-year-olds. She is intending on speaking to the daycare about their plans.

What key concept should be included in this conversation?

A) At this age, education regarding sexuality should come from parents.

B) Children are sexual beings from before birth.

C) Understanding the body and sexuality are a part of growth and development.

D) Sexual activity is beginning at earlier ages.

Answer: A Explanation: A) Correct. The primary consideration is that preschool education on sex and sexuality should come from parents.

B) Incorrect. While all of these statements are true, the one to consider in this conversation is that early childhood discussions of sex should begin with the parents in the home.

C) Incorrect. While all of these statements are true, the one to consider in this conversation is that early childhood discussions of sex should begin with the parents in the home.

D) Incorrect. While all of these statements are true, the one to consider in this conversation is that early childhood discussions of sex should begin with the parents in the home.

Type: MC Learning Outcome: 45-1

7 .

15) Ms. Jenner is a community health nurse teaching sexual health to teenagers in the local high school. Which of the following conversations heard in the hallway following her lesson indicates the need for follow-up teaching?

A) Sexually transmitted infections are on the rise in Canada.

B) Preventing pregnancies will prevent sexually transmitted infections.

C) Teen pregnancies are actually decreasing in Canada.

D) Sexually transmitted infections can cause infertility.

Answer: B Explanation: A) Incorrect. This is a correct statement: STIs are on the rise in teenagers.

B) Correct. Ms. Jenner needs to complete some follow-up teaching in relation to this comment.

While it is true that some methods of preventing pregnancy may prevent sexually transmitted infections (STIs) (like the use of condoms), preventing pregnancies by the use of oral contraceptives will have no effect on preventing STIs. C) Incorrect. This is a correct statement: Teenage pregnancies, abortions, and birthrates amongst teens are decreasing in Canada.

D) Incorrect. This is a true statement: STIs, especially when gone untreated, can result in infertility later in life.

Type: MC Learning Outcome: 45-9 16) The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the P section of this format?

A) Ask the physician for permission to discuss sexual topics with the client B) Obtain informed consent from both the client and partner prior to providing them with sexual information C) Acknowledge the client's spoken and unspoken sexual concerns when providing care D) Arrange for peer counselling sessions for clients when appropriate Answer: C Explanation: A) Incorrect. There is no need to ask permission from the physician prior to discussing sexual topics; this is well within a nurse's scope of practice.

B) Incorrect. Informed consent is a term used to obtain consent before treatment of any kind; it is not obtained for the provision of information.

C) Correct. The P section of this format reflects permission giving. This giving of permission refers to acknowledging the client's spoken and unspoken sexual concerns and giving the client permission to be a sexual being.

D) Incorrect. Peer counselling is not a part of the "PLISSIT" model.

Type: MC Learning Outcome: 45-8

8 .

17) The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the LI section of this format?

A) Limit information given to clients regarding adverse sexual side effects of treatments or medications B) Give the client accurate but concise information in regard to any sexual questions that might be asked C) Use slang terms to refer to sexual body parts because the client is not likely to know the proper terms D) Review current research literature associated with the sexual concerns of the client and partner Answer: B Explanation: A) Incorrect. Clients deserve to have accurate and complete information regarding sexual side effects, and the nurse is obligated to provide that information.

B) Correct. LI represents limited information. The nurse should give accurate but concise information regarding sexual matters.

C) Incorrect. This is not what the LI refers to in the "PLISSIT" model.

D) Incorrect. While reviewing current literature is always a good idea, it does not relate to the LI level of the PLISSIT model.

Type: MC Learning Outcome: 45-8 18) The nurse uses the PLISSIT model in assisting clients who have sexual dysfunction. Which action by the nurse best reflects the SS section of this format?

A) Use the nurse's knowledge about how disease affects sexuality to offer specific suggestions to the client B) Focus interventions on explaining the somatic sexual difficulties and their treatment C) Offer the client a list of expected sexual side effects of drugs or treatments D) Identify any concerns the client has regarding attraction to the same sex Answer: A Explanation: A) Correct. SS represents specific suggestions. The nurse should use specialized knowledge and skill about how sexuality and functioning is affected by disease process or therapy to offer specific suggestions for intervention.

B) Incorrect. While some therapy may have somatic effects, the nurse should not focus solely on those effects.

C) Incorrect. Providing the client a list of expected sexual side effects is not appropriate at this level of the format.

D) Incorrect. SS does not stand for same sex within this model.

Type: MC Learning Outcome: 45-8

9 .

19) The nurse uses the PLISSIT model in assisting clients who have sexual dysfunction. Which action by the nurse best reflects the IT section of this format?

A) Use information technology (the Internet) to obtain suggestions for the client B) Use of informal therapeutic groups to assist the client and partner C) Evaluate previous interventions and treatment D) Recommend therapy with a qualified sex therapist Answer: D Explanation: A) Incorrect. Using information technology does not reflect this level of the format.

B) Incorrect. Using informal therapeutic groups does not reflect this level of the format.

C) Incorrect. Evaluation of previous interventions and treatments is not a part of the model.

D) Correct. IT represents intensive therapy. At this point in intervention, the nurse recognizes that the client requires therapy with a nurse who has specialized preparation and knowledge of sexual and gender identity disorders.

Type: MC Learning Outcome: 45-8 20) The daughters of an 80-year-old man who is aphasic after suffering a cerebrovascular accident express concern that their father is "always exposing and playing with himself and his catheter" while they are in the room. Upon assessment, the nurse finds the client pulling on and rubbing his penis. What is the nurse's priority action?

A) Tell the client to keep his hands away from his penis B) Assess the client's penis for irritation from the catheter C) Ask the client to keep his linens at waist level when he has visitors D) Collaborate with the physician regarding medications to control this behaviour Answer: B Explanation: A) Incorrect. Because this client is suffering from aphasia, he may be touching his penis as a means of communicating a physical problem. The nurse needs to assess for reasons and not simply tell the client to keep his hands away from his genitals.

B) Correct. Before determining whether the behaviour is inappropriate, the client should be assessed for any physical reason for his behaviour. The nurse should assess whether this client has an irritation of the penis that is causing his actions.

C) Incorrect. Asking the client to keep his linens pulled up assumes the client is masturbating and that it is wrong. The nurse needs to complete an assessment to determine if there is cause for his behaviour.

D) Incorrect. Medicating the client to control the behaviour may mask a physical problem and assumes that the client is doing something wrong. All three incorrect options overlook the possibility of a physical reason such as irritation that the client is trying to communicate.

Type: MC Learning Outcome: 45-8

10 .

21) A client was a victim of sexual incest as a child. Now, when she attempts to have intercourse, her vaginal muscles contract, preventing penile penetration. What is this condition called?

A) Impotence B) Vaginismus C) Vestibulitis D) Orgasmic dysfunction Answer: B Explanation: A) Incorrect. Impotence (also referred to as erectile dysfunction) is the inability of a man to achieve or maintain an erection sufficient for sexual satisfaction for himself or his partner.

B) Correct. Vaginismus is an involuntary contraction of the outer one third of the vaginal muscles, making penetration of the vagina painful and sometimes impossible.

C) Incorrect. Vestibulitis refers to the severe pain experienced by women when touch or penetration of the vagina is attempted.

D) Incorrect. Orgasmic dysfunction is the inability of a woman to reach orgasm.

Type: MC Learning Outcome: 45-8 22) During sexual encounter, both partners can experience diminished sensory awareness. In which of the following phases of the sexual response cycle is this a common finding?

A) Resolution B) Desire C) Orgasmic D) Excitement Answer: C Explanation: A) Incorrect. During the resolution phase, changes in breasts and genitals returns to normal pre-excitement condition, sex flush disappears, and all vital signs return to base line.

B) Incorrect. The desire phase begins in the brain and is the first of four phases. It is when sexual arousal occurs.

C) Correct. This is one of the physiological changes both partners can experience during the orgasmic phase, along with an increase in respiratory rate, involuntary muscle spasms throughout the body, and increase in heart rate.

D) Incorrect. The excitement phase involves an increase in blood flow resulting in penile and clitoral erection and swelling of the labia, testes, and breasts.

Type: MC Learning Outcome: 45-5

11 .

23) Ms. Bowman is scheduled for a mitral valve replacement tomorrow, and has been admitted for her presurgical assessments. Which of the following is an appropriate initial question to include in her health history? A) Has your illness altered your usual sexual experiences? B) Do your sexual experiences include men and or women? C) What are your partner's concerns about your future sexual functioning? D) How has your illness affected how you see yourself as a sexual being? Answer: A Explanation: A) Correct. This is an appropriate first question to ask Ms. Bowman. It makes no assumptions about her sexual experiences, and whether they include relationships with other individuals. The response will help determine whether additional questions may be necessary. B) Incorrect. At this point, this question is irrelevant. The first question should determine whether there have been changes in normal sexual experiences since her illness. C) Incorrect. This makes the assumption that Ms. Bowman has a sexual partner. D) Incorrect. This question may be a follow-up to the first question if it is determined that her illness has caused changes in her normal sexual experiences. Type: MC Learning Outcome: 45-7 24) Which of the following is a term that reflects the outward expression of one's sense of sexuality or of what is perceived as appropriate with regard to one's sexuality?

A) Sex B) Gender C) Sexuality D) Sexual health Answer: B Explanation: A) Incorrect. Sex is used to describe the anatomical differences between men and women.

B) Correct. Gender refers to the ways in which a person lives life that demonstrate or reflect masculinity and femininity.

C) Incorrect. Sexuality encompasses biological sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction.

D) Incorrect. Sexual health is "a state of physical, emotional, mental and social well being in relation to sexuality: it is not merely the absence of disease, dysfunction or infirmity" (Health Canada).

Type: MC Learning Outcome: 45-2

12 .

25) What information should the nurse offer a heterosexual couple who have expressed interest in trying anal intercourse? A) The condom should not be lubricated because it may tear. B) Condom use is unnecessary because one cannot become pregnant as a result of anal intercourse. C) Condom use should not be used for subsequent vaginal intercourse. D) Condom use will cause rectal tissue to tear and become infected. Answer: C Explanation: A) Incorrect. Condoms will not tear with lubrication. Because anorectal tissue is not selflubricating, condoms should be used with lubrication. B) Incorrect. While it is true that a client cannot become pregnant during anal intercourse, a condom should be worn during because they can prevent sexually transmitted infections. C) Correct. A condom worn during anal intercourse should not be used for subsequent vaginal intercourse because of the risk of transmitting organisms from the anal canal to the vagina. D) Incorrect. Condoms will not cause rectal tissue to tear and become infected. Condoms should be worn during anal intercourse to prevent STIs. Type: MC Learning Outcome: 45-6 26) Which of the following reflects the P phase of the PLISSIT model of intervention?

