Concepts for Nursing Practice 4th Edition by Jean Foret Giddens | TEST BANK

TEST BANK

TEST BANK

Concept 1. Development Concept 2. Functional Ability Concept 3. Family Dynamics Concept 4. Culture Concept 5. Self-Management Concept 6. Fluid and Electrolytes Concept 7. Acid–Base Balance Concept 8. Thermoregulation Concept 9. Sleep Concept 10. Cellular Regulation Concept 11. Intracranial Regulation Concept 12. Hormonal Regulation Concept 13. Glucose Regulation Concept 14. Nutrition Concept 15. Elimination Concept 16. Perfusion Concept 17. Clotting Concept 18. Gas Exchange Concept 19. Reproduction Concept 20. Sexuality Concept 21. Immunity Concept 22. Inflammation Concept 23. Infection Concept 24. Mobility Concept 25. Tissue Integrity Concept 26. Sensory Perception Concept 27. Pain Concept 28. Fatigue Concept 29. Stress and Coping Concept 30. Mood and Affect Concept 31. Anxiety

Concept 32. Cognition Concept 33. Psychosis Concept 34. Substance Misuse and Addiction Concept 35. Interpersonal Violence Concept 36. Professional Identity Concept 37. Well-Being and Resilience Concept 38. Leadership Concept 39. Evidence Concept 40. Clinical Judgment Concept 41. Person-Centered Care Concept 42. Ethics Concept 43. Diversity, Equity, and Inclusion Concept 44. Communication Concept 45. Collaboration Concept 46. Safety Concept 47. Health Care Quality Concept 48. Technology and Informatics Concept 49. Health Disparities and Health Equity Concept 50. Care Coordination Concept 51. Health Promotion Concept 52. Patient Education Concept 53. Palliative Care Concept 54. Population Health Concept 55. Public Health Emergencies Concept 56. Spheres of Practice Concept 57. Health Systems Concept 58. Health Care Economics Concept 59. Health Policy Concept 60. Health Care Law

PN Concept 01: Development Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to review for needs related to a. anticipatory guidance. b. low-risk adolescents. c. physical development. d. sexual development.

ANS: A The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which reviews home, education, activities, drugs, sex, and suicide for the purpose of identifying high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not low-risk, adolescents. Physical development is reviewed with anthropometric data.

Sexual development is reviewed using physical examination.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the expected stage of development for a preschooler is a. concrete operational. b. formal operational. c. preoperational. d. sensorimotor.

ANS: C The expected stage of development for a preschooler (3–4 years old) is pre-operational.

Concrete operational describes the thinking of a school-age child (7–11 years old). Formal operational describes the thinking of an individual after about 11 years of age. Sensorimotor describes the earliest pattern of thinking from birth to 2 years old.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 3. The school nurse talking with a high school class about the difference between growth and development would best describe growth as a. processes by which early cells specialize. b. psychosocial and cognitive changes. c. qualitative changes associated with aging. d. quantitative changes in size or weight.

ANS: D

Growth is a quantitative change in which an increase in cell number and size results in an increase in overall size or weight of the body or any of its parts. The processes by which early cells specialize are referred to as differentiation. Psychosocial and cognitive changes are referred to as development. Qualitative changes associated with aging are referred to as maturation.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 4. The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b. identifies a need for physical therapy. c. is a developmental screening tool. d. provides a framework for health teaching.

ANS: C The Denver II is the most commonly used measure of developmental status used by healthcare professionals; it is a screening tool. Screening tools do not provide a diagnosis.

Diagnosis requires a thorough neurodevelopment history and physical examination.

Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 5. To plan early intervention and care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b. failure to thrive. c. fetal alcohol syndrome. d. hydrocephaly.

ANS: D Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of adaptive developmental delay. Failure to thrive is an exemplar of social/emotional developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental delay.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 6. To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition.

ANS: C

Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes); hence determination of development would be the focus of preventive interventions. Environment is considered to significantly affect development. Nutrition is considered to significantly affect development.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychological evaluation. The nurse’s best initial response is to a. refer the child to a psychologist immediately. b. explain that playing make believe is normal at this age. c. complete a developmental screening using a validated tool. d. separate the child from the mother to get more information.

ANS: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. b. rebel against rules. c. regress because of stress. d. want to know everything.

ANS: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors.

An adolescent may want to “know everything” with their logical thinking and deductive reasoning, but that would not explain why they would act like a child.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

RN Concept 01: Development Giddens: Concepts for Nursing Practice, 3rd Edition MULTIPLE CHOICE 1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to assess for needs related to a. anticipatory guidance. b. low-risk adolescents. c. physical development. d. sexual development.

ANS: A The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not low-risk, adolescents. Physical development is assessed with anthropometric data.

Sexual development is assessed using physical examination.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the expected stage of development for a preschooler is a. concrete operational. b. formal operational. c. preoperational. d. sensorimotor.

ANS: C The expected stage of development for a preschooler (3–4 years old) is pre-operational.

Concrete operational describes the thinking of a school-age child (7–11 years old). Formal operational describes the thinking of an individual after about 11 years of age. Sensorimotor describes the earliest pattern of thinking from birth to 2 years old.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 3. The school nurse talking with a high school class about the difference between growth and development would best describe growth as a. processes by which early cells specialize. b. psychosocial and cognitive changes. c. qualitative changes associated with aging. d. quantitative changes in size or weight.

ANS: D

Growth is a quantitative change in which an increase in cell number and size results in an increase in overall size or weight of the body or any of its parts. The processes by which early cells specialize are referred to as differentiation. Psychosocial and cognitive changes are referred to as development. Qualitative changes associated with aging are referred to as maturation.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 4. The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b. identifies a need for physical therapy. c. is a developmental screening tool. d. provides a framework for health teaching.

ANS: C The Denver II is the most commonly used measure of developmental status used by healthcare professionals; it is a screening tool. Screening tools do not provide a diagnosis.

Diagnosis requires a thorough neurodevelopment history and physical examination.

Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 5. To plan early intervention and care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b. autism. c. attention-deficit/hyperactivity disorder (ADHD). d. failure to thrive.

ANS: D Failure to thrive is also a physical development exemplar. Cerebral palsy is an exemplar of motor/developmental delay. Autism is an exemplar of social/emotional developmental delay. ADHD is an exemplar of a cognitive disorder.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 6. To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition.

ANS: C

Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes); hence determination of development would be the focus of preventive interventions. Environment is considered to significantly affect development. Nutrition is considered to significantly affect development.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychological evaluation. The nurse’s best initial response is to a. refer the child to a psychologist immediately. b. explain that playing make believe is normal at this age. c. complete a developmental screening using a validated tool. d. separate the child from the mother to get more information.

ANS: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. b. rebel against rules. c. regress because of stress. d. want to know everything.

ANS: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors.

An adolescent may want to “know everything” with their logical thinking and deductive reasoning, but that would not explain why they would act like a child.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

9. The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b. identifies a need for physical therapy. c. is a developmental screening tool. d. provides a framework for health teaching.

ANS: C The Denver II is the most commonly used measure of developmental status used by healthcare professionals; it is a screening tool. Screening tools do not provide a diagnosis.

Diagnosis requires a thorough neurodevelopment history and physical examination.

Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

10. To plan early intervention a n Nd care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b. autism. c. attention-deficit/hyperactivity disorder (ADHD). d. failure to thrive.

ANS: D Failure to thrive is also a physical development exemplar. Cerebral palsy is an exemplar of motor/developmental delay. Autism is an exemplar of social/emotional developmental delay. ADHD is an exemplar of a cognitive disorder.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

11. To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition.

ANS: C

Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes); hence determination of development would be the focus of preventive interventions. Environment is considered to significantly affect development. Nutrition is considered to significantly affect development.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

12. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychological evaluation. The nurse’s best initial response is to a. refer the child to a psychologist immediately. b. explain that playing make believe is normal at this age. c. complete a developmental screening using a validated tool. d. separate the child from the mother to get more information.

ANS: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time.

OBJ:

NCLEX Client NeedsNCategory: Health Promotion and Maintenance

13. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. b. rebel against rules. c. regress because of stress. d. want to know everything.

ANS: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors.

An adolescent may want to “know everything” with their logical thinking and deductive reasoning, but that would not explain why they would act like a child.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

Concept 02: Functional Ability Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is assessing a patient’s functional ability. Which patient best demonstrates the definition of functional ability? a. Considers self as a healthy individual; uses cane for stability b. College educated; travels frequently; can balance a checkbook c. Works out daily, reads well, cooks, and cleans house on the weekends d. Healthy individual, volunteers at church, works part time, takes care of family and house ANS: D Functional ability refers to the individual’s ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, healthy individual, church volunteer, part time worker, and the patient who takes care of the family and house fully meets the criteria for functional ability.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. The nurse is assessing a patient’s functional performance. What assessment parameters will be most important in this assessment? a. Continence assessment, gait assessment, feeding assessment, dressing assessment, N transfer assessment b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Health and well-being, amount of community volunteer time, working outside the home, and ability to care for family and house ANS: A Functional impairment, disability, or handicap refers to varying degrees of an individual’s inability to perform the tasks required to complete normal life activities without assistance.

Height, weight, BMI, and vital signs are part of a physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient’s functional ability. What question would be the most appropriate? a. “Are you able to shop for yourself?” b. “Do you use a cane, walker, or wheelchair to ambulate?” c. “Do you know what today’s date is?” d. “Were you sad or depressed more than once in the last 3 days?”

ANS: B

“Do you use a cane, walker, or wheelchair to ambulate?” will assist the nurse in determining the patient’s ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient? a. Eating and drinking, personal cleansing and dressing, working and playing b. Toileting, transferring, dressing, and bathing activities c. Sleeping, expressing sexuality, socializing with peers d. Maintaining a safe environment, breathing, maintaining temperature ANS: D The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service after left knee replacement. Which tool is the best for the nurse to utilize? N a. Minimum Data Set (MDS) b. Functional Status Scale (FSS) c. 24-Hour Functional Ability Questionnaire (24hFAQ) d. The Edmonton Functional Assessment Tool ANS: C The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is assessing a patient’s functional abilities and asks the patient, “How would you rate your ability to prepare a balanced meal?” “How would you rate your ability to balance a checkbook?” “How would you rate your ability to keep track of your appointments?” Which tool would be indicated for the best results of this patient’s perception of their abilities? a. Functional Activities Questionnaire (FAQ) b. Mini Mental Status Exam (MMSE) c. 24hFAQ d. Performance-based functional measurement ANS: A

The FAQ is an example of a self-report tool which provides information about the patient’s perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is used to assess functional ability in postoperative patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient’s risk for falls so that falls prevention can be implemented if necessary.

Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence ANS: B, D, E, F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Taking meNdications to treat hypertension that may lead to hypotension and dizziness is a fall risk. Dizziness does contribute to falls.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Concept 03: Family Dynamics Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions and lack of family support for a patient would be to a. enforce hospital visiting policies. b. monitor the dysfunctional interactions. c. notify the primary care provider. d. role model appropriate support.

ANS: D Nurses can, at times, role model more appropriate interactions or provide suggestions for improving communication and interactions among family members. If the nurse determines that the number of visitors has a negative impact on the patient, hospital policy may be to limit visitors, but that would not be the initial action. Monitoring the dysfunctional interactions would not be an adequate response. The primary care provider should certainly be notified, but that would not be the initial response.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. The nurse caring for a patient would identify a need for additional interventions related to family dynamics when a. extended family offers to help. b. family members express cNoncern. c. the ill member demands attention. d. memories are shared.

ANS: C It is not uncommon for the ill family member to become demanding and indicate that they deserve special treatment and care, and the supportive family may need assistance in understanding the dynamics of the illness in order to continue to be supportive. Offers from extended family to help can be indicative of positive dynamics. Concern expressed by family members can be indicative of positive dynamics. Sharing of family memories can be indicative of positive dynamics.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. Two women have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of a baby. The nurse identifies them as which type of family? a. Cohabiting b. Nuclear c. Same-sex d. Single parent ANS: C

This family would be considered a same-sex family. Cohabiting refers to a couple who live together with no legal bond. Nuclear refers to the traditional male and female core family with one or more children. Single parent refers to a family with one adult and one or more children.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. The nurse identifies the family with a child graduating from college as having which effect on the family life cycle? a. Minimal impact b. Considered to be a negative impact on the family unit c. Leads to role confusion d. Expectation of role change ANS: D The family life cycle developmental theory focuses on the growth and development of changes in role relationships during transitional periods. A child graduating from college is an example of a transition which requires a role change. As this is a transition, one would expect to see a change so minimal impact would not be expected. Graduation does not imply that it will be a negative change on the family life cycle or lead to role confusion.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of which aspect of the family?

N a. Development b. Function c. Political views d. Structure ANS: C An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nurse is planning to assess the structure of a family. Which question should the nurse ask? a. “Who lives with you in this home?” b. “Who does the grocery shopping?” c. “Who provides support in your family?” d. “How old are the members of your family?”

ANS: A

The structure of the family includes who is in the family and what their relationship is.

“Who does the shopping?” would provide information about family functioning. “Who provides support?” would provide information about family functioning. “How old are the members?” would provide information about family development.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. Which factors which would alert the nurse to negative/dysfunctional family dynamics? a. Aging of family members b. Chronic illness of a family member c. Disability of a family member d. Intimate partner violence ANS: D Intimate partner violence is an exemplar of negative/dysfunctional family dynamics. Aging of family members is an exemplar of changes to family dynamics. Chronic illness of a family member is an exemplar of changes to family dynamics. Disability of a family member is an exemplar of changes to family dynamics.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 04: Culture Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for an older Chinese adult male who is grimacing and appears restless after abdominal surgery. What is the nurse’s best action? a. Ask the patient if he is anxious about his hospital stay. b. Ask a translator to conduct a FACES pain scale assessment. c. Ask the patient about pain and assess vital signs. d. Ask the patient about any history of depression or anxiety.

ANS: C In the Chinese culture, elderly Chinese people believe that they must be stoic about pain and there is a stigma about talking about any mental health problems. The nurse should ask the patient about pain and also assess vital signs for physiological signs of pain, since the patient may not admit to any pain. Assuming the patient is depressed or anxious is not the best action when considering individual cultural differences and the risk of pain after major surgery. The registered nurse should never delegate assessment to any unlicensed member of the healthcare team such as a translator. The translator may assist with communication, but the nurse is responsible for the pain assessment.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. Understanding cultural differN ences in health care is important because it will help the nurse to understand the manner in which people decide on obtaining treatments and medical care.

In independent cultures an individual will a. put himself first. b. consult family members for advice. c. ask for a second opinion. d. travel great distances to receive the best care.

ANS: A In independent cultures, an individual will put himself first in the case of a life-threatening illness, whereas even in dire circumstances, members of collectivist cultures may still consult other family members for the best course of action. In independent cultures, an individual will not consult with other family members, ask for a second opinion, or travel great distances to receive the best care.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the patient nodding yes to everything that is being said. With a better understanding of cultural interdependence in self-concept, a nurse should immediately a. write everything down for the patient to refer to later. b. prompt further to elicit additional questions or concerns. c. call the recognized elder for this patient. d. call the oldest male relative for help with decision making.

ANS: B When a nurse provides nutritional education to a patient who is from a culture that values greater power distance, it might appear that the patient is willing to accept all that the nurse suggests, when further prompting would elicit additional questions or concerns. The patient from a collectivist culture will usually consult family members for a best course of action. It is not acceptable for nurses to take it upon themselves to call the recognized elder or oldest male relative for help with decision making. While writing everything down may be OK for some cultures, with Asian patients it may be best to prompt further to elicit additional questions or concerns.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. Women who are given the job of caretaker for aging relatives are subject to caregiver strain due to a. feminine attributes. b. unequal gender. c. fixed gender roles. d. female inequality.

ANS: C In cultures with more fixed gender roles, women are usually given the role of caretaker for aging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers to harmonious relationships, modesty, and taking care of others. Unequal gender refers to roles of males and females being unevenly distributed. Female inequality refers to female gender and roles being less than or unequal to male roles.

N OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. A 60-year-old Italian immigrant presents for an annual physical. He is counseled about diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and pneumococcal vaccination. His reply is “If it ain’t broke, don’t try to fix it.” When developing a plan of care, the nurse should consider which cultural orientation for this patient? a. Short term b. Long term c. Leisurely term d. Noncommittal ANS: A Short-term cultural orientation focuses on the present or past and emphasizes quick results.

Long-term cultural orientation focuses the future and long-term rewards.

Long-term-oriented cultures favor thrift, perseverance, and adopting to changing circumstances. Leisurely term and noncommittal are undefined in cultural orientation.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. The emphasis on understanding cultural influence on health care is important because of a. disability entitlements. b. HIPAA requirements.

c. increasing global diversity. d. litigious society.

ANS: C Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. What interrelated constructs facilitate a nurse to become culturally competent? a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge b. Cultural desire, self-awareness, cultural knowledge, and cultural identity c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity d. Cultural desire, self-awareness, cultural knowledge, and cultural skill ANS: D The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and histoNrical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

Concept 05: Spirituality Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is assessing a patient's spirituality and observes the patient meditating before any treatments. What is the nurse’s best action? a. Document that the patient is not religious. b. Offer the patient a copy of the Bible to read. c. Arrange for quiet time for the patient as needed. d. Limit the time patient can meditate before procedures.

ANS: C The nurse can best promote the patient’s spirituality practices by arranging for the patient to be left alone when possible to meditate. Meditation is an exemplar of spirituality, not necessarily of the Christian faith. The Bible is most often read by believers in the Christian faith. Meditation does not imply that the patient is not religious. Time for meditation should not be limited, whenever possible.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Health Promotion and Maintenance 2. When conducting a spiritual assessment of a hospitalized patient, the nurse should remain aware of which potential barrier to effective communication? a. Clarifying the meaning of a patient’s statement. b. Multi-tasking while talkinNg to the patient. c. Listening to patients’ complete statements. d. Discussing patient’s feelings while hospitalized.

ANS: B Several barriers may result in the nurse’s inability to be totally present and communicate effectively with the patient. First, the nurse may be distracted by other things and may not pay attention to the patient. Multi-tasking while trying to listen to a patient may be a barrier to effective communication. Second, the nurse may miss the meaning of the patient’s message because of failure to clarify the meaning of a word, a phrase, or a facial expression.