A) Giving an accurate but concise explanation of what is normal B) Using specialized knowledge to suggest specific therapeutic interventions C) Acknowledging the client's sexual concerns D) Referring the client to a clinical nurse-specialist or sex therapist Answer: C Explanation: A) Incorrect. Giving an accurate but concise explanation of what is normal and how the client's present situation or condition may affect sexual functioning represents the LI (limited information) part of the model.

B) Incorrect. Giving an accurate but concise explanation of what is normal and how the client's present situation or condition may affect sexual functioning represents the LI (limited information) part of the model.

C) Correct. The P section of this format reflects permission giving. This giving of permission refers client to acknowledging the client's spoken and unspoken sexual concerns and giving the permission to be a sexual being.

D) Incorrect. Using specialized knowledge to suggest specific interventions (including referral) represents the SS portion of the model. Intensive therapy can follow upon referral.

Type: MC Learning Outcome: 45-8

13 .

27) Mr. Edwards is seeing his health care provider regarding erectile dysfunction. He is intending on asking specifically about the use of Viagra. Which of the following medications that Mr. Edwards currently takes may preclude the use of Viagra? A) Nitroglycerin B) Levothyroxin C) Lasix D) Lanoxin Answer: A Explanation: A) Correct. Viagra is contraindicated in clients who are taking nitrates or amyl nitrate. B) Incorrect. Viagra is not contraindicated when clients are taking Levothyroxin. C) Incorrect. Viagra is not contraindicated when clients are taking Lasix. D) Incorrect. Viagra is not contraindicated when clients are taking Lanoxin. Type: MC Learning Outcome: 45-8 28) A man and woman at the nursing home have become very attached and want to have intimate sexual relations. Which nursing action would be most appropriate?

A) State that this is not allowed in the facility B) Tell them they will have to leave C) Provide them with uninterrupted time alone D) Tell them they will need permission from their physician Answer: C Explanation: A) Incorrect. Interventions for the elderly include providing them with the privacy to meet their sexual needs.

B) Incorrect. Suggesting that they need to leave is unacceptable, and does not assist them in meeting their sexual needs.

C) TheCorrect. Loss of privacy can be an obstacle to a satisfying relationship in a nursing home. most appropriate nursing action would be to provide the couple with uninterrupted time alone.

D) Incorrect. This is a mutual decision by consenting adults and it would be inappropriate to suggest that they would need permission to engage in a sexual relationship.

Type: MC Learning Outcome: 45-1

14 .

Fundamentals of Canadian Nursing, 4e(Kozier) Chapter 46 Spirituality 1) What is the rationale for considering a client's spiritual needs when developing a plan of care?

A) Nurses are the only health professionals that provide this type of holistic care.

B) Meeting the client's spiritual needs can decrease suffering.

C) Until spiritual needs are met, physical needs cannot be met.

D) It is important that the nurse's idea of spirituality matches the client's ideas.

Answer: B Explanation: A) Incorrect. Nurses are not the only health care providers that provide holistic care.

B) Correct. The nurse knows that meeting spiritual needs may help to decrease suffering.

C) Incorrect. Physical needs can be addressed and healed without considering the spiritual side, but in order to provide holistic care both should be addressed.

D) Incorrect. While the nurse must assess and understand the client's spirituality, it is not necessary for the nurse's ideas to be congruent with those of the client.

Type: MC Learning Outcome: 46-3 2) What should be the nurse's primary intervention for a client experiencing spiritual distress?

A) Establish a trusting nurse-client relationship B) Have the client describe the basic problem C) Ask the client what religion is practiced in the home D) Identify the client's belief in a supreme being Answer: A Explanation: A) Correct. The first step in successfully working with a client with spiritual distress is establishing a trusting nurse-client relationship. Until that relationship is established, it will be difficult to complete any other interventions.

B) Incorrect. The client is not likely to describe anything to the nurse before a nurse-client relationship is developed.

C) Incorrect. This option is confusing spirituality with religious beliefs.

D) Incorrect. This option also confuses spirituality with religion.

Type: MC Learning Outcome: 46-1 3) Buddhism is considered to be a theistic religion.

Answer: FALSE Explanation: A theistic religion is one that believes in a god or higher being. Buddhism focuses attention on noble truths.

Type: TF Learning Outcome: 46-1

1 .

4) The nurse has identified that many of the clients in the long-term care facility have spiritual concerns and distress. What is the nurse's first step in becoming a competent provider for these clients?

A) The nurse must possess a healthy spiritual self-awareness.

B) The nurse must learn about diverse spiritual beliefs and practices.

C) The nurse should start going to church more often.

D) The nurse should establish regular religious services in the facility.

Answer: A Explanation: A) Correct. The first step of becoming a competent provider for clients who have spiritual distress is for the nurse to possess a healthy spiritual self-awareness.

B) Incorrect. This is the next step in becoming a competent provider for spiritual needs.

C) Incorrect. This option confuses spiritual concerns with religious practices.

D) Incorrect. Establishing regular religious services in the facility and going to church more often presuppose that spirituality and religion are one, which is not true.

Type: MC Learning Outcome: 46-1 5) During assessment, the client tells the nurse, "I don't believe that the existence of God has been proven. I don't see the scientific evidence I need to be certain." How does the nurse document this finding?

A) The client demonstrates polytheism.

B) The client is an atheist.

C) The client has beliefs that support monotheism.

D) The client is agnostic.

Answer: D Explanation: A) Incorrect. Polytheism is the belief in more than one God. B) Incorrect. Atheists do not believe in a God. C) Incorrect. Monotheism is the belief in one God. D) Correct. Agnostics are persons who doubt the existence of God or a supreme being or believe the existence of God has not been proven.

Type: MC Learning Outcome: 46-1 6) Which of the following is considered spiritual wellness?

A) A lifestyle that views and lives life as purposeful and pleasurable B) The ability to experience meaning and purpose in life C) A challenge to the core value system that provides strength D) A feeling of being generally alive and purposeful Answer: A Explanation: A) Correct. Spiritual wellness is a way of living, a lifestyle that views and lives life as purposeful and pleasurable.

B) Incorrect. This option defines spiritual well-being.

C) Incorrect. This option defines spiritual distress.

D) Incorrect. This option defines spiritual health.

Type: MC Learning Outcome: 46-1

2 .

7) During assessment, the client says that it has been "a long time" since she has thought very much about religion. The nurse caring for this client has a strong belief in God and the healing power of prayer. What action should be taken by the nurse?

A) Mention the nurse's belief and offer to pray with the client for forgiveness B) Tell the client that the nurse will pray for her often C) Ask the client if there are any spiritual needs with which the staff can assist D) Refer the client for spiritual counselling Answer: C Explanation: A) Incorrect. The nurse must understand that personal spiritual beliefs cannot be brought into the work situation unless the client asks for information and the nurse is comfortable sharing.

B) Incorrect. Offering to pray with or for the client is over the boundary of professional practice unless the client requests such intervention and the nurse is comfortable with the arrangement.

C) Correct. Asking the client to detail how staff can help meet spiritual needs is one of the first steps in completion of a spiritual assessment.

D) Incorrect. At this point, there is no information that indicates the client is in need of referral for counselling. This would occur only if the client demonstrates spiritual distress at the level best handled by a specialist.

Type: MC Learning Outcome: 46-5 8) The client being prepared for an elective outpatient colonoscopy asks to be allowed to wear a religious medal during the procedure. The client states, "I have worn this medal and have not removed it since I was a teenager." What action should be taken by the nurse?

A) Tell the client that it is policy that all jewellery must be removed B) Tell the client that the medal can be worn C) Advise staff in the colonoscopy department about the significance of the medal D) Remove the medal and place it on the head of the bed Answer: C Explanation: A) Incorrect. The fact that there is a policy to remove all jewellery is simply a policy, and demonstrates no consideration for the client and her religious beliefs.

B) Incorrect. The nurse should not tell the client that the medal will be allowed as this decision belongs to those directly involved in the procedure.

C) Correct. The nurse should explain the significance of the medal to the colonoscopy staff and request that the client be allowed to wear it during the procedure.

D) Incorrect. Placing the medal on the head of the bed might risk losing it when the client is transported or in the colonoscopy department.

Type: MC Learning Outcome: 46-3

3 .

9) The emergency department nurse contacts the admissions office to request a bed for a bedbound client who is a practicing Muslim. How can the nurse best prepare to meet the client's prayer needs on the unit?

A) Try to find a private room for the client B) Coordinate care to allow for five prayer sessions daily C) Prayers should be accommodated on Fridays and Sundays D) Should share a room with only other Muslims Answer: B Explanation: A) Incorrect. There is no restriction that the room must be private or that the other client in a semi-private room must be Muslim.

B) Correct. The Muslim religion prescribes prayers five times daily. Efforts should be made to coordinate, when possible, providing care to accommodate this practice.

C) Incorrect. If possible, the religious practices should be accommodated fully, not just on certain days of the week.

D) Incorrect. There is no restriction that the room must be private or that the other client in a semi-private room must be Muslim.

Type: MC Learning Outcome: 46-5 10) A client who is devoutly Jewish is hospitalized during Yom Kippur, a time when many of the Jewish faith fast. The client expresses a desire to follow this religious pattern. How should the nurse respond to this wish?

A) Support the client's desires to the extent possible B) Let the client know that nutrition can be provided parenterally C) Attempt to convince the client to ignore the tradition due to illness D) Tell the client that the physician must make this decision Answer: A Explanation: A) Correct. The nurse should support the client's desires to the extent possible. In some circumstances, religions will lift fasting requirements for clients who are critically ill and for believers for whom fasting may be detrimental for their health.

B) Incorrect. This option does not respect the need of the client to follow religious doctrine.

C) Incorrect. Asking the client to ignore the tradition is disrespectful and does not support his religious needs.

D) Incorrect. The physician also cannot ethically make this decision for the client. The doctor may provide the client with information that may help the client determine whether fasting is advisable, but it should be the client's decision.

Type: MC Learning Outcome: 46-8

4 .

11) Mrs. El Kadri is a member of a religious group that expects women to dress conservatively, covering her arms and legs. She expresses concern to the nurse that her body will be exposed during her cardiac catheterization. How should the nurse respond to Mrs. El Kadri's concerns?

A) Tell the client that she will be sedated and will be unaware of her body being exposed B) Make a note in the client's chart that she is particularly modest C) Explain to the client that in order to perform the study, her body must be exposed D) Ask the cath lab charge nurse to come to the client's room to talk with her about the concerns Answer: D Explanation: A) Incorrect. This option does not address her concerns about her modesty or support her religious beliefs.