Third, the nurse may interject personal feelings and reactions into the patient’s situation rather than allow the patient to explore and discuss his own feelings and reactions. The last barrier occurs when the nurse is busy formulating a response while the patient is still talking. In this instance, the nurse never hears the patient’s message.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity 3. A patient uses rosary beads and attends mass once a week. This expression of spirituality is best described with which term? a. Religiosity b. Faith c. Belief d. Authenticity

ANS: A There are a few similar and related terms to spirituality worth mentioning to provide distinction and clarification. Faith, as defined by Dyess, refers to an “evolving pattern of believing, that grounds and guides authentic living and gives meaning in the present moment of inter-relating.” Religiosity, another similar term, is an external expression (public or private), in the form of practicing a belief or faith, whereas spirituality is an internalized spiritual identity (or experiential). Specifically, religiosity is defined as “the adherence to religious dogma or creed, the expression of moral beliefs, and/or the participation in organized or individual worship, or sacred practices.”

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity 4. When developing a plan of care, the nurse should consider which attribute of the concept of spirituality? a. Spirituality is not a well-known universal concept. b. Chronic versus acute illnesses affect spirituality. c. Convincing patients to pray is a priority intervention. d. Referrals may be needed to spiritual counselors.

ANS: D The attributes of the concept of spirituality in the context of nursing care are described below.

• Spirituality is universal. All individuals, even those who profess no religious belief, are driven to derive meaning and purpose from life.

• Illness impacts spirituNality in a variety of ways. Some patients and families will draw closer to God or however they conceive that higher Power to be in an effort to seek support, healing, and comfort. Others may blame and feel anger toward that Higher Power for any illness and misfortune that may have befallen a loved one or their entire family. Still others will be neutral in their spiritual reactions.

• There has to be willingness on the part of patient and/or family to share and/or act on spiritual beliefs and practices.

• The nurse needs to be aware that specific spiritual beliefs and practices are impacted by family and culture.

• The nurse needs to be willing to assess the concept of spirituality in patients and families and based on this ongoing assessment to integrate the spiritual beliefs of patients and families into care.

• The nurse needs to be willing to refer the patient or family to a Spiritual Expert i.e., a Minister, Priest, Rabbi, an Imam.

• Community-based religious organizations can provide supportive care to families and patients and nurses need to be aware of these resources.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity MULTIPLE RESPONSE

1. When completing the FICA tool for spiritual assessment, which questions should the nurse ask the patient? (Select all that apply.) a. What things do you believe in that give meaning to life? b. Are you connected with a faith center in your community? c. How has your illness affected your personal beliefs? d. When was the last time you have been to church? e. What can I do for you?

ANS: A, B, C, E The FICA tool for spiritual assessment stands for Faith or beliefs, Importance and influence, Community, and Address. “When was the last time you have been to church?” is not a question included in the FICA assessment. The patient may attend community activities, besides church, that foster his/her spiritual well-being.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. Which are true statements about the definition of spirituality in nursing? (Select all that apply.) a. Patient’s quality of life, health, and sense of wholeness are affected by spirituality. b. An exact definition was developed and adopted in the late 1980s. c. Encompasses principle, an experience, attitudes, and belief regarding God d. Head knowledge affects spirituality more than heart knowledge. e. Mind, body, spirit, love, and caring are interconnected.

ANS: A, C, E The concept of Spirituality is an elusive concept to define. Authors who write about spirituality in nursing advocaNte the position that a patient’s quality of life, health, and sense of wholeness are affected by spirituality, yet still the profession of nursing struggles to define it. Why? There are a number of explanations for this. One explanation is that spirituality represents “heart” not “head” knowledge and “heart” knowledge is difficult to encapsulate into words. A second explanation is that spirituality is unique to each person so a precise definition is somewhat elusive. The definitions of spirituality encompass the following: a principle, an experience, attitudes and belief regarding God, a sense of God, the inner person. Most descriptions of spirituality include not only transcendence but also the connection of mind, body, and spirit, plus love, caring, and compassion and a relationship with the Divine.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Health Promotion and Maintenance 3. Which life events should the nurse recognize as being spiritually life changing? (Select all that apply.) a. Births b. Weddings c. Medical diagnoses d. Career day to day job duties e. Loss of independence ANS: A, B, C, E

The meaning and significance of the event might only be experienced by one individual; others who might be participants in the event might be left virtually untouched and unchanged. These life changing spiritual events include just about any occurrence that has intense and personal relevance to those involved in the event. Examples of spiritually life changing events include births, deaths, weddings, divorces, illnesses, diagnoses, and loss of abilities, loss of independence, death and so many more. These events, having the power to change individuals and families, also have the power to draw people toward the transcendent—for many people that transcendent is known as God but this is not universal.

Day-to-day activities are not the best examples of spiritually life changing events.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity

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Concept 06: Adherence Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? a. The patient will select the type of learning materials they prefer. b. The patient will verbalize an understanding of the importance of following the regimen. c. The patient will demonstrate coping skills needed to manage hypertension. d. The patient will verbalize the side effects of treatment.

ANS: A Adults learn best when given information they can understand that is tailored to their learning styles and needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. After the nurse implements a teaching plan for a newly diagnosed patient with hypertension, the patient can explain the information but fails to take the medications as prescribed. What is the nurse’s next action? a. Reeducate the patient, be N c ause learning did not occur because the patient’s behavior did not change. b. Assess the patient’s perception and attitude toward the risks associated with not taking their anti-hypertensives. c. Take full responsibility for helping the patient make dietary changes. d. Ask the provider to prescribe a different medication, because the patient does not want to take this medication.

ANS: B Although the patient behavior has not changed, the patient’s ability to explain the information indicates that learning has occurred. The nurse would need to ask what the patient’s perceptions are of taking the medications to determine if the patient understands the ramifications of not taking the medication. The patient may be in the contemplation or preparation state (see Health Belief Model). The nurse should reinforce the need for change and continue to provide information and assistance with planning for change.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. A diabetic patient presents to the diabetes clinic with A1c levels of 7.5%. The nurse has met this patient for the first time. When applying principles of Theory of Planned Behavior (TPB), which teaching strategy by the nurse is most likely to be effective? a. Provide information on the importance of blood glucose control in maintenance of long-term health and evaluate how the patient has been following the prescribed regime.

b. Establish a rapport with the patient by complimenting them on what they did correctly, and ask what strategies they have tried thus far. c. Refer the patient to a certified diabetic educator, because the educator is an expert on management of diabetes complications. d. Have the patient explain what medications they are on and what diet they should be following.

ANS: B Principles of a TPB indicate that the patient will need to establish a good rapport with the nurse in order to talk about nonadherence. If the patient finds it difficult to discuss their diabetes self-management and adherence with the nurse, the patient may not open up to the nurse. Although a referral to an educator is a good idea, it would be better to use this resource as a follow-up for this visit. Having the patient verbalize medications and diet is not part of the TPB method.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. The nurse is assessing a newly diagnosed diabetic, and the patient’s readiness to learn about glucose monitoring. Before planning teaching activities, which approach would be most effective? a. Assist the patient with long-term goals and plan teaching according to these goals. b. Provide the patient with all the latest research from the Internet on glucose monitoring. c. Refer the patient to the diabetic specialist who can assist the patient with the glucometer. d. Assist the patient in developing realistic short-term goals.

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ANS: D Concordance reflects development of an alliance with patients based on realistic expectations. Providing the patient with the research will not help with the practical skill of using the glucometer. Long-term goals are useful; however, the goals need to be immediate with a newly diagnosed patient learning a new skill. Referring the patient would be useful if the patient has not been able to grasp the concept after several attempts.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse is developing a care plan for a patient who has low motivation and nonadherence with blood glucose monitoring. Which statement by the patient would indicate to the nurse that the patient is not motivated and will most likely not comply? a. “I do not like to test my sugar, but I do it because my wife nags me.” b. “I forget to check my sugar once in a while.” c. “I don’t see or feel any different when I do keep my blood sugars under control.” d. “I have no idea what the signs of low blood sugar are.”

ANS: C If patients do not perceive any benefit from changing their behavior, sustaining the change becomes very difficult. Having someone remind the patient is more likely to reinforce compliance. Forgetting to check glucose occasionally may indicate the patient needs memory cues or joggers. The patient who does not know the signs of low glucose will need further teaching.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is preparing a discharge teaching plan for a patient who has peripheral vascular disease and has poor circulation to the feet. Which learning goal should the nurse include in the teaching plan? a. The nurse will demonstrate the proper technique for trimming toenails. b. The patient will understand the rationale for proper foot care after instruction. c. The nurse will instruct the patient on appropriate foot care before discharge. d. The patient will post reminder stickers on the calendar to check feet every day and record scheduled appointments with podiatrist.

ANS: D To improve the patient adherence to treatment, it will be important to help them develop reminder strategies that fit into their lifestyle. Options A and C describe actions that the nurse will take, rather than behaviors that indicate that patient learning has occurred. Option B is too vague and nonspecific to measure whether learning has occurred.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. A patient with hypertension is prescribed a low-sodium diet. The patient’s teaching plan includes this goal: “The patient will select a 2-gram sodium diet from the hospital menu for the next 3 days.” Which intervention would be most effective at increasing the patient’s compliance with the diet? a. Check the sodium content of the patient’s menu choices over the next 3 days. b. Ask the patient to identify which foods on the hospital menus are high in sodium. c. Have the patient list favo N r ite foods that are high in sodium and foods that could be substituted for these favorites. d. Compare the patient’s sodium intake over the next 3 days with the sodium intake before the teaching was implemented.

ANS: C Including a patient’s favorite foods will most likely increase compliance, because the patient is not being deprived. Checking the sodium will be useful for teaching strategies but will not be the most effective means of increasing adherence.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 8. The nurse is evaluating the need to refer a patient with osteoarthritis for a home care visit to be sure the patient can function in accomplishing daily activities independently. What is the nurse’s first priority? a. Determine if the patient has had home visits before and if the experience was positive. b. Check the patient’s ability to bathe without any assistance the next day. c. Have the patient demonstrate the learned skills at the end of the teaching session. d. Arrange a physical therapy visit before the patient is discharged from the hospital.

ANS: A

To begin the assessment of adherence, it is first important to clarify with the patient (a) their beliefs and perceptions about their health risk status, (b) their existing knowledge about cardiovascular disease risk reduction, (c) any prior experience with healthcare professionals, and (d) their degree of confidence with controlling the disease. The other actions allow evaluation of the patient’s short-term response to teaching.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

9. A 73-year-old male patient is seen in the home setting for a routine physical. The nurse notes which behavior as the most reassuring sign that the patient has been following the treatment plan for the diagnoses of hypertension, diabetes, and hyperlipidemia? a. The patient has a list of glucose readings for the past 10 days. b. The patient has a list of medications along with newly refilled meds. c. The patient has a list of all foods and beverages for a 3-day period. d. The patient verbalizes the side effects of all his medications.

ANS: B Confirming how often a patient renews or refills his/her prescriptions is a measurement of the patient’s persistence with continuation of the treatment. Having a list of glucose readings or verbalizing side effects does not necessarily mean that the patient is compliant unless the readings were all normal, which is not indicated. Listing foods may not indicate the patient is following the treatment plan.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

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Concept 07: Self-Management Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is developing a plan of care for a newly diagnosed hypertensive patient who is being discharged on medications and given the Dietary Approaches to Stop Hypertension (DASH) diet to follow. What statement by the patient signals to the nurse that the patient is motivated to learn? a. “I am sure the medications will help to bring down my blood pressure.” b. “I can’t wait to try the new recipes, and I’m hopeful I will lose weight.” c. “Do I really need to follow the diet and take medications?” d. “I have my parents to blame for this. They both have high blood pressure.”

ANS: B A patient who is motivated will see what the benefits of following the teaching will do for them and will most likely be able to manage their own care. The patient who believes medications are the only solution may not be motivated to follow the prescribed diet.

Blaming the parents for their condition does not show accountability or motivation for change.

OBJ: NCLEX Client Needs Category: Physiological Integrity | NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is assessing a patient’s readiness to be discharged and ability to manage care at home. What is the most approNpriate question for the nurse to ask to determine the patient’s learning needs before planning teaching activities? a. “What are your hobbies and occupation?” b. “What do you need to know before you go home from the hospital?” c. “Do you have any cultural or religious beliefs that you would like incorporated into your plan of care?” d. “What were your grades and learning style when you were in school?”

ANS: B Motivation and readiness to learn depend on what the patient values. The other questions are also important but do not address what information interests the patient most at present and will assist the patient in managing his own care.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. Which acute medical event should the nurse identify as requiring self-management when planning care for a patient? a. Prenatal care b. Depression c. Diabetes d. Femur fracture ANS: D

A femur fracture is considered an acute medical event. Pregnancy is an expected and normal life event/condition. Depression and diabetes are considered disease states.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. An 8-year-old child is newly diagnosed with asthma. Which nursing intervention best promotes self-efficacy for the parents to help the child follow the prescribed treatments? a. Ask parents to list all possible triggers for asthma. b. Request a spacer for the metered dose inhaler. c. Suggest the parents enforce a strict exercise regimen. d. Recommend replacing carpeting in the home with wood flooring.

ANS: B The most realistic and helpful interventions will promote self-management. A spacer is helpful for children learning to use inhaled medication. Listing all the triggers for asthma may be overwhelming. The parents should focus on the individual triggers for the child.

Enforcing a strict exercise regimen is restrictive and will not promote self-management.

Environmental changes must be feasible and cost-effective. Replacing carpeting is optimal but may not be affordable.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. When developing a plan of care to promote self-management, which patient is least likely to be affected by depression? a. A 55-year-old employed female b. A 35-year-old Hispanic male c. A 40 year old with 5th grN ade education d. A 42 year old with private insurance ANS: D Individuals most affected by depression are midlife adults ages 45–64, women, minorities, individuals without a high school education, and individuals without health insurance.

Treatment for depression includes the use of medication and psychological therapy.

Additionally, patients must learn to manage moods including suicidal thoughts, recognize triggers and relapse, and set goals for behavioral management of their disease.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is assisting an older adult patient, diagnosed with type 2 diabetes, with self-injection of insulin. What is the most appropriate intervention for this patient at discharge? a. Arrange daily home visits for injections. b. Request an insulin pen prescription. c. Recommend upper arm injection sites. d. Supply patient with 100 unit insulin syringes.

ANS: B

An insulin pen will be the most effective method for injection for an older adult secondary to reduced eyesight and dexterity compared to using syringes. A 100 unit syringe has very small calibration marks and numbers, making it more difficult for older adults to see the appropriate doses. Daily home visits are not usually paid for by insurance. Most patients must learn to administer medications themselves. The upper arm subcutaneous site is too difficult for self-administration and may not be feasible for an older adult.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. The nurse is developing a teaching plan for a patient diagnosed with congestive heart failure. Which are the most appropriate teaching points to include that will assist in self-management of the disease? (Select all that apply.) a. Side effects of medications b. Activity restrictions c. Daily weights d. Increased sodium intake e. Blood pressure monitoring ANS: A, B, C, E Congestive heart failure (CHF) is one of the most common complications of coronary artery disease in which the heart fails to pump efficiently enough to meet the metabolic demands of the body. Fluid overload is a common complication. As with most chronic conditions, patients with CHF benefit from education about their disease and self-managing diet, physical activity, weight, andNmedication adherence. Fluid retention occurs with increased sodium intake; therefore sodium is usually restricted in a congestive heart failure diet.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

Concept 08: Fluid and Electrolytes Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which physician order should the nurse question? a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr b. Furosemide (Lasix) 20 mg PO now c. Oxygen via face mask at 8 L/min d. KCl 20 mEq PO two times per day ANS: A A patient with decompensated heart failure has extracellular fluid volume (ECV) excess.

The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to t hNe physician? a. Swollen ankles in patient with compensated heart failure b. Positive Chvostek sign in patient with acute pancreatitis c. Dry mucous membranes in patient taking a new diuretic d. Constipation in patient who has advanced breast cancer ANS: B Positive Chvostek sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek sign.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it.

Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a. Weight gain of 2 pounds since last week b. Dry mucous membranes and skin tenting c. Urine output 8 mL/hr

d. Blood pressure 98/58 ANS: C Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. An overnight weight gain indicates a fluid gain.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a. Vomiting all day and not replacing any fluid b. Tumor that secretes excessive antidiuretic hormone (ADH) c. Tumor that secretes excessive aldosterone d. Tumor that destroyed the posterior pituitary gland ANS: B ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia.

The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.

OBJ:

NCLEX Client NeedsNCategory: Physiological Integrity: Reduction of Risk Potential

5. The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a. Development of ankle or sacral edema b. Increased skin tenting and dry mouth c. Postural hypotension and tachycardia d. Decreased level of consciousness ANS: D Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a. Severe hemorrhage b. Diabetes insipidus c. Oliguric renal disease d. Adrenal insufficiency

ANS: C When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. The patient’s laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the priority nursing intervention? a. Raise bed side rails due to potential decreased level of consciousness and confusion. b. Examine sacral area and patient’s heels for skin breakdown due to potential edema. c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

ANS: D Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

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1. The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all that apply.) a. Bilateral ankle edema b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau sign e. Flat neck veins when upright f. Decreased patellar reflexes ANS: B, C, D Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient?

(Select all that apply.) a. Test for skin tenting. b. Measure rate and character of pulse. c. Measure postural blood pressure and heart rate. d. Check Trousseau sign. e. Observe for flatness of neck veins when upright. f. Observe for flatness of neck veins when supine.

ANS: A, B, F ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

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Concept 09: Acid–Base Balance Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse’s teaching about the acid-base imbalance has been effective? a. “To prevent another problem, I should eat less sodium during diarrhea.” b. “My blood became too acid because I lost some base in the diarrhea fluid.” c. “Diarrhea removes fluid from the body, so I should drink more ice water.” d. “I should try to slow my breathing so my acids and bases will be balanced.”

ANS: B Diarrhea causes metabolic acidosis through loss of bicarbonate, which is a base. Eating less sodium during diarrhea increases the risk of ECV deficit. Although diarrhea does remove fluid from the body, it also removes sodium and bicarbonate which need to be replaced.

Rapid deep respirations are the compensatory mechanism for metabolic acidosis and should be encouraged rather than stopped.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see? a. pH high, PaCO2 high, HCO3– high b. pH low, PaCO2 low, HCO3– low O 3 – high c. pH low, PaCO2 high, HCN d. pH low, PaCO2 high, HCO3– normal ANS: C Type B COPD is a chronic disease that causes impaired excretion of carbonic acid, thus causing respiratory acidosis, with PaCO2 high and pH low. This chronic disease exists long enough for some renal compensation to occur, manifested by high HCO3–. Answers that include low or normal bicarbonate are not correct, because the renal compensation for respiratory acidosis involves excretion of more hydrogen ions than usual, with retention of bicarbonate in the blood. High pH occurs with alkalosis, not acidosis.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to perform in order to detect development of the highest risk acid-base imbalance? a. Urine output and color b. Level of consciousness c. Heart rate and blood pressure d. Lung sounds in lung bases ANS: B

Thyroid hormone increases metabolic rate, causing a patient with severe hyperthyroidism to have high risk of metabolic acidosis from increased production of metabolic acids.