B) Incorrect. Making a note in the chart does not address Mrs. El Kadri's concerns.

C) Incorrect. This response by the nurse is not therapeutic or supportive. It does not do anything to address Mrs. El Kadri's concerns or support her religious beliefs.

D) Correct. The best plan is to have the cath lab charge nurse talk to the client about her concerns. The charge nurse can then assure the client that even though a small part of her body must be exposed, her modesty will be protected.

Type: MC Learning Outcome: 46-8 12) Mrs. Cruz is in the delivery room in the last stages of labour. She has found out earlier that her son has died in utero. Since this baby's parents are Catholic, what planning should the nurse consider?

A) Arrange to have the baby circumcised immediately after birth B) Ask the hospital chaplain to be present in the delivery room C) Ask the nursing supervisor to find a Catholic nurse to attend the birth D) Consider emergency transport of the mother to a Catholic hospital Answer: B Explanation: A) Incorrect. The family will want their son baptized, not circumcised.

B) Correct. In this situation, the best choice is to have the hospital chaplain present in the delivery room.

C) Incorrect. A Catholic nurse who understands the requirements of the religion at this time may be desirable if a chaplain is not available. A chaplain is preferred.

D) Incorrect. Transfer of a labouring woman to another facility is not advised or required.

Type: MC Learning Outcome: 46-8

5 .

13) The family of a dying client has informed the nurse that their religion requires a ritual bath be given by members of the faith after death. The unit is busy, at full census, and there is another client waiting in the ER for the bed. How should the nurse respond to this request?

A) Notify the mortuary of the family's request B) Arrange for supplies and privacy for the family C) Arrange for the bath after the body is removed from the hospital D) Give the family a 1-hour time period to complete the bath Answer: B Explanation: A) Incorrect. There is no need to notify the mortuary, as the bath will be completed on the unit where the client has died. B) Correct. When a client is dying, much of the nursing care shifts from the client to support of the family. The nurse should allow this bath and should provide supplies and privacy and time for the family to complete the ritual. C) Incorrect. Asking the family to wait until the body is removed is not supportive of the family's religious needs. D) Incorrect. The nurse should not put a deadline on the bath; this is not supportive of the family's needs at this time. Type: MC Learning Outcome: 46-4 14) The client tells the nurse, "I don't know what to do. The treatment plan my physician has suggested is against some of my religious beliefs."

What nursing diagnosis problem statement should the nurse assign to this client? A) Ineffective coping B) Decisional conflict C) Impaired religiosity D) Anxiety Answer: B Explanation: A) Incorrect. While there is evidence that this situation is causing stress for the client, there is no evidence that this client is coping ineffectively. B) Correct. The best nursing diagnosis problem statement is decisional conflict. The client is being asked to make a decision between two highly regarded but conflicting plans. C) Incorrect. Impaired religiosity is impairment of the ability to exercise religious beliefs, which has not occurred. D) Incorrect.

While there may be some anxiety, that nursing diagnosis is not as specific to this case as is decisional conflict. Type: MC Learning Outcome: 46-6

6 .

15) The nurse caring for wheelchair-dependent residents of a long-term care environment is developing a care plan and wants to include interventions that will meet their spiritual needs.

Which of the following interventions would be appropriate?

A) Planning outings to the local shopping mall on a regular basis B) Taking the clients outdoors to enjoy the gardens when weather permits C) Allowing opportunities for clients to receive sacraments when requested D) Allowing for opportunities for the client and family to pray together Answer: B Explanation: A) Incorrect. This intervention would not meet spiritual needs.

B) Correct. Keeping in touch with nature is a form of spiritual care.

C) Incorrect. While this is important, this particular intervention would meet religious needs, not spiritual.

D) Incorrect. This would meet religious needs, not spiritual.

Type: MC Learning Outcome: 46-2 16) The nurse has obtained supplies to change a complex abdominal dressing on a post-operative client. When the nurse arrives at the room, the client is praying with family. What action should be taken by the nurse?

A) Stand quietly just inside the room door until the prayer is completed B) Come to the bedside and join in with the prayer C) Politely ask the client to allow the dressing change to proceed D) Quietly shut the door and wait in the hall until asked to enter Answer: D Explanation: A) Incorrect. Clients and families should be provided with the privacy required for prayers.

B) Incorrect. While it is perfectly acceptable for the nurse to pray with clients, joining the prayer without invitation is not acceptable.

C) Incorrect. It would not be appropriate to ask the client and family to stop their prayers.

D) Correct. The nurse should wait in the hall until the prayer is over and the client or family give permission to enter the room.

Type: MC Learning Outcome: 46-4

7 .

17) The nurse is caring for a client requiring transfusion of multiple units of blood. The client has a religious objection to this treatment even though it is necessary to sustain life. What action should be taken by the nurse?

A) Use established rapport to influence the client to accept the blood transfusions B) Explain why the blood transfusions are necessary and why refusal is dangerous C) Encourage the client, his spiritual adviser, and the physician to discuss this conflict and any possible alternative therapies D) Suggest to the client that, as the illness progresses, the blood will be transfused despite religious objections Answer: C Explanation: A) Incorrect. Using the established rapport to influence the decision is unethical, as is suggesting that the blood will be transfused anyway if the disease progresses.

B) Incorrect. Explaining scientific reasons will not generally make a difference in the client's decision.

C) Correct. The best response is to support the discussion between client, physician, and spiritual adviser. At that point, the nurse must be prepared to support whatever decision the client makes, even if it is not to permit the transfusions.

D) Incorrect. Suggesting that the blood will be transfused anyway if the disease progresses is unethical. All clients have the right to determine their treatment options even if the decision may affect their life.

Type: MC Learning Outcome: 46-8 18) Mr. Baber is required to have blood transfused for a very low Hgb. He has a religious objection to the transfusion. In a multidisciplinary approach to this situation, what is the nurse's role?

A) Provide information required for informed consent B) Speak with the family to encourage him to change his mind C) Inform the spiritual advisor that Mr. Baber will die without the transfusion D) Help prepare the client and family for death Answer: A Explanation: A) Correct. The nurse's major role is to provide the client with enough information so that he can make an informed decision.

B) Incorrect. Speaking to the family would be considered a breach of confidentiality.

C) Incorrect. The spiritual advisor most likely is aware of the consequences of not having the transfusion. The major role of the nurse is to provide information so the client can determine the best course of action.

D) Incorrect. This is premature. After providing all the information, Mr. Baber could decide to have the transfusion.

Type: MC Learning Outcome: 46-8

8 .

19) How can the nurse best support the spiritual development of a hospitalized 5-year-old?

A) Ask the child who God is to them B) Listen to the child's routine bedtime prayer C) Encourage the child to pray before each meal D) Bring a Bible storybook in to read to the child at bedtime Answer: B Explanation: A) Incorrect. Asking who God is assumes that the child's religion recognizes God. Also, at this age, the child is too young to articulate the identity of God. B) Correct. The nurse should support the routine spiritual practices encouraged by the family. If the client says routine bedtime prayers, the nurse can support this practice by listening to the prayer.

C) Incorrect. If the child does not routinely pray before meals, the nurse should not introduce this activity.

D) Incorrect. Bringing in a Bible storybook to read to the child assumes that the child holds the same religious beliefs as the nurse.

Type: MC Learning Outcome: 46-2 20) Which of the following are considered defining characteristics of spiritual distress? (Select all that apply) 1. Feeling a sense of spiritual emptiness 2. Focusing on the development of inner self 3. Questioning the meaning of life 4. Choosing not to practice usual religious rituals 5. A state of mental uneasiness, apprehension, or dread Answer: 1, 3, and 4 Explanation: Answers 1, 3, and 4 are characteristics of spiritual distress. As well, spiritual distress can include questioning the credibility of a personal belief system, having ambivalent feelings or doubts about beliefs, and showing emotional detachment from self and others. A state of mental uneasiness or apprehension describes a general state of anxiety. Focusing on the development of the inner self is a characteristic of spiritual health.

Type: SA Learning Outcome: 46-4

9 .

21) During the morning bath, the client asks if the nurse is religious and believes in God. What guideline would be most helpful to the nurse in formulating a response to this question?

A) The nurse's personal life is none of the client's business. B) Religion and politics are two subjects not discussed in polite society. C) Will sharing this information positively contribute to the relationship? D) What is the culture of the facility regarding self-disclosure? Answer: C Explanation: A) Incorrect. While it is true that the nurse's personal life is private, the nurse might decide to self-disclose if she believes that it will contribute to a therapeutic nurse-client relationship. B) Incorrect. Some cultures do believe that religion and politics should not be discussed in polite society, but the client does deserve some answer to the question. C) Correct. Practice guidelines regarding support of religious practices indicate that the nurse should first consider whether such self-disclosure will contribute to a therapeutic nurse-client relationship. D) Incorrect. Although considering the culture of the unit is important, the nurse can determine whether or not to answer the question. Type: MC Learning Outcome: 46-1 22) The nurse and client have spent several minutes praying together that the client's upcoming surgery will be successful. What action should the nurse take at this point? A) Gently tell the client that the nurse must take care of other duties B) Smile and pat the client and silently leave the room C) Stay with the client until the emotion evoked by the prayer dissipates D) Ask the client if there is anything else the nurse can do Answer: C Explanation: A) Incorrect. Prayer can sometimes create strong emotions in clients. The nurse should stay with the client until the emotion has subsided. B) Incorrect. Smiling and being gentle are correct, but the nurse should stay with the client for at least a few minutes. C) Correct. The nurse should stay with the client a few minutes after the prayer has ended until the strong emotions that can be evoked by joint prayer dissipate. D) Incorrect. Asking if there is anything else the nurse can do makes the prayer look like just another task in a busy day.

Type: MC Learning Outcome: 46-6

10 .

23) Mr. Khan was diagnosed with diabetes mellitus 6 months ago. He is hospitalized in diabetic ketoacidosis after a religious fast. Once stabilized, Mr. Khan tells the nurse, "I have fasted during this season every year since I became an adult. I am not going to stop now." The nurse is not knowledgeable about this particular religion. What is the best action for this nurse? A) Tell the client that it is different now because of the diabetes B) Do some research into the meaning of fasting in this religion C) Ask family members of the same religion to discuss fasting with the client D) Request a consult from a diabetes educator Answer: D Explanation: A) Incorrect. Telling the client that life is different now does not support Mr. Khan's religious beliefs. B) Incorrect. Research into the meaning of fasting in this religion would be educative for the nurse, but would not provide the client with information on how he can fast safely in the future. C) Incorrect. Asking the family to talk to the client might help, but the diabetes educator may have more applicable strategies because of his or her specialized knowledge of diabetes. D) Correct. The diabetes educator should be contacted to work with the client on strategies that might allow the fasting to occur in a safe manner. Type: MC Learning Outcome: 46-8 24) The client states, "I don't know what all this fuss is about religion. God died years ago." The nurse does believe in God and has a strong inclination to share reasons for that belief with the client. What is the best question for the nurse to consider before responding to the client's remark? A) "Will I get into trouble if I say anything?" B) "How much longer will I be caring for this client?" C) "Am I meeting my needs or the client's?"