Metabolic acidosis decreases level of consciousness. Changes in urine output, urine color, and lung sounds are not signs of metabolic acidosis. Although metabolic acidosis often causes tachycardia, many other factors influence heart rate and blood pressure, including thyroid hormone.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. The nurse is making a home visit to a child who has a chronic disease. Which finding has the most implication for acid-base aspects of this patient’s care? a. Urine output is very small today. b. Whites of the eyes appear more yellow. c. Skin around the mouth is very chapped. d. Skin is sweaty under three blankets.

ANS: A Oliguria decreases the excretion of metabolic acids and is a risk factor for metabolic acidosis. Jaundice requires follow-up but is not an acid-base problem. Perioral chapped skin needs intervention but is not an acid-base issue. With three blankets, diaphoresis is not unusual.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first? a. “Is there a place that I canNdispose of my unused morphine pills?” b. “I want to lose at least 20 pounds without getting sick this time.” c. “I think I have asthma because I cough when dogs are near.” d. “I ran out of money and am cutting my insulin dose in half.”

ANS: D Decreasing an insulin dose by half creates high risk of diabetic ketoacidosis, and this patient has the highest priority. The other patients have less priority due to lower risk situations with longer time course before development of an acid-base imbalance. The coughing when dogs are near is not a sign of a severe asthma episode that causes respiratory acidosis, although this patient does need attention after the insulin situation is handled. Disposing of morphine properly helps prevent respiratory acidosis from opioid overdose. Guidance regarding weight loss helps prevent starvation ketoacidosis.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Management: Management of Care MULTIPLE RESPONSE 1. The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.) a. Skin pale and cold b. Tingling of fingertips

c. Heart rate of 102 d. Numbness around mouth e. Cramping in feet ANS: B, D, E Hyperventilation is a risk factor for respiratory alkalosis. Respiratory alkalosis can cause perioral and digital paresthesias and pedal spasms. Pallor, cold skin, and tachycardia are characteristic of activation of the sympathetic nervous system, not respiratory alkalosis.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 2. Which statements said by patients indicate that the nurse’s teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.) a. “Baking soda is an effective and inexpensive antacid.” b. “I should take my insulin on time every day.” c. “My aspirin is on a high shelf away from children.” d. “I have reliable transportation to dialysis sessions.” e. “Fasting is a great way to lose weight rapidly.”

ANS: B, C, D Taking insulin as prescribed helps prevent diabetic ketoacidosis. Safeguarding aspirin from children prevents metabolic acidosis from increased acid intake. Regular dialysis reduces the risk of metabolic acidosis from decreased renal excretion of metabolic acid. Baking soda is sodium bicarbonate and should not be used as an antacid due to the risk of metabolic alkalosis. Fasting without carbohydrate intake is a risk factor for starvation ketoacidosis.

OBJ:

NCLEX Client NeedsNCategory: Health Promotion and Maintenance

Concept 10: Thermoregulation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Which newborn should the nursery nurse identify as being at significant risk for hypothermic alteration in thermoregulation? a. Large for gestational age b. Low birth weight c. Born at term d. Well nourished ANS: B Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well-nourished infant is not at significant risk.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about the temperature. What is the nurse’s best response? a. Older people have a diminished ability to regulate body temperature because of active sweat glands. b. Older people have a diminished ability to regulate body temperature because of N increased circulation. c. Older people have a diminished ability to regulate body temperature because of peripheral vasoconstriction. d. Older people have a diminished ability to regulate body temperature because of slower metabolic rates.

ANS: D Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older adults have reduced circulation.

The body conserves heat through peripheral vasoconstriction, and older adults have a decreased vasoconstrictive response, which impacts ability to respond to temperature changes.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates which assessment finding? a. Decreased respirations b. Low pulse rate c. Red, sweaty skin d. Slow capillary refill ANS: C

With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. What is the priority nursing action for a patient suspected to be hypothermic? a. Assess vital signs. b. Hydrate with intravenous (IV) fluids. c. Provide a warm blanket. d. Remove wet clothes.

ANS: D The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. Which strategies should the nurse include in a community program for senior citizens related to dealing with cold winter temperatures? a. Avoiding hot beverages b. Shopping at an indoor mall c. Using a fan at low speed d. Walking slowly in the p a N rk ANS: B Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is recommended to conserve body temperature.

Physical activity can increase body temperature, and if the senior is going to walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a. Impaired cognition b. Occupational exposure c. Physical agility d. Temperature extremes ANS: C

Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation? a. Oral thermometer b. Rectal thermometer c. Temporal thermometer scan d. Tympanic membrane sensor ANS: B The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

8. Which similar exemplar should the nurse consider when planning care for a patient with hypothermia?

N a. Heat exhaustion b. Heat stroke c. Infection d. Prematurity ANS: D Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

Concept 11: Sleep Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient tells the nurse that he experiences daytime fatigue even after 7–8 hours of sleep each night. What is the best assessment question for the nurse to ask? a. Have you tried getting 10 hours of sleep instead of 8 hours? b. How long are you in the rapid eye movement (REM) stage? c. Do you also have any recent lifestyle or behavior changes? d. Do any of your close relatives have any sleep disorders?

ANS: C The best question to elicit the most pertinent information is “Do you also have any recent lifestyle or behavior changes?” The patient is getting 7–9 hours/sleep each night, which is expected for the average adult. The patient will not be able to recall an unconscious state such as REM sleep. The patient may have close relatives with sleep disorders but this does not necessarily affect the patient’s own sleep habits.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. The nurse is making rounds on the hospital unit and observes a patient sleeping. The patient’s pulse and respiratory rates are slower than baseline. The nurse realizes the patient has most likely just entered which stage of non-rapid eye movement sleep? a. Stage 1 N b. Stage 2 c. Stage 3 d. Stage 4 ANS: B In Stage 2 (N2), eye movement ceases; brain waves become even slower with the exception of an occasional burst or more rapid brain waves. Pulse rate and respirations slow and body temperature decreases as the individual moves toward deeper stages of sleep. Stage 3 (N3) and Stage 4 (N4) are the periods of deep sleep.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

3. The nurse enters a patient’s room and the patient startles easily and appears to jerk his arms and legs before awakening. Which stage of non-rapid eye movement sleep did the patient most likely awaken from? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANS: A

In Stage 1 (N1 or Non-REM Stage 1), referred to as light sleep, the individual can be awakened easily. In this stage, brain waves slow and, on EEG, the slower wave pattern known as alpha waves appears. The individual at this point is likely to drift in and out of sleep and can be awakened easily. Sensations known as hypnagogic hallucinations can occur during this stage. A common sensation of this type is the feeling of falling.

Uncontrolled muscle jerks sometimes occur at this stage along with sudden movements that can startle the individual and restore wakefulness.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

4. The nurse must awaken a patient from Stage 4 non-rapid eye movement sleep in order to prepare the patient for a procedure. The patient is disoriented. What is the nurse’s best action? a. Notify the healthcare provider. b. Re-assess the patient’s orientation. c. Administer an anti-anxiety medication. d. Cancel the patient’s procedure.

ANS: B Stage 3 (N3) and Stage 4 (N4) are the periods of deep sleep. N3 is characterized by very slow brain waves called delta waves interspersed with smaller, faster waves. In Stage 4 (N4), the EEG shows almost exclusively delta waves. In this type of sleep it is difficult to awaken the individual and muscle activity is very limited or may be completely absent. A person awakened from Stage 3 or 4 of sleep could be disoriented for a brief period of time before regaining awareness.

OBJ:

NCLEX Client NeedsNCategory: Physiological Integrity: Basic Care and Comfort

5. A patient complains of not being able to fall asleep at night and asks the nurse if there is a safe, non-prescription medication he can try. After consulting the healthcare provider, the nurse should recommend which naturally occurring hormone? a. Melatonin b. Cortisol c. Luteinizing hormone d. Estrogen ANS: A A rise in the hormone melatonin at the onset of sleep helps to promote and maintain sleep, and a drop in levels leads to eventual awakening. The immune system is enhanced as well during sleep as proteins associated with fighting illness are produced. The circadian rhythm, or the typical 24 hour (more or less) cycle through which the body passes, including both awake and sleep cycles, is responsible for regulating all of the physiologic processes in the body. An adequate amount and quality of sleep, therefore, is essential to all of the regulatory mechanisms that take place in the body.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

6. A mother tells the nurse she is concerned because her 8-month-old infant sleeps all day and night and is only awake about 2–3 hours per day. What is the nurse’s best response? a. “This sleep pattern is very normal for an infant at this age.”

b. “Adding an additional feeding will keep the child awake more.” c. “I recommend that you notify the child’s pediatrician.” d. “Be sure you are laying the child on his back to sleep at night.”

ANS: C By approximately 6 months of age, the infant should sleep through the night with at least one nap during the day. 2–3 hours of wakefulness per day is not an expected finding at age 8 months and should be reported to the pediatrician to determine the underlying cause. An additional feeding may be warranted; however the pediatrician should be notified first.

Lying on infant on the back to sleep is recommended to prevent sudden infant death syndrome; however the priority concern is the length of time the child is sleeping.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. The nurse is caring for a child with tonsillar enlargement. What is the nurse’s priority concern? a. Low oxygen saturation b. Daytime fatigue c. Increased temperature d. Antibiotic administration ANS: A Tonsillar enlargement in children often leads to obstructive sleep apnea which can cause decreased oxygen saturation levels. Low oxygen is a priority concern which carries the highest safety risk to the child. Obstructive sleep apnea occurs in an estimated 1–3% of children, though the causative factors may differ with tonsillar enlargement being a significant component in chilNdren. Infection that leads to an increased temperature and requires antibiotic therapy is a concern, but the priority health concern is low oxygen levels.

Obstructive sleep apnea can interfere with sleep patterns and lead to daytime fatigue, but the highest priority of care is low oxygen.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

Concept 12: Cellular Regulation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Which of the following options should the nurse incorporate into the plan of care as a primary prevention strategy for reduction of the risk for cancer? a. Yearly mammography for women aged 40 years and older b. Using skin protection during sun exposure while at the beach c. Colonoscopy at age 50 and every 10 years as follow-up d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over ANS: B Primary prevention of cancer involves avoidance to known causes of cancer, such as sun exposure. Secondary screening involves physical and diagnostic examination.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. While the nurse is collecting a health history on a patient admitted for colon cancer, which of the following questions should the nurse ask as a priority? a. “Have you noticed any blood in your stool?” b. “Have you been experiencing nausea?” c. “Do you have back pain?” d. “Have you noticed any swelling in your abdomen?”

N

ANS: A Early colon cancer is often asymptomatic, with occult or frank blood in the stool being an assessment finding in a patient diagnosed with colon cancer. If pain is present, it is usually lower abdominal cramping. Constipation and diarrhea are more frequent findings than nausea or ascites.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? a. Prioritization and administration of nursing care throughout the day b. Completing all nursing care in the morning so the patient can rest the remainder of the day c. Completing all nursing care in the evening when the patient is more rested d. Limiting visitors, thus promoting the maximal amount of hours for sleep ANS: A Pacing activities throughout the day conserves energy, and nursing care should be paced as well. Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. The nurse is caring for a patient who received a recent bone marrow transplant. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a. Mucositis b. Confusion c. Depression d. Mild temperature elevation ANS: D The earliest sign of infection in an immunosuppressed patient can be a mild fever.

Mucositis, confusion, and depression are possible clinical manifestations but are representative of less life-threatening complications.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? a. Being a woman b. Family history of hypertension c. Cigarette smoking as a teenager d. Advancing age ANS: D Aging is a non-modifiable risk factor for the development of cancer with an associated increase seen with aging. In terms of gender and age, lifetime risk is higher for males than females. Family history of c oN- morbidities such as hypertension is not directly correlated with cancer development. Cigarette smoking as a teenager for the patient is a risk factor but may have mitigated impact at this point in time based on the patient’s stated age and length of time as a non-smoker.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. In caring for a patient admitted with lung cancer, which of the following should the nurse expect to find on assessment? a. No use of accessory muscles during respirations b. Orthostatic hypotension upon change of positioning c. Clear sputum d. Weight loss compared to last admission ANS: D Common signs/symptoms of lung cancer include coughing, hemoptysis, and weight loss, shortness of breath and chest pain. The nurse should expect to see weight loss and altered breathing patterns. Clear sputum and orthostatic blood pressure changes would not be seen.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A female patient complains of a “scab that just won’t heal” under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What is the nurse’s best action?

a. Continue to conduct a symptom analysis to better understand the patient’s symptoms and concerns. b. End the appointment and tell the patient to use skin protection during sun exposure. c. Suggest further testing with a cancer specialist and provide the appropriate literature. d. Tell her to put a bandage on the scab and set a follow-up appointment in 1 week.

ANS: A A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague. The nurse should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

8. A patient with prostate cancer is taking hormonal therapy to control tumor growth. He reports that his left calf is swollen and painful. Which of the following would be the nurse’s best action? a. Instruct the patient to keep the leg elevated. b. Measure the calf circumference and compare the measurement with the right calf circumference measurement. c. Apply ice to the calf after a 10-minute massage of the area. d. Document assessment findings as an expected response with estrogen therapy.

ANS: B N A nurse should be aware of potential complications from hormonal therapy such as the development of thrombus formation. Massaging a calf that is swollen and painful is never correct, because this action might break a clot, causing formation of an embolus, which could then travel to the lungs.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

9. A patient being evaluated for breast cancer is not certain whether she and her family should participate in a genetic screening plan since no one can guarantee the results. What is the nurse’s best response? a. “If you have a family history of breast cancer, the chances for you to have this type of cancer increases.” b. “The decision is up to you in the final analysis.” c. “If there is no family history, then there is no need to go through the process.” d. “If your insurance will pay for the screening, then there is no associated risk.”

ANS: A

Individuals with a family history of breast cancer (especially 1st degree relatives) are at increased risk for disease occurrence. The nurse should inform the patient of the outcome measures of the screening plan. The nurse should not dissuade the patient from the process based on stating there is no family history, as there is no evidence that an adequate family history has been obtained. Similarly, to correlate the need for genetic testing with insurance and no implied risk cannot be stated equivocally. Although the decision is up to the patient in the final analysis, that response does not address relevant information about the purpose of genetic screening.

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NCLEX Client Needs Category: Health Promotion and Maintenance

10. A nurse is reviewing assessment findings for a female patient admitted to the oncology unit.

Which finding should alert the nurse to contact the physician? a. Blood pressure 130/88 b. Noticeable difference in circumference of lower legs c. Presence of goiter previously identified on prior admission d. Negative guaiac test ANS: B Examination findings relative to oncology patients and neoplastic growth manifest as visible lesions, physical asymmetry, palpable masses, abnormal sounds or the presence of blood on screening tests. A blood pressure of 130/88 is within normal range as is a negative guaiac test. Observation of a previous goiter which is consistent with a prior admission is not a concern. The detection of physical asymmetry as seen by a difference in circumference should be reported to the physician.

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NCLEX Client NeedsNCategory: Physiological Integrity: Physiological Adaptation

Concept 13: Intracranial Regulation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient with increased intracranial pressure (ICP). Which action would be considered to be a collaborative intervention? a. Decreasing perfusion b. Administering an osmotic diuretic c. Assessing orientation d. Assessing for edema ANS: B Collaborative interventions are aimed at preventing secondary injury by improving cerebral perfusion. This would include decreasing edema by administering an osmotic diuretic which in turn would lead to decreased ICP and improved oxygenation. Assessing orientation and for the presence of edema would not be considered as a collaborative intervention.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation? a. Change in level of consciousness b. Inability to focus visually c. Loss of primitive reflexes N d. Unequal pupil size ANS: A A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refer to those reflexes found in a normal infant that disappear with maturation.

These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS. OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. When caring for a patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings? a. Hypertension and bradycardia b. Hypertension and tachycardia c. Hypotension and bradycardia d. Hypotension and tachycardia ANS: A

Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushing triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. Which components of the Glasgow Coma Scale (GCS) should the nurse use to assess a patient after a head injury? a. Blood pressure b. Cranial nerve function c. Head circumference d. Verbal responsiveness ANS: D Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale.

Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N 5. The nurse is teaching a patient about head injuries. Which information should the nurse include as a primary prevention strategy to reduce the occurrence of head injuries? a. Blood pressure control b. Smoking cessation c. Maintaining a healthy weight d. Violence prevention ANS: D Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse preparing to care for a patient after a suspected stroke would question which order? a. Antihypertensive b. Antipyretic c. Osmotic diuretic d. Sedative

ANS: A Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure.

Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand.

Long-acting sedatives would be avoided to provide times for periodic neurologic assessments.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. After shunt procedure, the nurse would monitor the patient’s neurologic status by using which test? a. Electroencephalogram b. Glasgow Coma Scale c. National Institutes of Health Stroke Scale d. Monro-Kellie doctrine ANS: B The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This scale is an example of one type of specific tool for nurses to use when assessing a patient following stroke. The Monroe-Kellie doctrine is not an assessment or monitoring strategy; it describes the interrelationship of volume and compliance of the three cranial components, brain tissue, cerebral spinal f lNui d, and blood.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 14: Hormonal Regulation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient presents to the emergency room complaining of vomiting with severe back and leg pain. The patient’s home medications include daily oral corticosteroids. Vital signs reveal a low blood pressure and there are peaked T waves on the electrocardiogram. What is the nurse’s priority intervention? a. Start an intravenous line b. Collect urine specimen c. Administer antiemetic d. Administer narcotic analgesia ANS: A The patient is exhibiting signs of adrenal insufficiency (Addison disease) given the regular use of corticosteroids. Cortisone, hydrocortisone (Cortef), prednisone, and fludrocortisone (Florinef) are used for the treatment of adrenocorticoid deficiency. Treatment of Addisonian crisis includes administration of hydrocortisone, saline solution, and sugar (dextrose) to correct the insufficiency. The priority intervention is to start an intravenous line so that appropriate treatments may be administered. A urine specimen may be collected but is not the priority intervention. Since the patient is vomiting, administration of antiemetics or analgesia would be given through an intravenous line. The nurse should also assess for changes in the level of consciousness; so administration of analgesia may be contraindicated if any decrease in level of consciousness occurs.

N

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. Which important teaching point should the nurse include in the plan of care for a patient diagnosed with Cushing disease? a. Daily weight using same scale b. Wash hands frequently c. Use exfoliating soaps when bathing d. Avoid yearly influenza vaccine ANS: B Cushing syndrome is characterized by chronic excess glucocorticoid (cortisol) secretion from the adrenal cortex. This is caused by the hypothalamus, or the anterior pituitary gland, or the adrenal cortex. Cushing syndrome can also be caused by taking corticosteroids in the form of medication (such as prednisone) over time—referred to as exogenous Cushing syndrome. Regardless of the cause, excess secretion of cortisol has a systemic affect affecting immunity, metabolism, and fat distribution (truncal obesity), reduced muscle mass, loss of bone density, hypertension, fragility to microvasculature, as well as thinning of the skin. Washing hands is important because the patient’s immune system is suppressed due to the excess glucocorticoid level. Daily weights are not indicated. Exfoliating soaps may damage thin skin. The patient should receive vaccinations due to being immunocompromised.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse is caring for a patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What is the nurse’s best action? a. Encourage increased fluid and water intake b. Teach about risk for malignancies c. Monitor for changes in level of consciousness d. Assess labwork for potassium level changes ANS: C As the name suggests, SIADH is a condition in which antidiuretic hormone (ADH) is secreted despite normal or low plasma osmolarity, resulting in water retention and dilutional hyponatremia. In response to increased plasma volume, aldosterone secretion increases and further contributes to sodium loss. Hyponatremia frequently manifests with changes in level of consciousness from confusion to coma. A large number of clinical conditions can cause SIADH including malignancies, pulmonary disorders, injury to the brain, and certain pharmacologic agents. Malignancies often lead to SIADH versus SIADH causing malignant conditions. Water intoxication can lead to hyponatremia, therefore water intake is restricted.

The most affected electrolyte from SIADH is sodium versus potassium.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. Following a parathyroidectomy, which electrolyte should the nurse most closely monitor? a. Potassium b. Sodium c. Magnesium d. Calcium

N

ANS: D Because the parathyroids are located on the thyroid gland, similar concerns for postoperative monitoring apply. Additionally, calcium levels are monitored to avoid hypocalcemic crisis.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. Radioactive iodine is indicated for the treatment of hyperthyroidism. Which item should the nurse include in the plan of care? a. Isolation is required for 6–8 weeks. b. Continued thyroid monitoring is required. c. Thyroid replacement therapy is prescribed. d. An overnight hospital stay is required.

ANS: B Radioactive iodine (RAI) is indicated for the treatment of hyperthyroidism. It is given as an oral preparation, usually as a single dose on an outpatient basis. The radioactive iodine makes its way to the thyroid gland where it destroys some of the cells that produce thyroid hormone. The RAI is completely eliminated from the body after about 4 weeks. The extent of thyroid cell destruction is variable, thus the patient has ongoing monitoring of thyroid function. If thyroid production remains too high a second dose may be needed. The goal of this procedure is to destroy thyroid hormone producing cells; additional thyroid hormone is not prescribed.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The nurse is caring for a patient who has undergone a thyroidectomy. Which patient complaint is highest priority requiring further evaluation? a. Pain at surgical site b. Thirst c. Hoarseness d. Nausea ANS: C Thyroidectomy involves a surgical incision in the anterior neck. Hoarseness may be a sign of airway edema. A patent airway is always a priority of care for any post-operative patient.

General anesthesia is used for this surgery requiring insertion of an artificial airway, therefore throat irritation and thirst is expected. Nausea may be a side effect from anesthesia. Pain is expected at the surgical site.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. Which statement made by a student nurse indicates the need for additional teaching about pituitary insufficiency? a. “Synthetic human growth hormone may be prescribed for children who are small for gestational age.” b. “Testosterone supplements may be prescribed for women with gonadotropin deficiency.” c. “Estrogen is known to regulate the action of growth hormone in men and women.” d. “Chronic kidney disease tNreatment may include synthetic growth hormone replacement.”

ANS: B Synthetic human growth hormone (HGH) is used for growth hormone deficiencies caused by pituitary insufficiency, as well as other conditions such as Turner syndrome, chronic kidney disease, and children small for gestation age. Testosterone is used as supplement for men with gonadotropin deficiency. Estrogen and progesterone supplements, also referred to as hormone replacement therapy (HRT), are indicated for women with gonadotropin deficiency and for the relief of post-menopausal symptoms. Estrogen is also known to regulate secretion and action of GH in men and women.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

Concept 15: Glucose Regulation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin? a. Aldactone(Spironolactone) b. Dicumarol (Bishydroxycoumarin) c. Reserpine (Serpasil) d. Cimetidine (Tagamet) ANS: A Aldactone is a loop potassium-sparing diuretic and can affect serum glucose levels and also lead to hypokalemia; its use is contraindicated with insulin. Dicumarol, an anticoagulant; reserpine, an anti-hypertensive; and cimetidine, an H2 receptor antagonist, do not affect blood glucose levels.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dL? a. “Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity.”N b. “The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel.” c. “Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP.” d. “The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis.”

ANS: B The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the body’s circulation is needed to meet the fuel demands of the central nervous system.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Integrity: Physiological Adaptation 3. The nurse associates which assessment finding in the diabetic patient with decreasing renal function? a. Ketone bodies in the urine during acidosis b. Glucose in the urine during hyperglycemia c. Protein in the urine during a random urinalysis d. White blood cells in the urine during a random urinalysis ANS: C

Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end-stage renal disease. Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be filtered into the urine.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. What is the nurse’s best response about developing diabetes to the patient whose father has type 1 diabetes mellitus? a. “You have a greater susceptibility for development of the disease because of your family history.” b. “Your risk is the same as the general population, because there is no genetic risk for development of type 1 diabetes.” c. “Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore the risk for becoming diabetic is 50%.” d. “Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual development of the disease. However, your brothers will become diabetic.”

ANS: A Even though type 1 diabetes does not follow a specific genetic pattern of inheritance, those with one parent with type 1 diabetes are at an increased risk for development of the disease.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse recognizes which pNatient as having the greatest risk for undiagnosed diabetes mellitus? a. Young white man b. Middle-aged African-American man c. Young African-American woman d. Middle-aged Native American woman ANS: D The highest incidence of diabetes in the United States occurs in Native Americans. With age, the incidence of diabetes increases in all races and ethnic groups.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? a. Decreased hunger sensation b. Report of no urine output c. Increased respiratory rate d. Decreased thirst ANS: C

Ketoacidosis decreases the pH of the blood, stimulating the respiratory control area of the brain to buffer the effects of the increasing acidosis. The rate and depth of respirations are increased (Kussmaul respirations) to excrete more acids by exhalation. Usually polydipsia (increased thirst), polyphagia (increased hunger), and polyuria (increased urine output) are seen with hyperglycemia and ketoacidosis.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) a. Tremors b. Nervousness c. Extreme thirst d. Flushed skin e. Profuse perspiration f. Constricted pupils ANS: A, B, E When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.

OBJ:

NCLEX Client NeedsNCategory: Physiological Integrity: Physiological Adaptation

Concept 16: Nutrition Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern? a. The patient’s son uses a marked pillbox to set up the patient’s medications weekly. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient tells the nurse that a close friend recently died.

ANS: B A 10-pound weight loss in 1 month could indicate cancer or may be an indication of further progression of memory loss. Depression is also another common cause of weight loss. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an older patient would have friends who have died.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? a. “Your weight is within normal limits. Continue maintaining with current lifestyle choices.” b. “You are a little overweight. Cut down on calories and increase your activity, and N you should be fine.” c. “You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery.” d. “You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight.”

ANS: D This patient is at an increased risk for sarcopenia and should be instructed to increase activity that includes strength training to prevent muscle loss. Diet is not indicated. A BMI of 31 is considered obese; however, this patient does not qualify for surgical intervention until BMI reaches over 35.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

3. The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient? a. Regular diet b. Low sodium diet c. Pureed diet d. Low sugar diet ANS: B

A low sodium diet will prevent water retention which could increase blood pressure.

Patients with hypertension would not be on a regular diet due to sodium content. A pureed diet is indicated for stroke patients who may have impaired swallowing. A low sugar diet is indicated for patients with diabetes.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

4. During a nutritional assessment, the nurse calculates that a female patient’s BMI is 27. The nurse would advise the patient to follow which of these recommendations? a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. b. This measurement indicates that the patient is underweight and will need to take measures to gain weight. c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery. d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.

ANS: A A BMI of 25–29.9 is in the overweight range. A BMI of <18.5 is in the underweight range.

A BMI of 30–34.9 is obesity class I, a BMI of 35–39.9 is obesity class II, and a BMI of >40 is obesity class III (morbid obesity). A BMI of 19–24 is in the normal range.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a Nquick screening tool to assess dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall ANS: D A 24-hour recall is useful as a quick screening tool to assess dietary intake. A food diary provides detailed information, but it is not convenient and requires a follow-up visit. A calorie count requires several days to collect data and requires a trained dietician to analyze the results. A comprehensive diet history may provide more accurate reflection of nutrient intake, but it is time-consuming to acquire and requires a trained/skilled dietary interviewer.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

6. During a physical examination, the nurse notes that the patient’s skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein ANS: C

Dry and scaly skin is a manifestation of essential fatty acid deficiency. Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae. Vitamin B deficiency is too large a category to consider. Specific categories of vitamin B deficiency have been identified, such as pyridoxine and thiamine. Protein deficiency causes decreased pigmentation and lackluster hair.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. During a physical examination, the nurse notes that the patient’s skin is dry and flaking.

What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves and numbness and tingling in extremities d. Fissures and inflammation of the mouth ANS: A Hair loss (alopecia) and hair that is easily removed from the scalp (easy pluckability), like dry, flaking skin, is caused by essential fatty acid deficiency. Inflammation of the tongue (glossitis) and fissured tongue are manifestations of a niacin deficiency. Inflammation of peripheral nerves (neuropathy) and numbness and tingling in extremities (paresthesia) are manifestations of a thiamin deficiency. Fissures of the mouth (cheilosis) and inflammation of the mouth (stomatitis) are manifestations of a pyridoxine deficiency.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

N MULTIPLE RESPONSE 1. An African American is at an increased risk for which of the following? (Select all that apply.) a. Vitamin D deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome ANS: A, D, E, F Type 1 diabetes and celiac disease are more common in Northern European heritage.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

Concept 17: Elimination Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient who was diagnosed with senile dementia has become incontinent of urine. The patient’s daughter asks the nurse why this is happening. What is the nurse’s best response? a. “The patient is angry about the dementia diagnosis.” b. “The patient is losing sphincter control due to the dementia.” c. “The patient forgets where the bathroom is located due to the dementia.” d. “The patient wants to leave the hospital.”

ANS: B Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity: Physiological Adaptation 2. The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient’s elimination status. What is the nurse’s best action? a. Speak with the patient’s family about food choices. b. Establish a bowel and bladder program for the patient. c. Speak with the patient about past elimination habits. d. Establish a bedtime ritual for the patient.

N

ANS: B Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

3. The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a. Large intestine b. Stomach c. Small intestine d. Pancreas ANS: C Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3–4 minutes. The patient asks the nurse why this is happening. What is the nurse’s best response? a. “Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel.” b. “Some people have a slower bowel than others, and this is nothing to be concerned about.” c. “The foods you eat contribute to peristalsis, so you should eat more fiber in your diet.” d. “Bowel peristalsis is slow because you are not walking. Get more exercise during the day.”

ANS: A Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. What is a primary prevention tool used for colon cancer screening? a. Abdominal x-rays b. Blood, urea, and nitrogen (BUN) testing c. Serum electrolytes d. Occult blood testing ANS: D Occult blood testing will reveNal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening.

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NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a. Increase fiber intake. b. Increase water consumption. c. Decrease physical exercise. d. Refrain from alcohol. e. Refrain from smoking.

ANS: A, B Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on the quality of bowel movements.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. When conducting a health history assessment, which information would be viewed as most important as related to the patient’s elimination status? (Select all that apply.) a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine c. Time of day patient defecates d. Discomfort or pain with elimination e. List of medications taken by patient f. Patient’s preferences for toileting ANS: A, B, D, E Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Personal preferences are not the most important data the nurse needs to collect.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

N

Concept 18: Perfusion Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student makes which statement? a. “Central perfusion is monitored only by the physician.” b. “Central perfusion involves the entire body.” c. “Central perfusion is decreased with hypertension.” d. “Central perfusion is toxic to the cardiac system.”

ANS: B Central perfusion does involve the entire body as all organs are supplied with oxygen and vital nutrients. The physician does not control the body’s ability for perfusion. Central perfusion is not decreased with hypertension. Central perfusion is not toxic to the cardiac system.

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NCLEX Client Needs Category: Health Promotion and Maintenance

2. A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse’s best response? a. “Hypertension happens to everyone sooner or later. Don't be concerned about it.” b. “Hypertension can happen from eating a poor diet, so change what you are eating.” c. “Hypertension can happen from arterial changes that block the blood flow.” d. “Hypertension happens wNhen people do not exercise, so you should walk every day.”

ANS: C Hardening of the arteries from atherosclerosis can cause hypertension in the patient.

Hypertension does not happen to everyone. Changing the patient’s diet and exercising may be a positive life change, but these answers do not explain to the patient how the disease could have happened.

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NCLEX Client Needs Category: Health Promotion and Maintenance

3. The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse’s best response? a. “It stimulates the heart to beat in a normal rhythm.” b. “It protects the heart from atherosclerotic changes.” c. “It provides the heart with oxygenated blood.” d. “It protects the heart from infection.”

ANS: A The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with oxygenated blood.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? a. Mental alertness b. Perfusion c. Pain d. Reaction to medications ANS: B Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A patient’s serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? a. Tissue ischemia b. Brain malformations c. Intestinal blockage d. Cardiac dysrhythmia ANS: D Cardiac dysrhythmia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nurse is explaining the concept of perfusion to a student nurse. The nurse knows the student understands the concept of perfusion when the student makes which statement? a. “Perfusion is a normal function of the body, and I don't have to be concerned about it.” b. “Perfusion is monitored by the physician.” c. “Perfusion is monitored by vital signs and capillary refill.” d. “Perfusion varies as a person ages, so I would expect changes in the body.”

ANS: C The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

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NCLEX Client Needs Category: Health Promotion and Maintenance

7. The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a. Elevated blood pressure b. Bounding pedal pulses

c. Night blindness d. Reflux disease ANS: A Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes.

This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

Concept 19: Gas Exchange Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange? a. Blood glucose of 350 mg/dL b. Anticoagulant therapy for 10 days c. Hemoglobin of 8.5 g/dL d. Heart rate of 100 beats/min and blood pressure of 100/60 ANS: C The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential | NCLEX Client Needs Category: Physiological Adaptation 2. The nurse is reviewing the patient’s arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b. Tachycardia and decreaseNd blood pressure c. Increased anxiety and irritability d. Hyperventilation and lethargy ANS: A The patient is experiencing respiratory acidosis (pH and PaCO2) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO 2.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem? a. Peripheral arterial disease of the lower extremities b. Chronic obstructive pulmonary disease (COPD) c. Chronic asthma d. Severe anemia secondary to chemotherapy ANS: A Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is assessing a patient’s differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient’s gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. Eosinophil count will assist to identify the presence of a respiratory infection. c. White cell count will differentiate types of respiratory bacteria. d. Level of neutrophils provides guidelines to monitor a chronic infection.

ANS: A Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patient’s gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? a. Chronic lung disease with increased carbon dioxide retention b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention c. Decreased cardiac output with increased serum lactic acid production d. Gastric drainage with increased removal of gastric acid ANS: A N Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen? a. Hemoglobin level of 8.0 b. Bronchoconstriction and mucus c. Peripheral arterial disease d. Decreased thoracic expansion ANS: A Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a. The infant is becoming more active. b. There is an increase in intake of breast milk or formula. c. The infant is unable to maintain an adequate iron intake. d. A depletion of fetal hemoglobin occurs.

ANS: D Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2–3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

8. Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a. Decreasing venous stasis and risk for pulmonary emboli b. Implementation of strict hand washing routines c. Maintaining current vaccination schedules d. Prevention of pneumonia in patients with chronic lung disease ANS: D Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation,Nimmunizations, and prevention of postoperative complications.

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NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. Endocrine system c. Pulmonary system d. Immune system e. Cardiovascular system f. Hepatic system ANS: A, C, E The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange.

The immune system primarily protects the body against infection.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. Oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.

ANS: B, E, F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

N

Leaking of clear fluid from the vagina with back pain and elevated BP is associated with premature rupture of membranes, a complication of pregnancy. An ectopic pregnancy usually manifests as unilateral pain early in the pregnancy. Vaginal bleeding is a classic sign of miscarriage, or spontaneous abortion, not leaking of clear fluid. This patient’s blood pressure is elevated. Supine hypotension occurs when the woman is lying supine; then low blood pressure occurs due to the decrease in venous return from the gravid uterus placing pressure on the vena cava.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. The nurse is admitting a prenatal patient for diagnostic testing. While eliciting the psychosocial history, the nurse learns the patient smokes a pack of cigarettes daily, drinks a cup of cappuccino with breakfast, has smoked marijuana in the remote past, and is a social drinker. Which action should the nurse first take? a. Strongly advise immediate tobacco cessation b. Elimination of all caffeinated beverages c. Serum and urine testing for drug use and alcohol use d. Referral to a 12-step program ANS: A There are numerous risk factors for women and men affecting reproductive health and pregnancy outcomes. These can be categorized into biophysical, psychosocial, sociodemographic, and environmental factors. Some of the risk factors for human reproduction fit into multiple categories. Psychosocial factors cover smoking, excessive caffeine, alcohol and drug abuse, psychological status including impaired mental health, addictive lifestyles, spouse abuse, and noncompliance with cultural norms. Drinking a cup of a caffeinated beverage a d aNy is not associated with adverse fetal outcomes usually. Serum and urine testing for drug/alcohol use is not required for stated marijuana use in the remote past. Patient referral to a 12-step program is usually advisable for current alcohol and/or drug use.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A female infertility patient is found to be hypoestrogenic at the preconceptual clinic visit.

She asks the nurse why she has never been able to get pregnant. Which is the best nursing response? a. Circulating estrogen contributes to secondary sex characteristics. b. Estrogen deficiency prevents the ovum from reaching the uterus and may be a factor in infertility. c. Hyperestrogen may be preventing the zona pellucida from forming an ovum protective layer. d. The corona radiata is preventing fertilization of the ovum.