D) "How can I best make this client understand?" Answer: C Explanation: A) Incorrect. This should not be the determining factor in whether the nurse responds to the client. B) Incorrect.

This statement indicates that the nurse is tolerating, rather than accepting the beliefs of the client. C) Correct. The nurse should first determine if it is the nurse's needs or the client's needs that would be met by a response. D) Incorrect. This statement indicates that the nurse believes the client's beliefs are wrong, and that she must change his viewpoint. Type: MC Learning Outcome: 46-5

11 .

25) Which of the following is characteristic of spiritual distress?

A) A client prays five times a day.

B) A middle-aged adult abruptly stops going to church.

C) A young woman admits to being agnostic.

D) A Christian teenager attends a Jewish synagogue service.

Answer: B Explanation: A) Incorrect. There are some religions that require five times a day prayer. This would not be a sign of spiritual distress.

B) Correct. Someone who is choosing not to practice usual rituals of a religion may be spiritually distressed.

C) Incorrect. A client who admits to being agnostic is not necessarily in spiritual distress.

D) Incorrect. Attending another religions service demonstrates an openness to learning about other religious beliefs and should be encouraged.

Type: MC Learning Outcome: 46-4 26) A client with terminal cancer expresses extreme anger about an unsolicited visit by the hospital chaplain. He furiously states that he wants nothing to do with a god who has allowed him to suffer. In planning interventions to help this client cope effectively with spiritual distress, what would be an appropriate outcome criterion?

A) Verbalize relief of anger toward the transcendent being, self, and others B) Stop complaining about the hospital chaplain's visits C) Get involved in diversional activities that prevent him from dwelling on his problem D) Experience conversion and a sense of forgiveness Answer: A Explanation: A) Correct. Spiritual distress is evident by the client's extreme anger. Interventions to relieve this spiritual distress will revolve around helping the client deal with his anger. An appropriate outcome criterion would be for the client to verbalize relief of anger toward the transcendent being, self, and others.

B) Incorrect. An outcome of having the client stop complaining or diverting attention does not mean that the anger has been addressed.

C) Incorrect. Diversional activities will not address the anger this client is feeling.

D) Incorrect. Although conversion and a sense of forgiveness may be a positive long-term outcome (indicating connectedness with self, others, or a greater power), it is too early to know if this is an appropriate expectation for this client.

Type: MC Learning Outcome: 46-8

12 .

27) Which dietary adjustment would support a hospitalized Muslim's spiritual wellness during Ramadan?

A) Arranging for only one large meal to be served in the middle of the day B) Including whole grain foods and fresh fruit with each meal C) Providing herbal teas and unleavened bread before each meal D) Requesting that meals be served before dawn and after sunset Answer: D Explanation: A) Incorrect. This action does not meet the fasting during daylight requirements of Ramadan.

B) Incorrect. While these foods may be included on his diet, it does not address the fasting requirements of Ramadan.

C) Incorrect. Ramadan requires that Muslims fast during daylight hours; these foods are not restricted.

D) Correct. Requesting that meals be served before dawn and after sunset would be an appropriate dietary adjustment. During the month of Ramadan, devout Muslims eat no food and avoid beverages during daylight hours; the fast can be broken after sunset.

Type: MC Learning Outcome: 46-4 28) A 22-year-old client who is in the advanced stages of AIDS says to his primary nurse, "I know that I am not going to get better. I think I would like to pray, but I do not know how. I don't even know to whom." What is the most supportive response the nurse could make at this time?

A) "It is frightening to be facing the end of your life. I will pray for you."

B) "I will call the chaplain to speak with you about this."

C) "What do you want to say in your prayer?"

D) "Many people your age have been alienated by religion."

Answer: C Explanation: A) Incorrect. The key factor is that the client has made a request to pray at this time and the most supportive thing the nurse could do would be to assist the client to meet this spiritual need.

B) Incorrect. The key factor is that the client has made a request to pray at this time and the most supportive thing the nurse could do would be to assist the client to meet this spiritual need at this time.

C) Correct. By responding with "What do you want to say in your prayer?" the nurse is supporting client spirituality and autonomy.

D) Incorrect. There is nothing to suggest that the client has been alienated by religion.

Type: MC Learning Outcome: 46-4

13 .

Fundamentals of Canadian Nursing, 4e(Kozier) Chapter 47 Stress and Coping 1) The nurse elects to use a scale of stressful life events to assess the level of a newly admitted client's stress. What information should the nurse provide to the client about this scale?

A) "You will need to recall negative life events that have happened to you recently."

B) "You will need to recall stressful events that have occurred to you in the last 10 years."

C) "It gives us a stress level number that is used to compare your stress to others your age."

D) "It gives some idea about your stress related to both positive and negative recent events in your life."

Answer: D Explanation: A) Incorrect. The scales take into consideration both positive and negative events and focus on events that have taken place recently.

B) Incorrect. The scale focuses on recent events, not in the last 10 years.

C) Incorrect. This scale does not provide a number for comparison. The scales are only an idea of stress level because each individual reacts to stressful events differently.

D) Correct. Stress scales are useful to give the client and others an idea of the amount of stress that both positive and negative recent life events have placed on the client.

Type: MC Learning Outcome: 47-1 2) Mrs. Cossella has just received news of the death of her sister. Over the next few hours, what physiologic response would the nurse attribute to the shock phase of the alarm reaction caused by the stress of this event?

A) Blood pressure drop from 130/80 to 120/75 B) Bounding pulse C) Increase in urine output D) Decrease in oxygen saturation Answer: B Explanation: A) Incorrect. Blood pressure rises in response to angiotensin production.

B) Correct. During this shock phase the sympathetic nervous system is stimulated, resulting in increased myocardial contractility which would be reflected in the client as a bounding pulse.

C) Incorrect. Norepinephrine release decreases blood flow to the kidney, which could cause urine output to decrease.

D) Incorrect. The bronchial tree dilates, allowing more oxygen intake that would result in increased oxygen saturation.

Type: MC Learning Outcome: 47-2

1 .

3) Which of the following are considered essential to problem solving as it relates to stress?

A) Willfully putting a thought or feeling out of mind B) Analyzing or defining the problem C) Conveying a sense of being in control D) Reworking or replaying the situation Answer: B Explanation: A) Incorrect. This describes suppression which is a cognitive indicator of stress but is not involved in problem solving.

B) Correct. After assessing a problem, it is usually analyzed or defined before determining actions and evaluating the solution.

C) Incorrect. This is also a cognitive indicator of stress, self-control or discipline is assuming a manner and facial expression that convey a sense of being in control.

D) Incorrect. This is true of fantasy or daydreaming and occurs when an individual replays a situation with outcomes that are different than reality.

Type: MC Learning Outcome: 47-3 4) The nursing student admits to being mildly anxious about an upcoming examination. What is the likely result of this level of anxiety?

A) The student's perception and learning is enhanced.

B) The student's attention is focused solely on studying for the examination.

C) The student's only topic of conversation is the examination.

D) The student cannot talk about the examination without crying.

Answer: A Explanation: A) Correct. With mild anxiety, the student's perception and learning will be enhanced.

B) Incorrect. Focusing only on studying for the examination would indicate a moderate anxiety level.

C) Incorrect. Severe anxiety is the level at which the examination would consume all of the student's energy.

D) Incorrect. Panic is the state in which the student might lose control of emotions regarding the examination.

Type: MC Learning Outcome: 47-1

2 .

5) A nurse is developing a care plan where she needs to determine whether a client is experiencing anxiety or fear. What key point would help the nurse make this decision? A) Anxiety is a milder form of fear. B) Fear results in only a physiologic response. C) The source of fear is identifiable. D) Anxiety is generally based in reality, fear is not. Answer: C Explanation: A) Incorrect. Anxiety is not just a milder form of fear. A state of anxiety is related to future or anticipated event, while fear is related to what is happening now. B) Incorrect. Both fear and anxiety can have physiologic and psychological components. C) Correct. The source of fear is identifiable, but anxiety is vague. D) Incorrect. Both fear and anxiety can be based in reality or not. Type: MC Learning Outcome: 47-3 6) The newly licensed nurse feels overwhelmed by the demands of working on a busy acute care unit and caring for her growing family. What strategy should this nurse employ to lessen her stress?

A) Spend the lunch hour completing documentation while eating a sandwich B) Set the alarm earlier in order to get to work early C) Focus on work instead of on family until more familiar with the environment D) Differentiate between "have to do" and "nice to do" at work Answer: D Explanation: A) Incorrect. Completing work assignments over lunch does not provide necessary time peers for the nurse to rest during a shift. If this is a common occurrence the nurse and her should initiate conversations with management about workload.

B) Incorrect. Going in to work early may increase decisional conflict that exists when an individual is experiencing conflicting responsibilities.

C) the Incorrect. This option may cause increasing decisional conflict. In order to manage stress nurse must pay close attention to good nutrition, adequate sleep, and exercise. The nurse must also relax by spending time with family.

D) Correct. This nurse should differentiate between what is essential care at work, and what is nice are to do but can be delegated or not completed on days when stress is high and resources limited.

Type: MC Learning Outcome: 47-9

3 .

7) Brett is a 6-year-old child who is critically ill. While the nurse is preparing to administer a treatment to him, his mother becomes distraught and begins to cry loudly while stroking his face.

What is the nurse's best response to this occurrence?

A) Tell the mother that she needs to control herself for the benefit of her child B) Distract the mother by having her straighten the linens on the bed C) Explain the procedure to the mother D) Take the mother out of the room and comfort her Answer: D Explanation: A) Incorrect. Just telling the mother to control herself discounts the seriousness of her anxiety and may serve to alienate the mother from the nurse.

B) Incorrect. This mother is too upset to distract by smoothing linens.

C) Incorrect. While an explanation is important anytime the nurse is about to provide care or treatment, the mother may not be in a position to understand an explanation because she is so distraught.