ANS: B

The cilia in the tubes are stimulated by high estrogen levels, which propel the ovum toward the uterus. Without estrogen, the ovum won’t reach the uterus. The results of a series of events occurring in the ovary cause an expulsion of the oocyte from the ovarian follicle known as ovulation. The ovarian cycle is driven by multiple important hormones: (1) gonadotropic hormone, (2) follicle-stimulating hormone (FSH), and (3) luteinizing hormone (LH). The cilia in the tubes are stimulated by high (4) estrogen levels, which propel the ovum toward the uterus. The zona pellucida (inner layer) and corona radiata (outer layer) form protective layers around the ovum. If an ovum is not fertilized within 24 hours of ovulation by a sperm, it is usually reabsorbed into a woman’s body. A patient who is hypoestrogenic would not have excess circulating estrogen. A patient with low estrogen would not be classified as hyperestrogenic. Without sufficient estrogen, there can be no fertilization of the ovum.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. An obstetric multipara with triplets is placed on bed rest at 24 weeks’ gestation. Her perinatologist is managing intrauterine growth restriction with serial ultrasounds. This prescribed treatment is an example of which type of care? a. Antenatal diagnostics b. Primary prevention c. Secondary prevention d. Tertiary prevention ANS: C An example of secondary prevention relating to reproductive health would be managing fetal intrauterine growth restriction by serial ultrasounds. This type of diagnostic maternal/fetal monitoring is pNerformed to determine the best time for delivery due to potential fetal nutritional, circulatory, or pulmonary compromise. A cesarean section (operative delivery) may be performed if maternal or fetal conditions indicate that delivery is necessary. Antenatal diagnostics refers to prior to pregnancy. An example of primary prevention is teaching a high school class about reproductive health. An example of tertiary prevention would be aimed at improving health following an illness and/or rehabilitation.

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NCLEX Client Needs Category: Safe and Effective Care Environment

7. A female patient comes to the clinic after missing one menstrual period. She lives in a house beneath electrical power lines which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest implication for this patient’s plan of care? a. Electrical power lines are a potential hazard to the woman and her fetus. b. Living near an oil field may mean the water supply is polluted. c. Alcohol exposure should be avoided during pregnancy due to teratogenicity. d. Eating sweets may cause gestational diabetes or miscarriage.

ANS: C

Stages of development include ovum, embryonic, and fetal. The beginning of the fourth week to the end of the eighth week comprise the embryonic period. Teratogenicity is a major concern because all external and internal structures are developing in the embryonic period. A pregnant woman should avoid exposure to all potential toxins during pregnancy, especially alcohol, tobacco, radiation, and infections during embryonic development. Living in a house beneath power lines is not the greatest implication in this patient’s plan of care as there are no definite risks to the developing fetus. Living near an oil field has no definite risks to the fetus. Eating sweets may contribute to maternal obesity, large for gestational age fetus, and maternal gestational diabetes but does not have the immediate implication of a daily beer drinker which can cause fetal alcohol syndrome.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

Based on the patient’s reported complaint and obstetrical history, it may be likely that the patient has a pelvic prolapse. Therefore, a vaginal exam would be indicated to help identify possible anatomical changes. There is no clinical data that supports a potential pelvic mass and inspection alone would not confirm this finding. Obtaining vital signs as well as a urine culture may be needed, but the focus should be on determination of physical findings related to the pelvic area.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. An adult patient comes for a well-check up to the primary care provider’s office. In completing the office admission form, the patient does not indicate gender on the form and seems somewhat agitated when providing the form back to the nurse. How should the nurse respond? a. Ask the patient to complete all of the information at this time. b. Ask the patient if you can assist with completing the form. c. The nurse should just indicate which gender she/he thinks is appropriate. d. Tell the patient that if the form is not completed, then the doctor will not see you.

ANS: B Gender identity is defined by the individual patient. The nurse should not designate this description or identity nor should the nurse tell the patient that if the form is not completed, that the patient will not be seen by the healthcare provider. Asking the patient to complete the information without acknowledging that the patient is exhibiting signs of distress is not therapeutic. The nurse should offer to provide assistance to the patient.

OBJ:

NCLEX Client Needs Category: Psychological Integrity

N 5. A nurse is working with a male patient being treated for erectile dysfunction. Which statement indicates that additional teaching is needed? a. “I like to go walking around my community each night after dinner.” b. “I have a few drinks during the week when I go out after work.” c. “I have maintained my weight for the past 5 years after losing 20 pounds.” d. “I monitor my blood pressure at home using a portable cuff.”

ANS: B Erectile dysfunction (ED) is a common problem affecting the male population and can be chronic or transient in nature. Alcohol use can affect ED, so the patient’s reported alcohol intake indicates that additional teaching is warranted. Exercise, maintaining a healthy weight and monitoring of blood pressure are examples of appropriate activities.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nursery nurse performing the first physical assessment of the newborn observes that there is no clear identification of genitalia as being either female or male. How should the nurse identify this newborn? a. Gender neutral b. Bisexual c. Observation of intersex d. Asexual

ANS: C Intersex represents a group of conditions where the external genitalia of an infant does not appear as either male or female and/or is not consistent with genetic sex or organs. The nurse cannot attribute sexual preference such as asexual or bisexual. Gender neutral does not apply to this clinical situation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A nurse working with a family whose child has recently told them that he identifies with the LGBTQ community asks the nurse to explain how this happened considering the fact that the child was raised as a male and played with appropriate toys. What is the best nursing response to the family’s concerns? a. Tell them that there is no need for concern for their child has shared this information with them. b. Ask the parents if they ever noticed something different about their son as he was growing up. c. Explain that sexual orientation changes can occur over time. d. Suggest that this behavior may be temporary.

ANS: C Sexual orientation and gender identification is now thought of as a fluid concept, with the term sexual fluidity being used to convey this meaning for individuals who identify with other than heterosexual relationships. The nurse should respond to the parent’s concerns and not minimize their reaction but rather let them know that it is the chosen response of their child. Relating the sexual orientation or gender identification to how one was raised indicates an implied bias. Telling the family that the behavior may be temporary is not N correct.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

Concept 22: Immunity Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient’s discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques c. The importance of wearing a face mask in public d. Limiting contact with the general population ANS: B The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes Nt ha t the child’s growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition? a. Primary immunodeficiency b. Secondary immunodeficiency c. Cancer d. Autoimmunity ANS: A Primary immunodeficiency is a risk for patients with two or more of the listed problems.

Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12–24 hours post operation dependent on which condition? a. His immune system is functioning properly. b. He is properly vaccinated. c. He has an infection. d. The suppressor T-cells in his body are activated.

ANS: A Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the body’s response to intentional tissue impairment. The redness and swelling at the incision site in the first 12–24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement? a. “My body will treat the new kidney like my original kidney.” b. “I will have to make sure that I avoid being around people.” c. “The medications that I take will help prevent my body from attacking my new kidney.” d. “My body will only have a problem with my new kidney if the donor is not directly related to me.”

ANS: C Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will n o Nt treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they don’t have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient’s respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition? a. Suppressed immune response b. Hyperimmune response c. Allergic reaction d. Anaphylactic reaction ANS: D

The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication.

These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA).

The nurse should explain which goal of treatment to the patient? a. Eradicate the disease b. Enhance immune response c. Control inflammation d. Manage pain ANS: C Medications for RA are intended to control the inflammation that results from the body’s hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response.

The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

N MULTIPLE RESPONSE 1. The parents of a newborn question the nurse about the need for vaccinations: “Why does our baby need all those shots? He’s so small, and they have to cause him pain.” The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) a. Are only required for infants b. Are part of primary prevention for system disorders c. Prevent the child from getting childhood diseases d. Help protect individuals and communities e. Are risk free f. Are recommended by the Centers for Disease Control and Prevention (CDC) ANS: B, D, F Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient won’t get the disease, but it decreases the potential to contract the illness. No medication is risk free.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

Concept 23: Inflammation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following? a. “The coating on these medications is irritating to my intestines.” b. “I need a more immediate response from my medications than can be obtained from enteric coated medications.” c. “Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue.” d. “I don’t need to use these medications because they cause diarrhea, and I have had enough trouble with diarrhea and rectal bleeding over the past weeks.”

ANS: C Enteric coatings on medications are designed to prevent breakdown and absorption of the medication until lower in the digestive tract, usually to prevent stomach irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with ulcerative colitis, the intestinal lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, enteric coated medications should be avoided. The coating is not irritating, but the medication can be. The response time of the medication is not a concern in this instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.

N

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. What is the nurse’s best response? a. “Use ice only when the ankle hurts.” b. “Ice should be applied for 15–20 minutes every 2–3 hours over the next 1–2 days.” c. “Wrap an ice pack around the injured ankle for the next 24–48 hours.” d. “Ice is not recommended for use on the sprain because it would inhibit the inflammatory response.”

ANS: B Ice is used on areas of injury during the first 24–48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2–3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. A patient is being treated with an antibiotic for an infected orthopedic injury. What explanation should the nurse give to the patient about this medication?

a. b. c. d.

“Antibiotics will decrease the pain at the site.”

“An antibiotic helps to kill the infection causing the inflammation.”

“An antibiotic inhibits cyclooxygenase, an enzyme in the body.”

“Antibiotics will reduce the patient’s fever.”

ANS: B Antimicrobials treat the underlying cause of the infection which leads to inflammation.

Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient’s wound. The nurse realizes what information about this fluid? a. Contains the materials used by the body in the initial inflammatory response b. Indicates that the patient has an infection at the site of the wound c. Is destroying healthy tissue d. Results from ineffective cleansing of the wound area ANS: A Exudate is fluid moved from the vascular spaces to the area around a wound. It contains the proteins, fluid, and white blood cells (WBCs) needed to contain possible pathogens at the site of injury. Exudate appears as part of all inflammatory responses and does not mean an infection is present. Exudate is part of normal inflammatory responses which contain self-monitoring mechanisms to help prevent damage to healthy tissue. Exudate appears at wound sites regardless of cleaNning done to the area of injury.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The nurse reviews the patient’s complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates what type of inflammatory response? a. Chronic b. Resolved c. Early stage acute d. Late stage acute ANS: C Elevated neutrophils and monocytes within normal limits are findings indicative of early inflammatory response. Neutrophils increase in just a few hours, while it takes the body days to increase the monocyte levels. Chronic inflammation results in varying elevations in WBCs dependent on multiple issues. Elevated neutrophils are not indicative of resolved inflammation. Elevations in monocytes occur later in the inflammatory response.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. What teaching should the nurse provide for this patient?

a. b. c. d.

“Don’t eat with the other students.”

“Avoid sharing razors and other personal items.”

“Have a complete blood count (CBC) checked monthly.”

“Disinfect showers and bathroom floors weekly after use.”

ANS: B Avoidance of sharing personal items like razors and hairbrushes can decrease the spread of pathogens that cause inflammation and infection. Not eating with the others in his college apartment won’t relieve or prevent the spread of infection. A CBC monthly will not treat or prevent inflammation. Showers should be disinfected before and after each use.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. The nurse assesses the patient and notes all of the following. Which of the findings indicates systemic manifestations of inflammation? (Select all that apply.) a. Oral temperature 38.6 C/101.5 F b. Thick, green nasal discharge c. Patient complaint of pain at 6 on a 0–10 scale on palpation of frontal and maxillary sinuses d. WBC 20 cells/McL  109/L e. Patient reports, “I’m tired all the time. I haven’t felt like myself in days.”

ANS: A, D, E Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise andNfatigue. Purulent exudates and pain are both considered local manifestations of inflammation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Concept 24: Infection Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element? a. Host b. Mode of transmission c. Portal of entry d. Reservoir ANS: C Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry.

Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. While reviewing the completN e blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of which type of infection? a. Bacterial b. Fungal c. Parasitic d. Viral ANS: C Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels. Bacterial infections do not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T lymphocytes, neutrophils, and monocytes.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. Which set of assessment data is consistent for a patient with severe infection that could lead to system failure? a. Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours c. BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24

hours d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours ANS: B The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A nurse is teaching a group of business people about disease transmission. The nurse knows that additional teaching is needed when one of the participants states which of the following? a. “When traveling outside of the country, I need to be sure that I receive appropriate vaccinations.” b. “Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has no resistance.” c. “If I don’t feel sick, then N I don’t have to worry about transmitted diseases.” d. “I need to be sure to have good hygiene practices when traveling in crowded planes and trains.”

ANS: C People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. In order to provide an intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide? a. Whether a patient has an infection. b. Where an infection is located. c. The type of cells that are being utilized by the body to attack an infection. d. The specific type of pathogen that is causing an infection.

ANS: D

People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.) a. Administration of protease inhibitors b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission d. Preventing visitors from entering the room e. Administration of intravenous fluids f. Strict monitoring of intake and output ANS: B, C, E, F Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the use of personal protectiveNequipment and teaching on methods to inhibit transmission to help break the chain of infection. Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of Clostridium difficile, because it causes diarrhea with fluid loss.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort | NCLEX Client Needs Category: Physiological Adaptation 2. Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a. Uninsured or underinsured status b. Easy access to health screenings c. High cost of medications d. Inadequate nutrition e. Mostly female gender ANS: A, C, D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection. Gender has not been shown to be an increased risk factor for infection in the lower socioeconomic population.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort |

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? a. “Patients must have a trapeze over the bed to move properly.” b. “Patients should move themselves in bed to prevent immobility.” c. “Patients should always have a two-person assist to move in bed.” d. “Patients must be moved correctly in bed to prevent shearing.”

ANS: D Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional if the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly. A patient may move himself or herself if he or she is able; but shearing may still occur.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement? a. “Patients with impaired bed mobility have an increased risk for pressure ulcers.” b. “Patients with impaired bed mobility like to have extra visitors.” c. “Patients with impaired bed mobility need to have a mechanical soft diet.” d. “Patients with impaired bed mobility are prone to constipation.”

N

ANS: A Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is instituted.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. What percentage of hip fractures is the result of falls? a. 50% b. 80% c. 90% d. 100% ANS: C About 90% of falls end with a hip fracture.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. The lack of weight bearing leads to what effects on the skeletal system? a. Demineralization, calcium loss b. Thickened bones c. Increased range of motion

d. Increased calcium deposition in the bones ANS: A Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium that strengthen it. Thickened bones will not occur with the lack of weight bearing. Range of motion may be decreased with a lack of weight bearing movements.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity.

The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevNent sunburn by replacing lost nutrients. d. Apply sunscreen 30 minutes prior to exposure.

ANS: D Wearing sunglasses and sunscreen are recommended by the National Cancer Institute.

Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for additional teaching? a. “I wear a hat and sit under the umbrella when not in the water.” b. “I don’t bother with sunscreen on overcast days.” c. “I use a sunscreen with the highest SPF number.” d. “I wear a UV shirt and limit exposure to the sun by covering up.”

ANS: B The sun’s rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism? a. Candida albicans b. Group A -hemolytic streptococci c. Staphylococcus aureus d. E. Coli ANS: C Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

8. A nurse is conducting community education classes on skin cancer. One participant says to the nurse: “I read that most melanomas occur on the face and arms in fair-skinned women.

Is this true?” How should the nurse respond? a. “That is not correct. Melanoma is more commonly found on the torso or the lower legs of women.” b. “That is correct, because the face and arms are exposed more often to the sun.” c. “That is not correct. Melanoma occurs on the top of the head in men but is rare in women.” d. “That is incorrect. Melanoma is most commonly seen in dark-skinned individuals.”

ANS: A Melanoma is more commonlyN found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

9. The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse’s teaching? a. Bathing and drying the skin vigorously to stimulate circulation b. Keeping the head of the bed elevated 30 degrees c. Limiting intake of fluid and offer frequent snacks d. Turning the patient at least every 2 hours ANS: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

10. A patient asks the nurse what the purpose of the Wood’s light is. Which response by the nurse is accurate? a. “We will put an anesthetic on your skin to prevent pain.” b. “The lamp can help detect skin cancers.” c. “Some patients feel a pressure-like sensation.” d. “It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions.”

ANS: D The Wood’s light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 27: Sensory Perception Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A 75-year-old woman walks into the emergency department with complaints of “not feeling well.” Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings? a. Normal in the older adult b. A need for the patient to be evaluated for cognitive impairment c. A side effect of anti-hypertensive medication d. Pathologic impairment of sensory responses ANS: D This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli.

Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The nurse requests that a m o tNhe r give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? a. “This will help us to identify your baby’s risk for ear infections the first year of life.” b. “Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother.” c. “Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child.” d. “Imitation of sounds is the first step in language development, and it is important to identify alterations early.”

ANS: D Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby’s response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse’s best response? a. “Your wife should increase the spices in your food, as the pneumonia changes

your sense of smell.” b. “Notify your doctor immediately, because this is a concerning reaction to the medication.” c. “You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection.” d. “You should see an improvement in the next week or so. Call if this continues.”

ANS: D Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process.

Understanding of the instructions is evident when the daughter says which of the following? a. “I will make sure that dad always wears warm socks.” b. “Dad needs to wear his glasses so he can delay the onset of macular degeneration.” c. “I will ask the home health aide to carefully inspect dad’s feet every day when she helps him bathe.” d. “We will give him only warm foods, so that he doesn’t burn his mouth.”

ANS: C Diabetes increases risk of perNipheral neuropathy, and it is hard to inspect one’s own feet.

Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse’s best action to provide recreational activities during the rehabilitation phase? a. Place the television to the left or right of patient’s visual field. b. Encourage the patient to learn braille. c. Suggest use of talking books. d. Provide headphones for listening to music.

ANS: C Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the nurse’s priority action? a. Notify the physician. b. Document the finding in the records. c. Recheck the reflex after several hours. d. Monitor the eye movements and pupil reactions closely.

ANS: A The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? a. “I will take my child to the audiologist because he doesn’t seem to hear me except when I look directly at him.” b. “Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle.” c. “Making my child wear ear plugs when she goes to a rock concert may save her hearing!” d. “I see now why when my child has a cold, he complains about everything tasting blah!”

ANS: B Each person should always h Na v e their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

8. During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient’s wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure? a. Tympanoplasty b. Irrigation of the ear c. Pure tone test d. Otoscopic exam by a specialist ANS: B The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

Concept 28: Pain Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of what type of pain? a. Neuropathic pain b. Nociceptive pain c. Chronic pain d. Mixed pain syndrome ANS: B Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer.

Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A 19-year-old male has sustaN ined a transection of C-7 in a motor vehicle crash rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. What type of pain is this patient describing? a. Neuropathic pain b. Visceral pain c. Eudynic pain d. Nociceptive pain ANS: A Neuropathic pain results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Simply put, neuropathic pain is pathologic. Examples of neuropathic pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and post stroke pain syndrome. Patients with neuropathic pain use very distinctive words to describe their pain, such as “burning,” “sharp,” and “shooting.” Visceral pain arises from the body cavities and responds to stretching, swelling and decreased oxygen levels. Eudynic pain refers to the normal transmission of pain via nociceptive receptors. Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping or throbbing.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. Controlling pain is important to promoting wellness. Unrelieved pain has been associated with complication?

a. b. c. d.