D) Correct. In this situation, the nurse must analyze which of the available options would be best for this mother and child. At this level of emotion, the nurse should remove the mother from the room and comfort her.

Type: MC Learning Outcome: 47-9 8) Mr. Moore was admitted to the intensive care unit to rule out myocardial infarction. The patient is upset because he is restricted to the unit and is not allowed to smoke cigarettes. This morning the patient became so angry that he threw his breakfast tray at the nurse. How should the nurse respond to this outburst?

A) Refuse to take care of this patient until he is under control B) Apologize to the patient for the unit rules, but tell him the rules must be followed C) Tell the patient that it is understandable that he is upset, but the no smoking rule is not negotiable D) Tell the patient that he is acting like a child and that such behaviour will not be tolerated Answer: C Explanation: A) Incorrect. The nurse cannot refuse to care for the patient once the assignment has been accepted, since this may constitute client abandonment.

B) Incorrect. The nurse should not assume responsibility for the anger by apologizing.

C) Correct. Telling the patient that it is understandable that he is upset serves to show that the nurse accepts his right to be angry, but that the anger is the patient's.

D) Incorrect. Admonishing the patient by saying that he is acting like a child is not professional and will most likely serve to destroy any hope of resolving this issue.

Type: MC Learning Outcome: 47-9

4 .

9) The nurse's previous interaction was ineffective at calming Mr. Moore, who remains angry at not being able to go out of the intensive care unit for a cigarette. He picks up his radio from his bedside and appears to intend to throw it at the nurse. What should the nurse do?

A) Leave the room B) Tell Mr. Moore you are calling security C) Ask Mr. Moore to put the radio down D) Ask Mr. Moore if this has always been his reaction to stress Answer: A Explanation: A) Correct. In this scenario, when an attempt has been made to manage the client's anger and has failed, the priority becomes the nurse's safety. The nurse should leave the room and seek help from another individual.

B) Incorrect. The safety of the nurse is at risk in this situation. While it may become necessary to call security, telling Mr. Moore this before the nurse leaves the room may escalate his behaviour.

C) Incorrect. An attempt has already been made to calm him. At this point, the nurse's safety is the priority, and leaving the room is the appropriate action.

D) Incorrect. This is not the appropriate time to question Mr. Moore's previous reaction to stress.

The nurse's safety is at risk.

Type: MC Learning Outcome: 47-7 10) Jackson, 18 years old, was driving a car that has just skidded out of control and hit a tree. He was wearing a seatbelt, and the airbags in the car deployed, enabling him to escape without physical injury. As he exits the car, his hypothalamus is triggered by the stress. Which of the following endocrine responses happens first?

A) Release of antidiuretic hormone B) Secretion of adrenocorticotropin C) Increase in corticotropin releasing hormone D) Release of norepinephrine Answer: C Explanation: A) Incorrect. Antidiuretic hormone is released by the stimulation of the posterior pituitary by CRH. B) Incorrect. Corticotropin releasing hormone (CRH) is released by the hypothalamus which stimulates the anterior pituitary to release adrenocorticotropin.

C) Correct. Increased corticotropin is released first in the endocrine response.

D) Incorrect. While this may happen simultaneously with the corticotropin release, it is considered a nervous system response, not an endocrine.

Type: MC Learning Outcome: 47-4

5 .

11) Jackson, 18 years old, was driving a car that has just skidded out of control and hit a tree.

He was wearing a seatbelt, and the airbags in the car deployed enabling him to escape without physical injury. As he exits the car, his hypothalamus is triggered by the stress. Which of the following defines the stage of stress reaction he is experiencing? A) Alarm reaction B) Stage of resistance C) Stage of exhaustion D) Countershock phase Answer: A Explanation: A) Correct. This is the stage where the stressor is perceived consciously or unconsciously by the individual. B) Incorrect. Stage of resistance occurs when the body's adaptation takes place to deal with the stressor. C) Incorrect. Stage of exhaustion takes place when the adaptation that the body made to adapt to the stressor cannot be maintained. D) Incorrect. This is considered the second stage of alarm reaction. Jackson is not experiencing countershock yet; during this stage, the changes produced by the shock phase would be reversed. Type: MC Learning Outcome: 47-2 12) Jackson, 18 years old, was driving a car that has just skidded out of control and hit a tree.

He was wearing a seatbelt, and the airbags in the car deployed enabling him to escape without physical injury. As he exits the car, his hypothalamus is triggered by the stress. Which of the following physiological responses would the nurse expect to see in an individual related to changes in levels of epinephrine?

A) Flushed skin B) Increased blood pressure C) Pupils constrict D) Increased urine output Answer: B Explanation: A) Incorrect. Pale skin is a result of stress, not flushed skin, due to vasoconstriction in anbeattempt of the body to conserve blood for major organs or major muscle groups that may required for the fight-flight response.

B) Correct. A sympathetic response involved is an increase in the release of epinephrine which increases cardiac output and in turn increases blood pressure.

C) Incorrect. Pupils actually dilate as a response to stress, not constrict.

D) Incorrect. Urinary output is decreased due to the release of antidiuretic hormone which increases the reabsorption of water and sodium.

Type: MC Learning Outcome: 47-3

6 .

13) During a health clinic assessment, Mr. Banka describes his life as "in crisis." He reports that he has just lost his job, his wife is seeking a divorce, and he has been sick with a respiratory illness for 1 month. What statement, made by the nurse, reveals understanding of the care of a client in crisis?

A) "Once you reach the crisis state, you may remain there for several months until you recover."

B) "People generally find it easier to work through a crisis if someone is working with them."

C) "Men often handle crisis better individually, while women do better with a counsellor."

D) "Experiencing a crisis is never positive, so we must work to relieve your anxiety as soon as possible."

Answer: B Explanation: A) Incorrect. A crisis results in such a state of disequilibrium that it is generally self-limiting and not a long-term event.

B) Correct. In general, people are more successful in working through a crisis if they have someone to help them.

C) Incorrect. The need for help during crises is not gender dependent.

D) Incorrect. Experiencing a crisis may actually offer the family or individual a potential for growth and change.

Type: MC Learning Outcome: 47-6 14) The nurse identifies that a client has not met the expected outcome established for the nursing diagnosis of ineffective individual coping. What nursing action is priority?

A) Revise the nursing diagnosis B) Reassess the patient, looking for previously unknown stressors C) Rewrite the interventions used to address the problem D) Explore reasons why the outcome was not achieved Answer: D Explanation: A) Incorrect. There is nothing to indicate that the original diagnosis needs to be revised.

B) Incorrect. If a thorough assessment was completed before determining the diagnosis, there would be no need to revisit the client's stressors.

C) Incorrect. While new interventions may be appropriate, it would not be completed until the reasons why outcomes were not achieved are determined.

D) Correct. When the expected outcome is not met, the nurse, client, and support persons must explore reasons why before modifying the remaining portions of the care plan.

Type: MC Learning Outcome: 47-8

7 .

15) The client who has been experiencing slight anxiety is now communicating in a manner that makes it difficult for the nurse to understand the client's needs. When discussing this client with the physician, the nurse indicates the opinion that the client has progressed to which level of anxiety? A) Mild B) Moderate C) Severe D) Panic Answer: C Explanation: A) Incorrect. Mild anxiety causes an increase in questioning. B) Incorrect. Moderate anxiety results in voice tremors and pitch changes. C) Correct. Changes in verbalization can be indicative of increasing anxiety. At severe levels, communication is difficult to understand.

D) Incorrect. Panic is a state of heightened, often frightening state of anxiety that causes the client to lose control. Type: MC Learning Outcome: 47-5 16) Mrs. Barton, 72 years old, is seen in her physician's office 1 year after the death of her husband. Since his death she has been ill with shingles, and has just been released from the hospital after recovering from pneumonia. She says to the nurse, "I don't know why I have been so sick lately; I have looked after myself and have enjoyed good health all my life." What does research indicate may be a reason for Mrs. Barton's recent illness?

A) Reduced T cell function will render some clients susceptible to illness.

B) There is no correlation between the recent loss and client illness.

C) Psychosocial stress does not impact physical health.

D) Adaptation resources in the elderly are not adequate to fight illness.

Answer: A Explanation: A) Correct. Recent studies indicate that there is a relationship between stress and increase in morbidity and mortality. Others studies have identified specifically lower levels of T cell production after the loss of a spouse.

B) Incorrect. There is correlation between the recent loss and illness.

C) Incorrect. Stress can impact the overall physical health of a client especially when the adaptation made during the stage of resistance cannot be maintained.

D) Incorrect. There is no evidence to suggest that the elderly do not have adequate resources to manage stress and fight illness.

Type: MC Learning Outcome: 47-3

8 .

17) Mrs. Allimour has just received the news from her physician that her breast biopsy was negative. During discharge teaching the nurse finds the client to be easily distractible and unable to focus. What is the nurse's best interpretation of this situation? A) The client did not understand that there is no malignancy. B) Anxiety can result from both positive and negative stimuli. C) The client feels there is no need for teaching. D) Mrs. Allimour is mildly anxious, but should retain information taught. Answer: B Explanation: A) Incorrect. There is no indication that the client doesn't understand the report. B) Correct. Anxiety can be the result of both positive and negative stimuli. C) Incorrect. There is no indication that the client discounts the need for teaching. D) Incorrect. The amount of information retained may be reduced by the level of anxiety Mrs. Allimour is experiencing. The nurse should take extra care to ascertain that the she understands the teaching. Type: MC Learning Outcome: 47-5 18) Mr. Castillo has been admitted to the hospital with severe chest pain and has been diagnosed with myocardial infarction. The patient tells the nurse, "I don't think this is my heart. That spaghetti I ate for lunch tasted a little strange. I think I have food poisoning." What defense mechanism is this patient exhibiting?

A) Compensation B) Denial C) Displacement D) Identification Answer: B Explanation: A) Incorrect. Compensation is covering up weaknesses by emphasizing a strength or by overachievement.

B) Correct. Denial is an attempt to ignore unacceptable realities by refusing to acknowledge them.

C) Incorrect. Displacement is transferring emotional reactions from one object or person to another object or person.

D) Incorrect. Identification is an attempt to manage anxiety by imitating the behaviour of someone who is feared or respected.

Type: MC Learning Outcome: 47-6

9 .

19) The victim of domestic abuse tells the nurse, "I know my spouse didn't mean to hurt me.

The situation just got out of hand." The nurse recognizes that the client is exhibiting which of the following? A) Intellectualization B) Introjection C) Projection D) Minimization Answer: D Explanation: A) Incorrect. Intellectualization is a defense mechanism in which an uncomfortable or painful reality is evaded by using a rational explanation that removes personal significance from the event. B) Incorrect. Introjection is a form of identification in which the person adopts another person's norms or values, even if those norms or values are contrary to what the person would have previously assumed. C) Incorrect. Projection is blaming another person or the environment for one's own unacceptable thoughts, shortcomings, or failures. D) Correct. Minimization is not acknowledging the significance of a behaviour. Type: MC Learning Outcome: 47-6 20) Mrs. Parker was released from the hospital after a myocardial infarction. She is seeing a nutritionist to help plan a healthier diet and has also begun an exercise program to help lose weight. Which of the following describes her coping strategies?

A) Problem focused B) Emotion focused C) Maladaptive D) Short-term coping Answer: A Explanation: A) Correct. Considering that Mrs. Parker has had an MI, she is taking action to improve her health and prevent further cardiac problems.

B) Incorrect. Emotion focused response includes thoughts or actions that improve emotional distress but does nothing to improve the actual situation.

C) Incorrect. Maladaptive responses result in unnecessary distress for the client. Mrs. Parker's actions should result in an improvement in health.

D) Incorrect. This is an example of long-term coping strategies.

Type: MC Learning Outcome: 47-6

10 .

21) Ms. Petri is a student nurse presenting to her class on anxiety. Which of the following normal physiological responses to anxiety that she has included in her presentation indicates the need for further research on her part? A) Increased heart rate B) Increased respiratory rate C) Low hematocrit D) Low blood sugar Answer: D Explanation: A) Incorrect. An increase in heart rate would be considered to be a normal response to anxiety and should be included in the student's presentation. B) Incorrect. An increase in respiratory rate would be considered a normal response to anxiety and should be included in the student's presentation. C) Incorrect.

Sodium and water are also retained, which might reflect in a low-normal hematocrit due to increased blood volume. D) Correct. The blood sugar generally increases because of the release of glucocorticoids and gluconeogenesis. A low blood sugar is a misconception on the student's part and indicates the need for further study. Type: MC Learning Outcome: 47-3 22) Carter is a 2-year-old child who has experienced multiple hospital admissions to treat a congenital heart disorder. Upon today's admission, the nurse notices that the child is lying curled in the bed holding a stuffed animal and will not interact with his parents. How should the nurse interpret this behaviour?

A) The parents may have been abusing this child.

B) The child is probably developmentally delayed secondary to multiple hospitalizations.

C) The child is reacting as a normal 2-year-old.

D) The child could be suffering from a clinical depression.

Answer: C Explanation: A) Incorrect. While it would be important to assess for any physical signs, there is not enough information present here to draw that conclusion.

B) Incorrect. This is a normal response from a 2 year-old and does not indicate any developmental delay.

C) Correct. Toddlers and preschool children often react to anxiety by either withdrawing or acting out. This child is behaving in a normal manner.

D) Incorrect. There is no indication that the child is depressed; his responses are normal.

Type: MC Learning Outcome: 47-3

11 .

23) Which of the following models of stress uses scales to assess and document a person's stressful life events?

A) Stimulus B) Response C) Transaction D) Syndrome Answer: A Explanation: A) Correct. Stimulus-based models of stress consider that a life event or a set of circumstances arouses physiological or psychosocial reactions that may increase vulnerability to illness. A scale of stressful life events is used to document a person's recent experiences and may include up to 77 items, such as divorce, pregnancy, or retirement.

B) Incorrect. Response-based models of stress consider the effects of stressors on the body, and do not include scales for measurement.

C) Incorrect. Transaction-based models of stress seek to explain the individual coping that arises out of person-environment transactions. They do not use scales for assessment because it is believed that the reaction to stress is individualized.

D) Incorrect. There are no conceptualizations of stress as a syndrome.

Type: MC Learning Outcome: 47-1 24) How does Selye's general and local adaptation syndromes conceptualize stress?

A) As a stimulus B) As a response C) As a transaction D) As an interaction Answer: B Explanation: A) Incorrect. Selye's general and local adaptation syndromes are examples of conceptualizing stress as a response. It is not conceptualized as a stimulus.

B) Correct. Selye's general and local adaptation syndromes are examples of conceptualizing stress as a response. This model considers the effects of stressors on the body.

C) Incorrect. Transaction-based models of stress seek to explain the individual coping that arises out of person-environment transactions and is attributed to the work of Lazarus.

D) Incorrect. There are no conceptualizations of stress as an interaction.

Type: MC Learning Outcome: 47-1

12 .

25) Mr. Walsh cut his leg open severely in an accident with a chain saw. It bled profusely until he applied a pressure dressing with his shirt. After a short period of time, a clot formed and the wound stopped bleeding. According to Selye, what is this response called? A) Alarm reaction stage B) Stage of resistance C) Stage of exhaustion D) Local adaptation syndrome Answer: B Explanation: A) Incorrect. The initial reaction of the body is the alarm reaction stage, which alerts the body's defences against the stressor. B) Correct. Both the general adaptation syndrome (GAS) and the local adaptation syndrome (LAS) are comprised of three stages: alarm, resistance, and exhaustion. This response occurs during the stage of resistance; when the body's adaptation takes place. The body is coping with the stressor and limiting the stressor to the smallest area of the body that can deal with it. C) Incorrect. If the adaptation that the body made in the resistance stage cannot be maintained, the body enters the stage of exhaustion. This phase leads to either recovery or death. D) Incorrect. The local adaptation syndrome refers to a response to stress and includes alarm, reaction, resistance, and exhaustion. Type: MC Learning Outcome: 47-2 26) A student is preparing to take the final examination in Nursing 101. Which of the following findings would support that the student is experiencing a moderate level of anxiety?

A) Increased questioning B) Slightly increased respiratory and heart rates C) Palpitations D) Inability to relax Answer: B Explanation: A) Incorrect. Increased questioning is a response that would be evident in a mild stage of anxiety.

B) Correct. Anything beyond mild anxiety results in respiratory and circulatory changes.

Slightly increased respiratory and heart rates indicate moderate anxiety.

C) Incorrect. Palpitations would be evident in a state of panic.

D) Incorrect. An inability to relax would be an indicator of a severe anxiety reaction.

Type: MC Learning Outcome: 47-3

13 .

27) Mr. Batra is a new immigrant experiencing much stress since hospitalization. He has no family support. What would be the best nursing intervention to help him cope with stress? A) Keep patient busy so time goes by quickly B) Provide as much privacy as possible C) Provide for adequate rest and relaxation D) Ask questions until patient expresses feelings Answer: C Explanation: A) Incorrect. Keeping the patient busy will only compound a lack of rest. B) Incorrect. Providing as much privacy as possible may make the patient feel isolated. C) Correct. Stress can alter sleep patterns, thus compromising the basic physiological need for rest. By promoting rest and relaxation, the nurse is helping the patient cope with stress. D) Incorrect. Asking questions until feelings are expressed is not therapeutic. A variety of therapeutic communication techniques should be used to express empathy and promote the expression of the patient's feelings. Type: MC Learning Outcome: 47-9 28) Which nursing diagnosis is defined as "the state in which the individual experiences feelings of uneasiness and activation of the autonomic nervous system in response to a vague, nonspecific threat"?

A) Fear B) Anxiety C) Ineffective individual coping D) Decisional conflict Answer: B Explanation: A) Incorrect. Fear is defined as an emotion or a feeling of apprehension aroused by impending or seeming danger, pain, or other perceived threat.

B) Correct. This is the definition of anxiety. The source of anxiety is vague, whereas the source of fear is identifiable.

C) Incorrect. Ineffective coping is related to the use of ineffective problem solving skills.

D) Incorrect. Decisional conflict relates to uncertainty of course of action when the choices among competing actions involve risk, loss, or challenge to personal life values.

Type: MC Learning Outcome: 47-8

14 .

Fundamentals of Canadian Nursing, 4e (Kozier) Chapter 48 Loss, Grieving, and Death 1) The nurse is counselling a family in which a member is terminally ill. The family has children of varying ages. What should the nurse teach the family about the reactions of children to death? A) Toddlers perceive death as irreversible. B) Preschool children view death as a spiritual release. C) At about age 9, children begin to understand death is inevitable. D) Adolescents' views are influenced by cultural beliefs. Answer: C Explanation: A) Incorrect.

Toddlers do not understand the concept of death, and like preschoolers, tend to see death as reversible. B) Incorrect. Preschoolers view death as reversible, a temporary departure or sleep.

C) Correct. At about age 9, children's concept of death matures and most understand that death is an inevitable part of life. D) Incorrect. Adolescents believe that death can be defied.

Type: MC Learning Outcome: 48-3 2) What should the nurse understand when applying models of grief to terminally ill clients? A) The Kubler-Ross model is primarily used to describe anticipatory grief. B) No clear timetables exist, nor are there clear-cut stages of grief.

C) The models serve as clear and definitive predictors of grief behaviours. D) There is strong research proving that these models are not useful for many dying clients. Answer: B Explanation: A) Incorrect. Kubler-Ross describes stages of all grief and grieving. B) Correct.

Although the models of grief are useful in guiding nursing care of clients who are experiencing loss, there are no clear-cut stages of grief, nor are there exact timetables. C) Incorrect. None of the models are clear or definitive predictors of grief behaviours. D) Incorrect. The models of grief are useful in guiding nursing care of clients who are experiencing loss. Type: MC Learning Outcome: 48-2

1 .

3) The nurse is discussing end of life care with Mrs. Masters, a 61-year-old mother of two grown daughters. She has terminal uterine cancer. Mrs. Masters is very clear about the care she wishes to receive, and does not want to leave any difficult decisions to her daughters. Which of the following best describes the appropriate legal document to provide health providers with direction for future care for Mrs. Masters?

A) Living will B) Advance directive C) Proxy directive D) Power of attorney Answer: A Explanation: A) Correct. This is the most appropriate legal document. It is intended to identify the life sustaining treatment a person wants in certain situations.

B) Incorrect. Advance directives are the means to document and communicate a person's preferences regarding life sustaining treatment in the event they are unable to express their wishes for themselves. Advance directives may come in the form of a living will or a proxy directive.

C) Incorrect. A proxy directive would be used in the case where Mrs. Masters was choosing to have someone make decisions for her when the time came that she was unable to make them on her own.

D) Incorrect. A power of attorney is a broader legal document intended to assign a proxy for a person's legal affairs and does not always include decisions for care. A durable power of attorney, or a power of attorney for health care, may indicate or identify a person who would be delegated to make decisions for an individual if they were unable.

Type: MC Learning Outcome: 48-6

2 .

4) Which of the following is a useful nursing intervention in treatment of anxiety associated with receiving a terminal diagnosis?