Prolonged stress response and a cascade of harmful effects system-wide Large tidal volumes and decreased lung capacity Decreased tumor growth and longevity Decreased carbohydrate, protein, and fat destruction

ANS: A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or stress response.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis (OA) pain. You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include which actions or activities? a. Pilates, breathing exercises, and aloe vera b. Guided imagery, relaxatioNn breathing, and meditation c. Herbs, vitamins, and tai chi d. Alternating ice and heat to relieve pain and inflammation ANS: C Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi. Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs and vitamins.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A 70-year-old retired patent is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should the nurse consider in the plan of care considering the patient’s expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Mind-body therapies such as music therapy, distraction techniques, meditation,

prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services ANS: B Mind-body therapies are designed to enhance the mind’s capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others.

Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the mind’s capacity to affect bodily function and symptoms.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. A 30-year-old male is admitted to the hospital with acute pancreatitis. He is in acute pain described as a 10/10, which is localized to the abdomen, periumbilical area, and some radiation to his back. The abdomen is grossly distended. He is restless and agitated, with elevated pulse and blood pressure. An appropriate pain management plan of care may include which medication(s)? a. IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen b. Norco 5/500 q 4 hours PO and Benadryl 25 mg PO q 6 hours c. Phenergan 25 mg IM q 6 hours d. Tylenol 325 mg q 6 hoursN ANS: A A variety of routes of administration are used to deliver analgesics. A principle of pain management is to use the oral route of administration whenever feasible. All of the first-line analgesics used to manage pain are available in short-acting and long-acting formulations.

For patients who have continuous pain, a long-acting analgesic, such as modified-release oral morphine, oxycodone, or hydromorphone, or transdermal fentanyl, is used to treat the persistent baseline pain. A fast-onset, short-acting analgesic (usually the same drug as the long-acting) is used to treat breakthrough pain if it occurs. When the oral route is not possible, such as in patients who cannot swallow or are NPO or nauseated, other routes of administration are used, including intravenous (IV), subcutaneous, transdermal, and rectal.

Norco, Benadryl, Phenergan, and Tylenol are not appropriate solo choices for acute pancreatitis with pain reported as 10/10.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. An 80-year-old male patient is in the intensive care unit has suffered a fractured femur. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioid doses q 4 hours. What is the nurse’s first action? a. Call the rapid response team to care for the patient immediately. b. Discontinue the opioids on the medication administration record.

c. Assess the patient’s blood pressure and pain level. d. Start a second intravenous line with a large bore catheter.

ANS: A After establishing unresponsiveness, the next action is to call a Rapid Response. The patient is not able to subjectively describe pain if unresponsive. Another IV line may be needed, but first the nurse should call for help. The opioids should be discontinued on the MAR; however the priority action is to call for help.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

Concept 29: Fatigue Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Based on the significant effects of chronic idiopathic fatigue, what is the nurse’s priority assessment? a. Cholesterol level and lipid profile b. Creatinine and BUN levels c. Memory loss testing d. Mental health evaluation ANS: D Fatigue does not cause death or organ failure, but mortality from suicide was higher than the general population in patients with chronic idiopathic fatigue. Therefore a mental health evaluation is a priority assessment. Cholesterol and lipid levels are indicative of heart disease. Creatinine and BUN levels are indicators of kidney function. Memory loss is not a significant effect of chronic fatigue.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The nurse is assessing for fatigue in a patient diagnosed with multiple sclerosis. Which self -reporting tool is best for the nurse to utilize? a. Multidimensional Assessment of Fatigue (MAF) b. Fatigue Severity Scale (FSS) N F I) c. Brief Fatigue Inventory ( B d. Multidimensional Fatigue Inventory (MFI) ANS: B The FSS was developed for patients with multiple sclerosis and lupus. The MAF was designed for arthritis patients and is also used in cancer patients and those with chronic pulmonary disease. The BFI is used for cancer patients. The MFI is used with various patient populations, including cancer, chronic fatigue syndrome, and COPD. OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A patient presents to the clinic complaining of nausea, vomiting, and fatigue. Lab results reveal elevated BUN and creatinine levels. Which acute condition is this patient at most risk for developing? a. Influenza b. Mononucleosis c. Acute renal failure d. Pneumonia ANS: C

The patient’s symptoms are most congruent with dehydration. Hypovolemia, due to dehydration, can lead to decreased perfusion to the kidneys resulting in acute renal failure.

Influenza symptoms include headache, fever, body aches, and fatigue. Mononucleosis can manifest as severe fatigue. Pneumonia presents with cough, respiratory distress, and decreases in oxygen saturation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is caring for a patient diagnosed with amyotrophic lateral sclerosis. The nurse should assess for which priority problem? a. Fatigue b. Bradypnea c. Hypertension d. Fall risk ANS: B Amyotrophic lateral sclerosis is a chronic condition that causes fatigue; however specific respiratory muscle fatigue leading to bradypnea is the priority safety risk. Respiratory muscle fatigue can lead to bradypnea, decreased ventilation, and eventually cessation of breathing which is the condition of highest importance with this illness. Hypertension is not a high priority problem specifically related to ALS. While the patient is a fall risk due to overall skeletal muscle fatigue, respiratory depression is the priority safety risk.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A patient with chronic kidney disease is most likely to complain of which symptom?

N a. Fatigue b. Thirst c. Constipation d. Excess bleeding ANS: A Erythropoietin is produced by the kidneys. A patient with chronic kidney disease produces less erythropoietin, resulting in anemia and fatigue as a common symptom. Thirst, or polydipsia, is a common sign of hyperglycemia and diabetes which can lead to chronic kidney disease. Constipation is not a common symptom of chronic kidney disease.

Excessive bleeding can result from a decrease in platelets and clotting factors that are produced by the liver, not the kidneys.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A patient has been recently diagnosed with chronic fatigue syndrome and asks the nurse about the cause of this illness. What is the nurse’s best response? a. “The provider will be able to tell you when the lab results are back.” b. “An exact cause may not be determined, but a treatment plan will be discussed.” c. “Stress is the main cause; a referral to a counselor may be helpful.” d. “This is considered a psychiatric illness requiring behavioral medicine.”

ANS: B

Chronic fatigue syndrome is considered an illness with an unknown etiology. There are no specific lab results that reveal chronic fatigue syndrome. Stress and mental illnesses may be contributing factors, but are not classified as exact causes of chronic fatigue syndrome.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. The nurse palpates swollen nodes in a patient’s neck who presented to the clinic with complaints of fatigue lasting at least 2 weeks. What is the nurse’s best action? a. Advise patient this finding is normal. b. Review patient’s thyroid lab work. c. Perform deep tendon reflexes. d. Notify the healthcare provider.

ANS: D The nurse should notify the healthcare provider for further evaluation. Palpation is indicated to assess for the presence of lymphadenopathy, thyroid nodules or goiter. These findings could implicate the need to test further for cancer, thyroid disease or infection. These conditions should be ruled out by the healthcare provider. Thyroid nodules or changes in size indicate the need for further assessment of the thyroid. Deep tendon reflexes are part of a neuro-muscular examination and are not directly related to cervical node enlargement.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. The nurse is assessing a patient for risk factors of chronic fatigue syndrome. Which factors N should the nurse identify as placing the patient at risk for chronic fatigue syndrome? (Select all that apply.) a. Feeling tired upon awakening b. Chronic migraines c. Tenderness under the jaw d. 5 episodes tonsillitis/past year e. Swollen, painful knees ANS: A, C, D, E The individual has severe chronic fatigue for 6 or more consecutive months that is not due to ongoing exertion or other medical conditions associated with fatigue (these other conditions need to be ruled out by a doctor after diagnostic tests have been conducted). The fatigue significantly interferes with daily activities and work. The individual concurrently has four or more of the following eight symptoms: • Post exertion malaise lasting more than 24 hours • Unrefreshing sleep • Significant impairment of short-term memory or concentration • Muscle pain • Multi-joint pain without swelling or redness • Headaches of a new type, pattern, or severity • Tender cervical or axillary lymph nodes • Frequent or recurring sore throat

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The occupational health nurse is making rounds in a factory. Which employees need further education about energy conservation strategies? (Select all that apply.) a. Workers reaching up to high shelf often to obtain cleaning supplies b. Workers bending over to lift boxes onto conveyer belt c. Workers who have delegated out parts of their activities d. Workers standing for long periods e. Workers standing at desks at waist level ANS: A, B, D The employee health nurse should provide teaching to employees about energy conservation strategies to protect workers from job-related injuries. These strategies include: placing frequently used items within reach; using proper body mechanics (not bending over and straining the back); and standing for long periods of time. Delegating parts of activities is an appropriate energy conserving strategy. When standing is necessary, it is important that desks or tables are at waist level of the employee to prevent excess reaching or straining.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. The nurse recognizes that which patients are at highest risk for physiologic fatigue? (Select all that apply.) a. Parents of a newborn b. Adolescent with anorexia c. 25-year-old pregnant female d. Grandmother who takes N mile walks e. Businessman who consumes six cups coffee/day ANS: A, B, C, E Physiologic causes of fatigue include: protein–calorie malnutrition, excessive physical activity, sleep deprivation, excessive caffeine or alcohol use, and pregnancy. Parents of a newborn are likely experiencing sleep deprivation. A patient with anorexia is likely not consuming adequate amounts of protein. Consumption of six cups of coffee/day is considered excessive. A mile walk is an appropriate exercise for an older adult and not considered excessive physical activity.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. Which are treatment related causes of fatigue? (Select all that apply.) a. Blood transfusion b. Chemotherapy c. Radiation therapy d. Surgery e. Side effects of medications ANS: B, C, D, E

Cancer treatments, such as chemotherapy and radiation, commonly cause fatigue. A risk of any surgery is blood loss, which can possibly lead to fatigue if the hemoglobin and hematocrit drop significantly. Fatigue is a side effect of many medications. A blood transfusion is more likely to lead to increased energy versus fatigue as the hematocrit and hemoglobin levels would be expected to rise with the transfusion.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

N

The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient’s vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110–120/76–84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30–60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

ANS: C The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Benson’s relaxation response) will counter the sympathetic nervous system’s arousal, normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his body. Other options do not address his physiologic response pattern as directly or immediately.

OBJ: NCLEX Client NeedsNCategory: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function? a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. b. Alter the internal state by modifying electronic signals related to physiologic processes. c. Replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities. d. Reduce catecholamine production and promote the production of additional -endorphins.

ANS: A When the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse, blood pressure, and respiratory rate. Relaxation is achieved when the sympathetic nervous system is quieted and the parasympathetic nervous system is operative. Modifying electronic signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the cognitive approach to stress management. Reducing catecholamine production is the basis for guided imagery’s effectiveness.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A patient tells the nurse, “I’m told that I should reduce the stress in my life, but I have no idea where to start.” Which would be the best initial nursing response? a. “Why not start by learning to meditate? That technique will cover everything.” b. “In cases like yours, physical exercise works to elevate mood and reduce anxiety.” c. “Reading about stress and how to manage it might be a good place to start.” d. “Let’s talk about what is going on in your life and then look at possible options.”

ANS: D In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. As a result, further assessment is indicated before potential solutions can be explored. Suggesting further exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. A patient tells the nurse “My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking.” Which response would be in keeping with the doctor’s recommendations? a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts b. Encouraging the patient to imagine being in calming circumstances c. Teaching the patient to use instruments that give feedback about bodily functions d. Provide the patient with a blank journal and guidance about journaling ANS: A N Meaning-focused coping leads the individual to focus on his/her own values and beliefs to modify the personal interpretation and response to a problem. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient’s manner of thinking.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

8. A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient’s wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

ANS: C

Objective measures tend to be the most reliable means of gauging progress. In this case, the patient’s elevated blood pressure, an indication of the body’s physiologic response to stress, has diminished. The wife’s observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patient’s report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 9. The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress.

Which action should the nurse implement to assist the patient? a. Identifying the cause of fear b. Accessing a community support group c. Identifying relaxation methods d. Reviewing an educational pamphlet ANS: A Identifying the cause of a negative perception is the first step in helping an individual to be able to utilize coping strategies. Accessing a community support group is an example of accessing resources to enhance coping. Identifying relaxation methods is an example of developing an action plan. Reviewing an educational pamphlet is an example of using education to enhance coping.

OBJ:

NCLEX Client NeedsNCategory: Psychosocial Integrity

10. The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy? a. Scheduling a regular exercise program b. Attending a seminar on treatment options c. Identifying a confidant to share feelings d. Attending a support group for families ANS: C Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing community resources or attending educational seminars.

Exercise, emotional support, and support groups are emotion-based strategies that create a feeling of well-being.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

11. The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population? a. Altered vital sign readings b. Inaccurate perceptions of stressors c. Increased risk for suicide d. Decreased access to alcoholic beverages

ANS: C Adolescents with poor coping have increased risk for drug and alcohol use, risky sexual behaviors, and suicide. Pulse, respiratory rate, and blood pressure may change during stress, but patient safety is the priority concern. Adolescents may have inaccurate perceptions of stressors, and this actually increases the risk for unsafe behaviors. Adolescents under stress are more at risk for increasing their access to alcohol and illegal drugs.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

12. A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient? a. Ask if there is another family member who can help at home while the patient is in the hospital. b. Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover. c. Coordinate an ambulance transfer of the family member to an alternate family member’s home. d. Ask social services to assess what the patient’s needs will be after discharge to home.

ANS: A The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the immediate need to provide care for the disabled family member. An Nambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person’s needs, availability to provide the care by another, and distance of the transfer. Assessing the patient’s needs after discharge does not address the immediate need to provide care for the disabled family person.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

13. After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff? a. Ask administration to require staff to meditate daily for at least 30 minutes. b. Have a staff psychologist available on the unit once a week for required counseling. c. Have training sessions to help the staff understand their new responsibilities. d. Ask support staff from other disciplines to complete some nursing tasks to provide help.

ANS: C

Feeling unprepared for work responsibilities contributes to stress and poor coping in the workplace. Administration cannot require that staff participate in meditation or counseling sessions, although these can be recommended and encouraged. Asking other disciplines to assume nursing tasks is not appropriate for their scope of practice.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

14. The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool? a. “This tool will let us compare your stress to other patients in the hospital.” b. “This tool is short because it only measures the negative stressors you are experiencing.” c. “You will need to ask your parents about stressors you had as a child to complete this tool.” d. “This tool will help assess recent positive and negative events you are experiencing.”

ANS: D Coping measurement tools measure recent positive and negative life events as perceived by the individual. There is no objective scale for comparison with other patients because each person reacts differently to stressors. Both negative and positive events are assessed.

Childhood stressors are not part of this type of evaluation as they are intended to measure recently occurring events.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N MULTIPLE RESPONSE 1. Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.) a. Assess for bradycardia. b. Ask about epigastric pain. c. Observe for increased appetite. d. Check for elevated blood glucose levels. e. Monitor for a decrease in respiratory rate.

ANS: B, C, D The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and elevation of blood glucose levels. Stress causes an increase in the respiratory and heart rates.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse is working with a patient who recently lost her spouse after a lengthy illness. The patient shares that she would like to sell her home and move to another state now that her spouse has passed away. Which of the following interventions would be considered a priority for this patient? (Select all that apply.) a. Notify the provider to evaluate for antidepressant therapy.

b. c. d. e. f.

Suggest that the patient consider a support group for widows.

Suggest that the patient learn stress reduction breathing exercises.

Suggest that the patient take prescribed antianxiety medications.

Assist the patient in identifying support systems.

Notify the provider to evaluate the need for antianxiety medications.

ANS: B, C, E Stress prevention management involves counseling, education, and implementation of techniques to manage problem-oriented and emotion-oriented stress. To prevent physical symptoms, relaxation and deep breathing are effective and individuals can learn to prevent the stress response through cognitive behavioral strategies. Medications are not indicated for patients with known stressors unless the stress is prolonged or the patient has ineffective coping mechanisms.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 31: Mood and Affect Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant.

After taking the new medication, the patient states, “This medication isn’t working. I don’t feel any different.” What is the best response by the nurse? a. “I will call your care provider. Perhaps you need a different medication.” b. “Don’t worry. You can try taking it at a different time of day to help it work better.” c. “It usually takes a few weeks for you to notice improvement from this medication.” d. “Your life is much better now. You will feel better soon.”

ANS: C Seeing a response to antidepressants takes 3–6 weeks. No change in medications is indicated at this point of treatment because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that their life is better does not acknowledge their feelings.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A patient who has been diagnNosed with depression is scheduled for cognitive therapy in addition to receiving prescribed antidepressant medication. The nurse understands that the goal of cognitive therapy will be met when what is reported by the patient? a. “I will tell myself that I am a good person when things don’t go well at work.” b. “My medications will make my problems go away.” c. “My family will help take care of my children while I am in the hospital.” d. “This therapy will improve my response to neurotransmitter impulses.”

ANS: A Cognitive therapy helps patients restructure their patterns of thinking to various events or thoughts in a more healthy way. Medication alters neurotransmitters but does not make problems go away. Family support is important but is not the goal of cognitive therapy.

Neurotransmitters are affected by medication and brain stimulation therapy, not by cognitive therapy.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes a monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient? a. Serum blood levels must be regularly monitored to assess for toxicity. b. To prevent side effects, the medication should be administered as an intramuscular injection. c. Eating foods such as blue cheese or red wine will cause side effects.

d. This medication class may only be used safely for a few days at a time.

ANS: C MAOIs have serious food interactions when ingested with tyramine-containing foods such as aged or processed foods. Serum levels are routinely monitored when mood stabilizers such as lithium carbonate are prescribed. It is not necessary to administer this class intramuscularly. This medication takes several weeks to show effectiveness and should not be stopped abruptly; short-term use will not be effective.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. A patient with a diagnosis of depression and suicidal ideation was started on an antidepressant 1 month ago. When the patient comes to the community health clinic for a follow-up appointment he is cheerful and talkative. What priority assessment must the nurse consider for this patient? a. The medication dose needs to be decreased. b. Treatment is successful, and medication can be stopped. c. The patient is ready to return to work. d. Specific assessment for suicide plan must be evaluated.

ANS: D Energy levels increase as depression lifts; this may increase the risk of completing a suicide plan. An increase in mood would not indicate a decrease or discontinuation of prescribed medication. The patient may be ready to return to work, but assessment for suicide risk in a patient who has had suicidal ideation is the priority assessment.

OBJ: NCLEX Client NeedsNCategory: Safe and Effective Care Environment: Safety and Infection Control 5. A patient who is taking prescribed lithium carbonate is exhibiting signs of diarrhea, blurred vision, frequent urination, and an unsteady gait. Which serum lithium level would the nurse expect for this patient? a. 0–0.5 mEq/L b. 0.6–0.9 mEq/L c. 1.0–1.4 mEq/L d. 1.5 or higher mEq/L ANS: D Diarrhea, blurred vision, ataxia, and polyuria are all signs of lithium toxicity, which generally occurs at serum levels above 1.5 mEq/L. Serum levels within the normal range of 0.8–1.4 mEq/L are not likely to cause signs of toxicity.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. A patient newly diagnosed with depression states, “I have had other people in my family say that they have depression. Is this an inherited problem?” What is the nurse’s best response? a. “There are a lot of mood disorders that are caused by many different causes.