A) Explore the client's history with other stressful life events and how they coped at that time B) Speak with the family about how best to help the client cope C) Provide information about the client's terminal illness only on a need to know basis D) Encourage early pharmaceutical intervention with anti-anxiety and sedative medications Answer: A Explanation: A) Correct. The client who has received a terminal diagnosis needs to discuss the future and the implications of the diagnosis. The need for discussion and the amount of time needed will vary from client to client.

B) Incorrect. The first discussion needs to take place with the client. This option does not take into consideration that the family may need help coping with their own feelings about the impending loss.

C) Incorrect. The client must be given facts about the disease process and projected trajectory so that final business and relationships can be addressed. This may not be the right time to share with the client all information; this may be addressed once the initial anxiety regarding the diagnosis has dissipated.

D) Incorrect. Early use of anti-anxiety and sedative medications is not appropriate because these medications can adversely affect the client's ability to decision make and think clearly about the future.

Type: MC Learning Outcome: 48-4 5) Mrs. Jakobs' son has just died. He was living with HIV and most recently AIDS. What can the nurse do at this time to provide comfort for Mrs. Jakobs?

A) Be present in silence with Mrs. Jakobs B) Tell her that her son is at peace now C) Let her know that time will heal her wounds D) Ask her whether funeral arrangements have been made Answer: A Explanation: A) Correct. Often, especially if the nurse is unable to find the right words to say, being present and comfortable with silence can be supportive of the client at difficult times.

B) Incorrect. This is a platitude that is intended to provide comfort. Often these types of statements, made in an effort to fill the silence, deny the right of the client to fully experience, acknowledge, and express grief as a part of incorporating loss into their lives.

C) Incorrect. This is a platitude that is intended to provide comfort, often spoken when the nurse is at a loss for words.

D) Incorrect. It is too soon to discuss these details with Mrs. Jakobs. This would not provide comfort but instead make Mrs. Jakobs feel that it was time for her to leave.

Type: MC Learning Outcome: 48-4

3 .

6) A client with terminal lung cancer complains of being short of breath. He has bilateral crackles and wheezes, despite oxygen at 4 Lpm via nasal cannula and diuretic therapy. What nursing interventions are appropriate for this client? (Select all that apply.)

1. Move the client to a room closer to the nurse's desk for closer observation 2. Help the client assume a position lying on the right side 3. Place a fan in the room to move air around the client 4. Change the client's oxygen therapy to a non-rebreathing mask 5. Elevate the head of the client's bed to a Fowler's position 6. Consider use of a prn morphine sulfate order Answer: 3, 5, 6 Explanation: Placement of a fan to circulate air, elevating the head of the bed, and use of morphine sulfate may relieve shortness of breath. Moving the client who is short of breath is not advisable. Lateral positions are appropriate for unconscious clients, but this client is conscious.

Conscious clients who are short of breath do not tolerate oxygen therapy by mask.

Type: SA Learning Outcome: 48-8 7) The nurse is providing postmortem care for a client whose family would like to view the body before it is transported to the morgue. Which of the following interventions are necessary for this preparation? (Select all that apply.)

1. Provide a total bed bath 2. Place absorbent pads beneath the body 3. Remove dentures 4. Dress the client in street clothes 5. Place a pillow under the head 6. Tape the eyelids closed Answer: 2, 5 Explanation: The nurse should place a pillow under the head and place absorbent pads beneath the body. Soiled areas of the body should be washed, but a total bed bath is not necessary.

Dentures should be inserted. The eyelids should be held in place until they stay closed and should not be taped. The client should be dressed in a clean gown.

Type: SA Learning Outcome: 48-9

4 .

8) Mr. Raffin is caring for his terminally ill wife at home. He has children that live close by and are in daily contact with him. Mr. Raffin asks the nurse how he will know when death is close so that he can make sure his children are with him. Which of the following are signs of imminent death? (Select all that apply.)

1. Relaxation of the facial muscles 2. Flushed skin of extremities 3. Abdominal distention 4. Deep rhythmic breathing 5. Complaints of blurred vision Answer: 1, 3, 5 Explanation: Relaxation of the facial muscles may cause the jaw to sag. Abdominal distention may also be accompanied by accumulation of flatus, and possible urinary and fecal incontinence due to relaxation of the sphincters. Complaints of blurred vision and an impaired sense of taste and smell are common. Skin of the extremities is usually mottled and cyanosed, and may be cool to the touch. Breathing is usually shallow and irregular.

Type: SA Learning Outcome: 48-5 9) A client who has just been diagnosed with a slowly progressive terminal illness asks the nurse about the availability of hospice services. What information should the nurse share with this client?

A) When clients are designated as terminally ill, they are automatically assigned to hospice care.

B) Hospice services are generally reserved for those who have a life expectancy of 6 months or less.

C) Hospice care is based on seeking cure of the underlying illness.

D) Provision of hospice services is reserved only for those who refuse other palliative treatments.

Answer: B Explanation: A) Incorrect. Clients are not automatically assigned to hospice. Nurses can provide families with information on what care is available and appropriate for the individual. This may include, but is not limited to, hospice care.

B) Correct. Hospice services are generally provided only to those who are expected to live less than 6 months.

C) Incorrect. Hospice palliative care is based on the principles of providing care to improve the dying individual's quality of life rather than aiming for cure.

D) Incorrect. This is not a true statement. Hospice is available for clients who have less than 6 months to live.

Type: MC Learning Outcome: 48-9

5 .

10) Mrs. Donaldson's father has just died. She says to the nurse, "How will I help my young son cope with this loss?" What information can the nurse provide to Mrs. Donaldson?

A) Give the child permission to be sad B) Pray with him for his grandfather's soul C) Tell the child that his grandfather went to sleep and will not wake up D) Deal with your own grief privately first Answer: A Explanation: A) Correct. Children sometimes do not want to display sadness because they do not want to upset others. Expressions of sadness are important so that children receive the attention required after a loss.

B) Incorrect. This is an assumption about this woman and her family. There is not enough information about the family's belief system to determine whether prayer could be considered comforting to a child.

C) Incorrect. Telling the child that his grandfather fell asleep and will not wake up may invoke fears that the same thing could happen to him.

D) Incorrect. Involving the child who has experienced a loss with the grieving activities of others is a healthy and supportive approach.

Type: MC Learning Outcome: 48-4 11) Mrs. Donaldson has her extended family over to her house the day before her father's funeral.

With the exception of her youngest son, Daniel, everyone is helping to put a picture story board together before the service. Daniel is outside on the swing in the back yard. In regards to supporting Daniel and his grief, what should Mrs. Donaldson do?

A) Talk to Daniel to see how he is feeling B) Bring Daniel inside to join the other family C) Have the other children go out and join Daniel D) Have Daniel write a story about his grandfather for the picture board Answer: A Explanation: A) Correct. Mrs. Donaldson should check to see how Daniel is feeling but should not expect that he either join the others, or insist that he partake in activities which do not support his grieving process. Grief is expressed differently by different people. As long as Daniel is safe, he can be left alone if that is what comforts him.

B) Incorrect. Insisting that Daniel join the others may not meet his own needs at this time. Daniel may be better able to manage his grief with brief periods of solitude.

C) Incorrect. This may not be supportive of Daniel's needs at this time.

D) Incorrect. The scenario does not give an age for Daniel, and this may not be appropriate for him. It is also more prescriptive and assumes that this will be therapeutic for him.

Type: MC Learning Outcome: 48-2

6 .

12) Palliative care competencies include listening, engaging in difficult conversations, and the ability to be present with clients.

Answer: TRUE Explanation: According to the Canadian Association of Schools of Nursing, competencies include relational practice which includes skill in listening, engaging in difficult conversations, and being present with clients.

Type: TF Learning Outcome: 48-7 13) The nurse is caring for a client whose family does not want to tell him that he is dying. What is the nurse's best action according to these wishes?

A) Arrange an encounter with the client and tell him the truth B) Change the subject when the client asks about his impending death C) Tell the family that the patient has the right to know that he is dying D) Talk to the family about the situation and their concerns Answer: D Explanation: A) Incorrect. The nurse needs to assess further the reasons why the family feel so strongly about not telling the client.

B) Incorrect. The nurse should not change the subject if the client asks about impending death, but should not encourage such an encounter before discussing the situation with the family.

C) Incorrect. The nurse should have this discussion with the family before offering such advice as the client has a right to know. This approach is imposing the nurse's values and beliefs on the family.

D) Correct. In this situation, the best approach for the nurse to take is to talk with the family about what is happening and what their concerns are. The nurse should investigate religious, cultural, and family traditions regarding telling the client about impending death.

Type: MC Learning Outcome: 48-9 14) Which of the following is feared most by an older adult facing death?

A) Nausea B) Loss of control C) The cost of terminal care D) The unknown Answer: B Explanation: A) Incorrect. While nausea is a symptom of impending death, it is not something that the older adult fears.

B) Correct. For older people, an anticipated loss such as their own death may not be viewed as a highly negative loss, and they may be apathetic about it instead of reactive. More than fearing death, some may fear loss of control or becoming a burden.

C) Incorrect. This may be a fear of the partner or family of the terminally ill.

D) Incorrect. Older adults have experienced loss at higher rates than younger people. They do not fear the unknown.

Type: MC Learning Outcome: 48-3

7 .

15) In which of the following age ranges is it characteristic to accept one's own mortality?

A) 9 to 12 years B) 12 to 18 years C) 18 to 45 years D) 45 to 65 years Answer: D Explanation: A) Incorrect. At 9 to 12 years the child begins to understand their own mortality.

B) Incorrect. At 12 to 18 years, the individual may seem to reach adult perception of death but be emotionally unable to accept it.

C) Incorrect. At age 18 to 45 years, attitudes toward death are influenced by religious and cultural beliefs and this leads to eventual acceptance of one's own mortality.

D) Correct. At age 45 to 65 years, the individual accepts one's own mortality.

Type: MC Learning Outcome: 48-2 16) Which of the following is a clinical sign of imminent death?

A) Flat encephalogram B) Sensory impairment C) Muscle rigidity D) Unconsciousness Answer: B Explanation: A) Incorrect. A flat encephalogram is a sign of actual, not imminent death.

B) Correct. The four main clinical signs of imminent death include loss of muscle tone, slowing of the circulation, changes in respirations, and sensory impairment.

C) Incorrect. Loss of muscle tone, not muscle rigidity, is a sign of imminent death.

D) Incorrect. Various consciousness levels (from alertness to comatose) occur just before death.

Type: MC Learning Outcome: 48-5 17) Ms. Cruikshank is a student nurse who is experiencing her first day on a palliative care unit.