Inheriting these disorders is not likely.” b. “Current research is focusing on fluid and electrolyte disorders as a cause for mood

disorders.” c. “All of your family members raised in the same area have probably learned to respond to problems in the same way.” d. “Members of the same family may have the same biological predisposition to experiencing mood disorders.”

ANS: D Research is showing a genetic or hereditary role in the predisposition of experiencing mood disorders. These tendencies can be inherited by family members. Fluid and electrolyte imbalances cause many problems, but neurotransmitters in the brain are more directly linked to mood disorders. Mood disorders are not a learned behavior, but are linked to neurotransmitters in the brain.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient? a. Assess for depression and ask directly about suicide thoughts. b. Ask the care provider to prescribe blood lab work to assess for depression. c. Focus on the presenting problems and refer the patient for a mental health evaluation. d. Interview the patient’s family to identify their concerns about the patient’s behaviors.

ANS: A Assessing directly for thoughts of harm to self or others is a priority intervention for any patient exhibiting signs of a mNe nt al health disorder. It is estimated that 50% of individuals who succeed in suicide had visited a healthcare provider within the previous 24 hours.

Currently there is no serum lab that identifies depression. The risk of self-harm is a priority safety issue that is monitored in all health care within the scope of the nurse. It is important to obtain information directly from the patient when possible, and then validate the information from family or other secondary sources.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

8. An older adult has experienced severe depression for many years and is unable to tolerate most antidepressant medications due to adverse effects of the medications. He is scheduled for electroconvulsive therapy (ECT) as a treatment for his depression. What teaching should the nurse give the patient regarding this treatment? a. There are no special preparations needed before this treatment. b. Common side effects include headache and short-term memory loss. c. One treatment will be needed to cure the depression. d. This treatment will leave you unconscious for several hours.

ANS: B Common side effects of ECT include headache, sleepiness, short-term memory loss, nausea, and muscle aches. Preparations before and after the procedure are the same as any operative procedure involving the patient receiving anesthesia. Treatment is typically three sessions a week for 4 weeks, not once. Patients are not unconscious after the procedure due to the use of precisely placed electrodes and the use of anesthesia.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE 1. A nurse is developing a plan of care for a patient admitted with a diagnosis of bipolar disorder, manic phase. Which nursing diagnoses address priority needs for the patient?

(Select all that apply.) a. Risk for caregiver strain b. Impaired verbal communication c. Risk for injury d. Imbalanced nutrition, less than body requirements e. Ineffective coping f. Sleep deprivation ANS: C, D, F Risk for injury, poor nutrition, and impaired sleep are priority needs of the patient experiencing mania related to their impulsivity, inability to attend to activities of daily living such as diet and hygiene, and disruption of sleep. Caregiver strain is important to be addressed but is not a priority need on admission for the patient. Verbal communication improves when the mania is managed, and racing thoughts return to normal patterns.

Ineffective coping will require stabilization of the acute phase along with cognitive therapy over time.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control N

Concept 32: Anxiety Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient complains of insomnia during his stay in the hospital. Which nursing diagnosis would be a top priority for this patient? a. Anxiety related to hospitalization b. Ineffective coping related to hospitalization c. Denial related to hospitalization d. High risk for insomnia related to hospitalization ANS: A The information about the patient indicates that anxiety is an appropriate nursing diagnosis.

The patient’s data do not support defensive coping, ineffective denial, or risk-prone health behavior as problems for this patient.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time? a. Massage b. Meditation c. Guided imagery N d. Relaxation breathing ANS: D Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practice and learn.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate? a. “How do you feel about what happened to you as a child?” b. “How do you feel about what is going on right now?” c. “Remember a time when you were calm.” d. “Tap your hands until the feeling goes away.”

ANS: B Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Recalling and remembering being calm or previous experiences is not included in mindfulness training. Eye movement desensitization and reprocessing (EMDR) includes expression of feelings and memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. The nurse is assessing the social support of a patient who is recently divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic? a. Encourage the patient to begin dating again, perhaps with members of her church. b. Discuss how divorce support groups could increase coping and social support. c. Note that being so particular about potential friends reduces social contact. d. Discuss using the Internet as a way to find supportive others with similar values.

ANS: B Use of support groups is a method whereby the individual uses inter-related coping strategies in the presence of a stressor. The nurse should focus on providing the patient with coping strategies aimed at decreasing stress. Resuming dating soon after a divorce could place additional stress on the patient rather than helping them cope with existing stressors.

Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose the patient to predators misrepresenting themselves to take advantage of vulnerable persons.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. A patient reports that he is overwhelmed with anxiety. Which question would be most important to use in assessing the patient during your first meeting? a. “What kinds of things do you do to reduce or cope with your stress?” b. “Tell me about your family history—do any relatives have problems with stress?” c. “Tell me about exercise—how far do you typically run when you go jogging?” d. “Stress can interfere with sleep. How much did you sleep last night?”

N

ANS: A The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. These data would indicate whether his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses such as drinking) and would help you understand how he copes and how well his coping strategies and resources are serving him. Therefore, of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended or broad-opening inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. A patient is newly diagnosed with anxiety and placed on a selective serotonin reuptake inhibitors (SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become effective? a. The medication will become effective immediately. b. The medication may take up to 12 weeks to become effective. c. The medication may take up to 6 weeks to become effective. d. The medication may take up to 4 weeks to become effective.

ANS: B Efficacy may take at least 8–12 weeks. The other options are not realistic.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. The nurse knows that which of the following medical conditions are most commonly associated with anxiety? (Select all that apply.) a. Cancer b. Pancreatitis c. Hypothyroidism d. Dysrhythmias e. Encephalitis f. Hyperthyroidism ANS: A, C, D, E, F Cancer, COPD, dysrhythmias, encephalitis, hypothyroidism, and hyperthyroidism are all associated with anxiety. Pancreatitis is not listed as a condition most commonly associated with anxiety.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. The nurse is reviewing the medication profile of a patient admitted with an anxiety disorder.

Which medications should a lNe r t the nurse to a potential interaction? (Select all that apply.) a. St. John’s Wort b. Kava kava c. Aspirin 81 mg d. Valerian root e. Multi-vitamin ANS: A, B, D Although supplements are available to purchase that “treat” anxiety, they are not under control of the Food and Drug Administration (FDA), so the nurse should obtain additional information relative to the use of any supplements that the patient is taking. Dosage of aspirin relates to a cardiac dose and a multi-vitamin would not pose a problem.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Patients with a cognitive impairment benefit from a predictable routine and consistent caregivers. Trips off of the unit may confuse the patient and disrupt their normal routine.

Offering too many selections causes confusion and can lead to agitation. Being in large groups for activities can overstimulate the patient and lead to agitation and fear.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? a. “Don’t worry; the patient should be fine once they are in a familiar environment.” b. “I can make a referral for a home health aide to assist with the patient.” c. “Once the dehydration is corrected, the patient’s confusion should improve.” d. “I can show you how to care for the patient once you return home.”

ANS: C The confusion caused by an underlying medical condition is a temporary condition that can be corrected once the underlying condition is treated, in this case once the patient is rehydrated. It is not necessary to teach home care or make a referral to home health because it is not expected that the patient will be confused at discharge. Telling the daughter that there is nothing to worry about diminishes her concern and may decrease her trust in the nurse.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. An older adult who is cognitively impaired is admitted to the hospital with pneumonia.

Which sign or symptom would the nurse expect to be exhibited by the patient?

N a. Severe headache b. Flank pain c. Increased confusion d. Decreased blood glucose ANS: C Increased confusion is a symptom that occurs in cognitively impaired patients who experience an infection. Severe headache occurs with migraines, meningitis, and other conditions. Flank pain occurs with pyelonephritis. Blood glucose typically increases with an infection.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse’s best response? a. “Hormone therapy will reverse the condition.” b. “Vitamin C and zinc will reverse the condition.” c. “There is no treatment that reverses dementia.” d. “Dementia can be reversed with diet, exercise, and medications.”

ANS: C

Currently there is no proven treatment that has been shown to reverse dementia, although some treatments can slow the progression of the illness. Hormone therapy, vitamin therapy, diet, and exercise are all important for overall health but do not reverse the progression of dementia.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? a. Leave a night light on in the room at all times. b. Leave the television on at night with the volume up. c. Restrain the patient to maintain safety during the confusion. d. Administer a sleeping medication to help the patient sleep.

ANS: A Having a night light on for the patient can help orient them to their surroundings. Having the flickering light and sound from a television will not help a confused patient remain calm or oriented. Restraining a patient will increase their agitation and actually increase their risk of injury if they try to get out of bed. Sleeping medications often increase confusion in cognitively impaired patients.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 8. An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sl e N ep. What data does the nurse consider as a probable cause of the patient’s confusion? a. Pain medication received earlier in the night b. The death of the patient’s spouse 2 years ago c. The patient’s history of diabetes d. The age of the patient ANS: A Medications such as narcotics, hypertensives, sleeping meds, and others can cause disorientation and symptoms of delirium. The death of a spouse is more likely to cause depression than disorientation. A history of diabetes alone does not cause disorientation.

Normal aging alone does not cause disorientation, although it is a risk factor.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE 1. The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which topics would be included in the presentation? (Select all that apply.) a. Do not use substances such as cannabis and alcohol. b. Wear helmets when riding bicycles and motorcycles. c. Complete a Mini Mental Status Exam (MMSE) yearly. d. Correct acid-base imbalances related to underlying disease processes.

e. Wear a seat belt whenever riding in a motorized vehicle. f. Complete a Confusion Assessment Method (CAM) scale yearly.

ANS: A, B, E Primary prevention attempts to prevent injury. Not using chemical substances, wearing a helmet, and wearing a seat belt are all measures to prevent injury to the brain, which protects cognitive function. An MMSE and CAM are secondary prevention, or screening tools performed once symptoms are present. Correcting acid-base imbalances from underlying disease processes is a tertiary prevention level, aimed at minimizing complications for disease already present.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 34: Psychosis Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. What is the nurse’s best response? a. Ignore his remarks and remain silent when providing care. b. Express doubt that there are spiders on the wall. c. Ask the patient if he also sees spiders in the day room. d. Tell the patient there are no spiders and he should stop worrying about it.

ANS: B The patient is experiencing visual hallucinations. Appropriate care for this patient would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.

OBJ: NCLEX Patient Needs Category: Psychosocial Integrity 2. A patient with schizophrenia is admitted to the inpatient unit. Which behavior should the nurse expect to see that is most likely to be associated with this disorder? a. Wringing of hands b. Monotone speech pattern c. Engaged in conversations d. Presence of hallucinationN s ANS: D Individuals who have a clinical diagnosis of schizophrenia present with positive (delusions, hallucinations, disorganized speech and behavior, catatonia, and agitation) as well as negative symptoms (alogia, affective blunting, asocial behavior, anhedonia, and avolition) which distances the patient from society.

OBJ:

NCLEX Patient Needs Category: Psychosocial Integrity

3. The nurse is planning discharge teaching for a patient taking clozapine. Which information is critical to include in the teaching plan? a. Caution about sunlight exposure b. Reminder to call the clinic if fever, sore throat, or malaise develops c. Instructions regarding dietary restrictions d. A chart to record patient weight ANS: B Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.

OBJ: NCLEX Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Which side effect is the highest priority for the nurse to assess for when diphenhydramine is administered to a patient also taking antipsychotic medication? a. Increased psychosis b. Cognitive impairment c. Respiratory depression d. Impaired memory ANS: C Diphenhydramine is an anticholinergic medication that may induce drowsiness or even respiratory depression taken along with anti-psychotic medication. Respiratory depression and airway are always highest priorities of care. While increased psychosis may occur, respiratory depression is highest priority. Cognitive impairment and impaired memory are not well-known effects of diphenhydramine.

OBJ: NCLEX Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend’s apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to Nt hi s patient? (Select all that apply.) a. Allow opportunities for him to express his anger. b. Provide patient and family teaching regarding PTSD. c. Tell the patient that hurting himself will solve nothing. d. Report him to the authorities. e. Exhibit a nonjudgmental attitude. f. Reassure him that everything will be all right.

ANS: A, B, E Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse–patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.

OBJ:

NCLEX Patient Needs Category: Physiological Integrity: Basic Care and Comfort

2. In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) a. Father diagnosed with paranoid schizophrenia b. Rural residence c. Recent immigration from Ecuador d. Occasional cannabis use

e. January birth date f. Physical abuse by the father ANS: A, C, E, F Genetic predisposition has been identified as a risk factor for development of schizophrenia.

Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.

OBJ:

NCLEX Patient Needs Category: Health Promotion and Maintenance

3. Patients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in patients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) a. Hallucinations b. Disorganized speech and behavior c. Anhedonia d. Delusions e. Agitation ANS: A, D, E Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the patient experiences hallucinations, delusions, or agitation.

Negative symptoms are those that cause a loss of normal function, such as when the patient exhibits disorganized speech and behavior and anhedonia.

N OBJ: NCLEX Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Concept 35: Addiction Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is assessing a patient using the CAGE Questionnaire. The patient answers yes to all of the questions. The nurse suspects alcoholism and feels the patient is in denial when the patient makes which statement? a. “I go to meetings once a day and still drink.” b. “My family and friends have been avoiding me lately.” c. “I don’t have a problem with alcohol. I can quit anytime I want to.” d. “I know it will be hard to quit, but I am willing to try.”

ANS: C The patient may need help admitting that there is a problem. The CAGE is designed to objectively assist in assessing problems related to alcohol use. A patient who states they are going to meetings is admitting they have a problem even if they still drink. Admitting that quitting is difficult is acceptance that there is a problem. Reality is setting in for a patient who can see that family and friends are avoiding them.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. A patient who was admitted 24 hours ago has become increasingly irritable and now says there are bugs on his bed. Which condition should the nurse suspect? a. Alcohol-induced psychosis b. Delirium tremens (DTs) N c. Neurologic injury related to a fall d. Posttraumatic stress reaction ANS: B Beginning 6–9 hours after the last alcohol use, patients may experience DTs, as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse rate, and blood pressure measurement and visual and auditory hallucinations.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. To prevent Wernicke’s encephalopathy from heavy alcohol use, the nurse anticipates an order for which medications? a. Benzodiazepine b. Thiamine and B complex c. Vitamins C and D3 d. Klonopin ANS: B The B vitamins will prevent or reverse Wernicke’s if given early enough. Benzodiazepines are often used to prevent and treat DTs and to decrease respiratory depression and hypertension. Vitamins C and D3 are not related to alcohol withdrawal. Klonopin is administered for hypertension and anxiety related to withdrawal.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the highest priority for this patient? a. Describe how the alcohol is causing the withdrawal effects. b. Leave the patient by him/herself so as not to cause agitation. c. Promote a safe, calm, and comfortable environment. d. Refer the patient to an alcohol-abuse counselor.

ANS: C The main priority is the patient’s safety due to risk of harm from seizures, DTs, and anxiety.

The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. The nurse assesses the outcomes of a motivational interview on a patient with a dual diagnosis of alcoholism with delirium tremens (DTs) and determines that the communication was nontherapeutic. What is the nurse’s next priority? a. Encourage the patient to think of ways to change environmental triggers to abuse substances. b. Ask the patient what methods they think would work and encourage participating N in self-help groups. c. Notify provider to obtain order for oxazepam and vitamin B infusion. d. Notify provider to obtain order for CT scan and psychological consult.

ANS: C The patient will need to be treated for the psychosis prior to conducting the motivational interview, because the patient can become violent and nonreceptive to the interventions.

Oxazepam and vitamin B are the two therapies that work for DTs. OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 6. A 45-year-old man is brought to the emergency department presenting with a respiratory rate of 6 breaths/min, and cardiac dysrhythmias. What is the most appropriate question the nurse should ask the patient’s friend? a. “Does he take amphetamines or uppers?” b. “Has he ever used LSD?” c. “Have you two been out of the country in the last 2 days?” d. “Is he using any opioids such as heroin?”

ANS: D

The clinical manifestations of an opioid overdose include seizures, shock, respiratory depression, dysrhythmias, and altered level of consciousness. An opioid overdose is a medical emergency. Amphetamine overdose is ruled out because it causes hypertension and central nervous system disturbances such as paranoia, panic, and delusions. LSD overdose would also manifest with hypertension and tachypnea along with hallucinations and possible loss of contact with reality. Travel outside the country is unrelated.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. During history-taking, a patient tells the nurse that he is addicted to alprazolam and that he takes six 1 mg tablets a day. He quit cold turkey yesterday and now presents with extreme agitation, increased heart rate, and panic. Which disorder should the nurse suspect? a. Stress reaction b. Delirium tremens c. Overdose d. Relapse ANS: A Stress reaction is a withdrawal symptom that can occur when detoxing too quickly. DTs are usually associated with alcohol withdrawal. Overdose of alprazolam would present with extreme drowsiness, confusion, muscle weakness, and loss of balance or coordination. The effects of alprazolam are dizziness, drowsiness, dry mouth, and lightheadedness.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

N

1. Strategies that a nurse could use in a motivational interview to increase the chances of change include which of the following? (Select all that apply.) a. Educating the patient on the physical damage the substance is causing b. Encouraging the patient to think of ways to change environmental triggers to abuse substances c. Asking the patient how they think substance abuse affects their family life d. Explaining to the patient that substance abuse affects everyone in the family and give examples e. Asking the patient what methods they think would work and encouraging participating in self-help groups ANS: B, C, E Empowering the patient by helping them see what effect the abuse has on their life is a key component of motivation. Educating the patient is too much like lecturing and may cause resistance. Explaining how the family responds to the problem may elicit guilt and resistance.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. The nurse recognizes a potential health threat to an alcoholic patient who is using the drug disulfiram when the nurse reads in the health record that the patient is also taking which of the following? (Select all that apply.)

a. b. c. d. e.

Blood thinners Diphenhydramine Alcohol Penicillin Mouthwash

ANS: A, C, E Disulfiram increases the effect of anticoagulants such as warfarin (Coumadin). Ingesting alcohol may cause headache, nausea, vomiting, tachycardia, chest pain, or dizziness.