She is interested in the physiological and sensory changes that occur before death. How does the RN respond when Ms. Cruikshank asks about which sense is the last lost before death?

A) Sight B) Smell C) Hearing D) Touch Answer: C Explanation: A) Incorrect. Blurred vision is thought to occur before death, usually before hearing is lost.

B) Incorrect. An impaired sense of taste and smell occur before death, usually before hearing is lost.

C) Correct. Hearing is thought to be the last sense lost before death, and it is thus important for those around the dying client to be conscious of spoken words and other auditory stimulation.

D) Incorrect. Hearing is the last sense lost before death, not touch.

Type: MC Learning Outcome: 48-5

8 .

18) Mr. Van Buskirk's wife just died 30 minutes ago on the medical unit. What actions by the nurse supports Mr. Van Buskirk's grieving? (Select all that apply.)

1. Be present, but comfortable with silence 2. Assists him with the arrangements for the funeral home 3. Suggest resources such as grief support groups 4. Speak in terms of what he needs and not his current pain 5. Respect his cultural and religious values related to his loss Answer: 1, 3, and 5 Explanation: A nurse can support and care in specific ways for a client experiencing loss by accepting, facilitating, and normalizing the experience and expression of grief through actions and attitudes including being present and comfortable with silence, and offering touch if the person indicates that would be comforting; acknowledging pain and suffering; exploring and respecting clients' racial, cultural, religious, personal, and family values in their expression of grief; and providing resource and support information, such as local grief support groups or counselling.

Type: SA Learning Outcome: 48-4 19) The nurse is providing support for a bereaved client. What does the nurse need to know about the experience of grief?

A) Experienced differently by different people B) Best carried out in solitude C) Expressions of grief for longer than 6 months are socially unacceptable D) Detrimental to emotional well-being Answer: A Explanation: A) Correct. The experience of grief is different for different individuals. Nurses should be aware that individuals should not be expected to adhere to others' expectations of appropriate expressions of grief.

B) Incorrect. This may be true for some individuals, but not for all.

C) Incorrect. A 6-month time period is not a long time period for feelings of grief. If this extended beyond a year, with the client still experiencing intense emotions, there may be cause to believe that they are suffering from complicated grief.

D) Incorrect. Grief is an important experience for emotional well-being.

Type: MC Learning Outcome: 48-2

9 .

20) The terminally ill client states to the nurse, "I'm just not ready to go." Which of the following is the most appropriate response by the nurse? A) "Tell me more about what you mean when you say that you're not ready." B) "You're not ready to go where?" C) "Don't be afraid, dying is a natural process." D) "I can understand that. Most people don't want to die."

Answer: A Explanation: A) Correct. The nurse should use an open-ended question to encourage expression of the client's thoughts and feelings. Exploring the reasons for his statement with the client will help build empathy and encourage client expression. B) Incorrect. Asking for an explanation for where the client is going does not encourage expression, but rather belittles the client's feelings. C) Incorrect. Telling the client that there is nothing to be afraid of, that most people don't want to die, or asking for an explanation for where the client is going does not encourage expression, but rather belittles the client's feelings. D) Incorrect. This statement closes all opportunities for the client to express his emotions. Using an open-ended question will encourage more dialogue and perhaps relieve the client's fear. Type: MC Learning Outcome: 48-7 21) Ms. Clarence is a student nurse caring for a terminally ill client on the palliative care floor. When discussing her plan of care for the day with the RN, she discusses pain control. What statement by Ms. Clarence indicates that a knowledge gap exists in relation to pain control of the palliative client? A) Analgesics are most effective if given prn. B) Opioids generally are the drugs of choice. C) Massage can be used as an adjunct treatment. D) Fear of precipitating a delirious episode may result in undertreatment. Answer: A Explanation: A) Correct. This is an incorrect statement.

Medication for chronic pain is more effective if given around the clock, not just on a prn basis. B) Incorrect. Opioids are generally the drugs of choice in palliative care. C) Incorrect.

Non pharmacological methods may be used as adjuncts to provide pain relief. This may involve baths, massage, and providing distraction. D) Incorrect. This is true. Often if health care staff are worried about the side effects of medications, this tends to result in undermedicating the client. Type: MC Learning Outcome: 48-8

10 .

22) After a biopsy, the client tells his physician that if the mass is malignant, he wants to know, but he does not want any further treatment or his family to know. What would be a major nursing responsibility in caring for the client?

A) Convince him to tell his family B) Suggest he consider treatment options C) Support his decisions regarding care D) Contact his family so they can help him Answer: C Explanation: A) Incorrect. Ultimately, the client is the decision-maker for his own care and it would be coercive to "convince" the client to do anything. The nurse needs to be aware of her own values, but respect those of the client.

B) Incorrect. While the nurse may assess the client's knowledge about treatment options, and provide him with information on them, ultimately the decision remains with the client.

C) Correct. The nurse must support the client's decisions regarding care. By establishing a clientfocused relationship, the nurse is able to explore the client's knowledge about illness, identify and assist with coping strategies, and meet client needs while promoting client autonomy.

D) Incorrect. Contacting the family would be a breach of nurse-client confidentiality.

Type: MC Learning Outcome: 48-10 23) The nurse in a palliative care unit is caring for Mrs. Redmond, an 81-year-old terminally ill client. While completing Mrs. Redmond's assessment, she complains of feeling short of breath.

Her vital signs are as follows: T-36.9, Pulse 52 and thready, and Respirations 18 and regular.

What should the nurse do next?

A) Consult the physician for possible chest X-ray (CXR) B) Provide prn bronchodilator C) Contact physician to report heart rate D) Change her position Answer: B Explanation: A) Incorrect. Mrs. Redmond does not need a CXR. She is experiencing shortness of breath even though it may not be apparent by her vital signs. A CXR will not do anything to relieve her symptoms.

B) Correct. This is the only option that treats Mrs. Redmond's shortness of breath. Dyspnea is a subjective finding which can be present only to the person experiencing it. Her respiratory rate although normal is not enough data to rule dyspnea out. The bronchodilator is an expected treatment option.

C) Incorrect. This may be a normal heart rate for someone who is close to death. In a palliative care unit, where the goal of care is comfort, a low heart rate would not necessarily be reported or treated.

D) Incorrect. While this may be appropriate, this is not a specific enough answer. The client may be more comfortable in a sitting up position.

Type: MC Learning Outcome: 48-8

11 .

24) A nurse is caring for terminally ill clients on a palliative care unit. What considerations does the nurse need to make to provide supportive care to these clients? A) Evaluate her own ability to interact supportively in this area B) Enhance the client's body image C) Provide accurate information and education D) Assist the client to identify spiritual concerns Answer: A Explanation: A) Correct. A nurse's self-awareness is a precursor to providing effective relational care. It is believed that a nurse needs insight into how their lived experiences, emotional life, thoughts, beliefs, and attitudes influence the ability to interact with patients, families, and other health care providers. B) Incorrect. Although enhancing the client's body image is important, without self-awareness of her own values and beliefs, the nurse may be providing care based on what was important to her, rather than meeting the client's needs. C) Incorrect. Providing accurate information to clients and families is important for their spiritual well-being. The nurse, however, needs to first evaluate her own capabilities to interact with clients in order to be present and open to their needs. D) Incorrect. Assisting the client to identify spiritual concerns may contribute to providing spiritual health care; however, none may be effective until the nurse first evaluates her own ability to interact supportively in this area. Type: MC Learning Outcome: 48-4 25) What is the earliest age at which most persons accept death as being irreversible? A) 3 years old B) 5 years old C) 9 years old D) 12 years old Answer: B Explanation: A) Incorrect. At this age, the toddler or preschooler believes that death is reversible, a temporary departure, or sleep. B) Correct. 5 years of age is the earliest age at which most persons accept death as being irreversible. C) Incorrect.

Between the ages of 5 to 9 years, the child obtains an understanding that death is final. D) Incorrect. By 12 years of age an individual may reach adult perception of death but is emotionally unable to accept it. Type: MC Learning Outcome: 48-3

12 .

26) Which of the following interventions would best help to maintain a dying client's dignity and sense of self-worth?

A) Allow the client to make choices and set timetables for scheduled activities B) Suggest that the client die quietly at home in a familiar environment C) Have other terminally ill individuals visit the client D) Schedule uninterrupted quiet time for the client to reflect on her past Answer: A Explanation: A) Correct. Dying clients may fear the loss of control even more than the actual death. The ability to relate to others and the environment allows the individual an important sense of control. Allowing the client to make choices and set timetables for scheduled activities utilizes autonomy and best helps to promote the dying client's dignity and self-worth.

B) Incorrect. This is a decision for the client and her family. Although the nurse may provide information as an option, this would not be a decision for her to make.

C) Incorrect. This does not focus on the client's needs. Supporting dignity in death is a relational experience, and should include conversations about what the client wants and is capable of participating in at this time.

D) Incorrect. This may not be what the client needs or wants at this time, and does not promote client autonomy.

Type: MC Learning Outcome: 48-8 27) Which of the following describes the legal document that specifies who will make care decisions for a client when they are unable?

A) Self-determination act B) Proxy directive C) Living will D) Advance directives Answer: B Explanation: A) Incorrect. This is not the correct term.

B) Correct. A proxy directive is a term used to specify who will make decisions regarding health care treatment when a client is unable.

C) Incorrect. A living will is the term used to describe an advance directive, a document used to communicate a person's preferences regarding life sustaining treatment in the event they become incapable of making decisions during that time.

D) Incorrect. Advance directives is the broad term used to provide a means to document and communicate a person's preferences regarding life-sustaining treatment in the event that they are incapable of expressing those wishes. They include both living wills and proxy directives.

Type: MC Learning Outcome: 48-6

13 .

28) The husband of a client with a terminal illness states that he will miss evening walks with his wife. This comment best indicates which type of loss?

A) Actual loss B) Perceived loss C) Anticipatory loss D) Anticipatory perceived loss Answer: D Explanation: A) Incorrect. An actual loss can be identified by others and can arise either in response to or in anticipation of a situation.

B) Incorrect. A perceived loss is experienced by one person but cannot be verified by others.

Psychological losses are often perceived losses in that they are not directly verifiable.

C) Incorrect. An anticipatory loss is experienced before the loss actually occurs. The loss described will occur in the future (anticipatory).

D) Correct. An anticipatory loss is experienced before the loss actually occurs. The loss described will occur in the future (anticipatory). Additionally, there are psychological components to this loss which are not directly verifiable. Therefore, the loss is an anticipatory perceived loss.

Type: MC Learning Outcome: 48-1

14 .