Mouthwash can have alcohol as one of the main ingredients and should be checked prior to using.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

N

Concept 36: Interpersonal Violence Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse is caring for a patient in the emergency department who has been a victim of intimate partner violence. What is most important for the nurse to include in the plan of care? a. Medication to calm the perpetrator of the violence b. A list of community resources c. A referral for self-defense training d. A referral to the victim’s religious advisor ANS: B Providing education that will address immediate safety needs for the patient is a priority action for the nurse. The nurse is not creating a plan for the perpetrator, nor is it the responsibility of the victim to receive medication for another person. Self-defense training does not meet the immediate safety concern for the patient and may aggravate the perpetrator further. Accessing support from a religious advisor is good for ongoing support, but it does not address the immediate need for safety information.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

2. The nurse working at a women’s health clinic is seeing a teenage female patient who has come in for a refill on her birth control medication and with a complaint of abdominal pain.

When the nurse enters the r o oNm , the patient is sitting in the chair with her head down, rocking back and forth, does not make eye contact, and answers questions with no expression on her face. What assessment question would be most important for the nurse to ask the patient? a. “What brings you to the clinic today?” b. “What can we do to help you today?” c. “Do you feel safe in your current relationship?” d. “Have you changed your diet lately?”

ANS: C This patient is exhibiting signs of being abused. It is important to ask about the safety of the patient. General questions about her visit do not give an opportunity for the patient to discuss her safety needs. While a diet change can cause stomach problems, this assessment would be addressed once safety is addressed.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is seeing a patient who has been in the clinic eight times in the past 6 months for injuries from an abusive partner. The patient states, “I don’t see any way to get away from my partner, and I can’t keep going on like this.” What assessment question is most important for the nurse to ask? a. “Do you have any family in the area that can help?” b. “Have you thought about hurting yourself or someone else?” c. “Have you thought about moving to a different city?”

d. “Have you discussed this with anyone else?”

ANS: B Depression and an increased risk of suicide are common outcomes from individuals experiencing interpersonal violence. It is critical that the nurse specifically assess for the risk of harm to the patient or to others during assessment. Asking if family or friends are available for support is good, but it is more important to assess for the safety concern of suicide or harm to others. It is not helpful to ask if a person who has stated that they don’t see a way out has thought of leaving—their comment indicates that they can’t see any solution. This situation is a high risk for suicide, or even homicide against the perpetrator.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. The nurse is reviewing case files for children at risk for injury resulting in brain injury.

Which child is at most risk for experiencing this type of violence? a. A Caucasian, 6-month-old infant living with a single mother b. An African-American, 24-month-old child living with her grandmother c. A Mexican, 3-year-old child living in an inner city apartment d. A Japanese, 8-year-old child living in a home with three generations of family ANS: A The highest incidence of traumatic brain injury occurs in Caucasian children aged birth to 1 year, and the abuse occurs most often from women.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. Critical Thinking: A crisis in N tervention nurse is training emergency department staff on treatment needs of persons in abusive relationships. What is a common difficulty staff encounter when caring for this population? a. There is not a good legal pathway to help persons in abusive relationships. b. The abused person may return to the abusive home setting. c. Hospital policies do not identify the legal care needed for abused persons. d. Because length of care is short in the emergency department, there is little staff can do for patients who have been abused.

ANS: B Abused persons return to abusive settings because they feel they have no other options or they fear reprisal from the abusive partner. There are policies in all healthcare facilities that describe the legal needs and the legal process that needs to be followed when caring for abused patients. Even in short-stay care settings there are interventions that can be helpful to a patient who has experienced abuse.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. The nurse is counseling women at a crisis shelter about risk factors for increased intimate partner violence. What event is most likely to trigger an increase in abusive behaviors? a. Moving to a new community b. Starting a new job c. Becoming pregnant d. The death of a grandfather

ANS: C Abuse is not likely to decrease, and can often increase when a woman becomes pregnant.

Moving, starting a new job, and a death in the family are all stressors, but they are not identified as factors that specifically increase violence more than pregnancy.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE 1. The nurse is admitting a child with a history of abuse. The nurse understands that the child may exhibit what behaviors that are consequences of being in an abusive environment?

(Select all that apply.) a. Reliving abuse incidents b. Sleep disturbance c. Overeating d. Acting out behaviors e. Intermittent fever ANS: A, B, D Posttraumatic stress disorder symptoms, depression symptoms, and aggression are all outcomes that children who are exposed to abuse experience. Overeating may be associated with some stressors, but it is not specifically indicative of abuse. Fever is not associated with abuse.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 37: Professional Identity Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Which key element is included in the scope of professional practice identity? a. Adhering to a fixed level of practice b. Finding out ways to get done faster with assigned tasks as the key focus of care c. Maintaining professional boundaries d. Remaining at the level of practice upon graduating from nursing school ANS: C The scope of professional identity includes five attributes, doing, and being, acting ethically, flourishing and changing identities. By maintaining professional boundaries, the nurse would be acting ethically. Adhering to a fixed level of practice would not be prudent for it would not allow the nurse to achieve attributes. Finding out ways to get done faster with assigned tasks would be in opposition to the attribute of “being” as the key focus is to do the right thing even when no one is looking. A nurse who remains at the level of practice upon graduation from nursing school would be in opposition to the attribute of flourishing.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A new registered nurse asks the registered nurse (RN) preceptor what could be done to become more professional. What is the preceptor’s best response? a. “Attend nursing educationNal meetings.” b. “Listen to other nurses.” c. “Read the agency newsletter.” d. “Pass the licensing exam.”

ANS: A Knowledge and commitment are essential components of professionalism. Attending nursing educational meetings can promote collaborative learning with peers and maintenance of competence in an ever-changing healthcare environment. Listening can promote professionalism, and communication is certainly a component of professionalism; however, there is also a social sense to listening, and without the educational/learning component, this is not the best answer. An agency newsletter could include information about professional opportunities, but it is not the best answer. The new nurse would have already passed the licensing exam, the legal requirement to be considered a nurse.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The qualities of leadership, clinical expertise and judgment, mentorship, and lifelong learning would best describe which type of nurse? a. Administrator b. Certified nurse specialist c. Practitioner d. Professional

ANS: D The qualities listed are those of a professional nurse. The other options are all nurses who may have these qualities, but the focus of their title includes qualities not essential for the professional nurse. The administrator would have management qualities; the clinical nurse specialist would have specialty area knowledge; and the practitioner would meet legal requirements as a healthcare provider.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The American Nurses Association (ANA) outlines expectations of nurse’s self-care habits in which type of documentation? a. Nurse Practice Acts b. Board of Nursing c. Code of Ethics d. Hospital Facility Protocols ANS: C The ANA focuses on the importance of nurses to develop their own personal self-care habits as part of their ethical code. This information is presented in the ANA Code of Ethics. Nurse Practice Acts define the scope of practice relative to the specific type of health professional.

The Board of Nursing provides minimum competency requirements for specific types of health professionals and identifies licensing, academic and practice requirements. Hospital facilities provide policies and protocols related to members of the interdisciplinary healthcare team.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Which nursing action best exemplifies clinical judgment? a. A nurse after performing an assessment seeks out additional information related to a finding. b. A nurse documents finding in the medical record in a timely manner. c. A nurse contacts the physician to provide the results of an imaging study for a patient. d. A nurse comforts a patient who is on hospice care.

ANS: A Clinical judgment represents a comprehensive well thought out series of action whereby the nurse incorporates assessment data in the context of norms and values. The nurse seeking out additional information to clarify a finding is demonstrating clinical judgment. A nurse who is documenting assessment data in the patients’ medical record in a timely manner is being efficient. A nurse contacting the physician to provide results of an imaging test is demonstrating effective communication. A nurse comforting a patient who is on hospice care is demonstrating compassion.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

6. Nursing demonstrates dedication to improving public health through which avenue? a. Changing healthcare standards b. Legal regulations c. Scope of practice d. Technology ANS: C Through the scope of practice, specialized knowledge, and code of ethics, the discipline of nursing has demonstrated its dedication to improving public health. The changing healthcare environment is one of the challenges to nursing, not an indicator of dedication. Legal regulations are generally promulgated by legislators rather than nurses to protect the public.

A highly technological environment is considered a challenge to nursing rather than an indicator of dedication.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. Components of a professional identity in nursing include which attributes? (Select all that apply.) a. Doing b. Being c. Acting ethically d. Flourishing e. Culture N ANS: A, B, C, D The scope of professional identity in nursing includes: doing, being, acting ethically, flourishing and changing identities. Cultural sensitivity is important to professional nursing; however, culture is an inherent quality of nurses and patients, not a component of the professional identity.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Responding entails adjusting the plan of care to the particular patient issue through one or more nursing interventions. In this case, the nurse is working with the patient’s wishes, knowing that the patient will most likely cheat. The patient will be allowed to “cheat.” The plan will be evaluated to be sure the snack does not elevate the glucose excessively and be readjusted if warranted. While it is true that most chocolate has a high glycemic index, providing a list of foods that do not include the one thing the patient enjoys will most likely lead to nonadherence to the diet. Advising the patient that they can have whatever they want to eat may lead to further dietary indiscretions and cause side effects such as obesity or high glucose readings. Knowledge Deficit is an inaccurate diagnosis for this patient as evidenced by the patient stating they understand the need to exercise and the need to diet.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A new graduate nurse is working with an experienced nurse to chart assessment findings.

The new nurse notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced nurse asks the new nurse what may be going on here. What is the best explanation for this statement? a. Data on the chart can sometimes be documented in a biased manner. b. Data on the chart changes as the patient’s condition changes. c. Data on the chart is usually accurate and can be verified from the patient. d. Reading the chart is not a wise use of time as this can be time consuming and tedious.

ANS: A It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record. N D a t a do indeed change (and need to be charted) as the patient’s condition changes, but this would not be the best answer to this question. Assessment data may at times be difficult to obtain, but that would not occur often enough to warrant a warning about the difficulty in charting it. Also, obtaining data is clearly a different activity from charting it. Charting can be time consuming and tedious, but this is not the most complete answer to this question.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A home care nurse receives a physician order for a medication that the patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient’s condition, questions its appropriateness, and examines alternative treatments. What is the nurse’s best action? a. Call the physician, explain rationale, and suggest a different medication. b. Consult an experienced nurse on whether there are other similar treatments. c. Hold the drug until the physician returns to the unit and can be questioned. d. Question other staff as to the physician’s acceptance of nursing input.

ANS: A

Determining how best to proceed on behalf of a patient’s best health outcomes care may require clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities have been examined. A home care nurse who is using good clinical judgment techniques should have confidence in their decision and may not have another nurse available as this is an autonomous setting. Holding the drug might jeopardize the patient’s health, so this is not the best solution. The nurse working at this level of critical thinking makes choices based on careful examination of situations and alternatives; whether or not the physician is open to nursing input is not relevant.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A patient has been admitted for a skin graft following third degree burns to the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes. When should the nurse initiate the educational plan? a. After the operation and the patient is awake b. On admission, along with the initial assessment c. The day before the patient is to be discharged d. When narcotics are no longer needed routinely ANS: B Initial discharge planning begins upon admission. After the operation has been completed is too late to begin the discharge planning process. The day before discharge is too late for the nurse to gather all pertinent information and begin teaching and coordinating resources.

After a complicated operation, the patient may well be discharged on narcotic analgesics.

Waiting for the patient to notNneed them anymore might mean the patient gets discharged without teaching being done.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse has designed an individualized nursing care plan for a patient, but the patient is not meeting goals. Further assessment reveals that the patient is not following through on many items. Which action by the nurse would be best for determining the cause of the problem? a. Assess whether the actions were too hard for the patient. b. Determine whether the patient agrees with the care plan. c. Question the patient’s reasons for not following through. d. Reevaluate data to ensure the diagnoses are sound.

ANS: B Having patient and/or family provide input to the care plan is vital in order to gain support for the plan of action. The actions may have been too difficult for the patient, but this is a very narrow item to focus on. The nurse might want to find out the rationale for the patient not following through, but instead of directly questioning the patient, which can sound accusatory, it would be best to offer some possible motives. Reevaluation should be an ongoing process, but the more likely cause of the patient’s failure to follow through is that the patient did not participate in making the plan of care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management

of Care 7. A new nurse appears to be second-guessing herself and is constantly calling on the other nurses to double-check their plan of care or rehearse what they will say to the doctor before she call on the patient’s behalf. This seems to be annoying some of the nurse’s coworkers.

What is the nurse manager’s best response? a. Explain to coworkers that this is a characteristic of critical thinking and is important for the new nurse to improve reasoning skills. b. Agree with the staff and have someone follow and work more closely with a preceptor. c. Have a talk with the nurse and suggest asking fewer questions. d. Tell the staff that all new nurses go through this phase, and ignore their behavior.

ANS: A Reflection-on-action is critical for development of knowledge and improvement in reasoning. It is where learning from practice is incorporated into experience. Inquisitiveness is a characteristic of critical thinking and reflects a desire to learn even when the knowledge may not appear readily useful. The manager should promote this. Suggesting the nurse work more closely with a preceptor implies that the manager thinks the nurse needs to learn more and increase confidence. In reality, this nurse is demonstrating a characteristic of critical thinking. Suggesting that the nurse ask fewer questions would hamper the development of the nurse as a critical thinker. All new nurses do go through a phase of asking more questions at one time, but dismissing the nurse’s behavior with this explanation is simplistic and will discourage critical thinking.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management N of Care 8. A nurse has committed a serious medication error and has reported the error to the hospital’s adverse medication error hotline as well as to the unit manager. The manager is a firm believer in developing critical thinking skills. From this standpoint, what action by the manager would best nurture this ability in the nurse who made the error? a. Have the nurse present an in-service related to the cause of the error. b. Instruct the nurse to write a paper on how to avoid this type of error. c. Let the nurse work with more experienced nurses when giving medications. d. Send the nurse to refresher courses on medication administration.

ANS: A

Nurturing critical thinking skills is done in part by turning errors into learning opportunities.

If the nurse presents an in-service on the cause and prevention of the type of error committed, not only will the nurse learn something but many others nurses on the unit will learn from it to. This is the best example of developing critical thinking skills. This option would allow the nurse to learn from the mistake, which is a method of developing critical thinking skills, but the paper would benefit only the nurse, so this option is not the best choice. Letting the nurse work with more experienced nurses might be a good option in a very limited setting, for example, if the nurse is relatively new and the manager discovers a deficiency in the nurse’s orientation or training on giving medications in that system.

Otherwise, this option would not really be beneficial. Sending the nurse to refresher courses might be a solution, but it is directed at the nurse’s learning, not critical thinking. The nurse might feel resentful at having to attend such classes, but even if they were helpful, only this one nurse is learning. Going to generic classes also does not address the specific reason this error occurred, and thus might be irrelevant. Critical thinking and learning can be enhanced by a presentation to the staff on the causes of the error.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nurse is caring for a patient in a long-term care facility who has not been sleeping well.

She notes that the patient is new to the facility, has been refusing therapy, and is also not eating well. The nurse interprets this to mean that the patient has been having trouble adjusting. The nurse decides to meet with the patient’s care team. The team decides to assess the patient’s willingneN s s to participate in group recreational activities. The patient agrees to participate. After 1 week, the nurse reevaluates the plan of care and notes that the patient has been sleeping much better. Which of the following terms best describe processes used in the nurse’s plan? (Select all that apply.) a. Clinical judgment b. Evidence-based practice c. The nursing process d. Collaborative care planning e. Positive reward process ANS: A, C, D Clinical judgment is a reflective process by which the nurse notices, interprets, responds, and reflects in action. The nursing process is a process by which the nurse assesses, diagnoses, implements, and evaluates the nursing care plan. Consulting and gaining input from the healthcare team is collaborative care planning. Evidence-based practice refers to using interventions found in research studies. The positive reward process is not a term used in care planning.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

action plan. d. The Chief Executive Officer (CEO) communicates the goal to the organizational directors and managers and states that they are entrusted to solve the problem.

ANS: C Transformational leaders communicate a vision and motivate employees to accomplish the goal. The Director who communicates the goal of reducing readmissions to the hospital operations team and tells them to submit their action plan by the end of the week leaves the solution to achieve the goal to the followers to develop without motivating them. The solution that is left to the work teams to resolve is not an example of transformational leadership. The CEO entrusts the managers and directors to solve the problem without giving them a vision or engaging in the solution with them.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The new Director of Case Management assessed the need to improve the organization’s patient satisfaction with the discharge process. Which statement below illustrates the vision that would lead the team to this goal? a. “The department will deliver reliable, collaborative, and compassionate discharge planning services to all patients.” b. “The department will hold weekly meetings every Tuesday at 11:00 AM.” c. “There will be implementation of a new uniform policy so staff can be readily identified.” d. “Staff are encouraged to complain about difficult patients, families, and physicians.”

N

ANS: A A vision is a statement about the long-term desired state for the department. The other choices describe specific actions, not a long-term vision statement.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. The clinical nurse leader needs to identify the staff who must go home due to low census.

Which answer below describes a democratic style of decision making? a. The clinical nurse leader identifies the staff person with the most vacation and asks them to go home. b. The clinical nurse leader tells the last person to show up for their shift to go home. c. The clinical nurse leader decides not to send anyone home because it is too difficult to decide who should lose hours. d. The clinical nurse leader asks the group if any of them would like the opportunity to go home and selects staff who volunteer.

ANS: D Democratic leaders use a participatory style of decision making. In the other choices, the clinical nurse leader makes the decision independent of the staff.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

6. A nurse is reviewing decision-making theories. Which statement is accurate according to situational and contingency theory? a. The theory challenges the concept that one leadership style is always best. b. The theory supports employee feelings, morale, and feedback during the change process. c. Motivation through inspiration and recognition is the focus for transforming employee behavior. d. A leader is someone who possesses great intelligence and decision-making authority.

ANS: A Situational and contingency theory challenges the assumption that there is “one best way” to lead. A theory that supports employee feelings, morale, and feedback during the change process describes behavioral leadership. Motivation through inspiration and recognition is the focus for transforming employee behavior describes transformational leadership. A leader is someone who possesses great intelligence and decision-making authority describes Great Man or Trait theory.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. To be an effective nursing leader today requires effective collaboration. Which model below best represents this process? a. The Nursing Manager of the observation unit was certain the psychology department would assist the unit with a motivational plan, so she did not request N their assistance. b. The Nursing Manager of the observation unit worked with the psychology department and physical therapy to develop a motivational plan for patients on the unit. c. The Nursing Director of Behavioral Health Services followed the administrative directive to reduce services and refused to provide services for patients on other units. d. Frustrated by the trend of patients unwilling to work with therapy, the Unit Manager recommended that these patients be placed on another unit.

ANS: B The nursing manager works collaboratively with other departments to solve the patient care issue. In the other choices, the unit manager does not involve collaboration to resolve the patient concern.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. What are the main features of complexity science that are relevant to nursing leadership?

(Select all that apply.) a. Focused on creating organizational change and looking at the whole versus

b. c. d. e.

individual parts Defined by efforts of leadership to mandate organizational change Autocratic in nature with a top-down structure for change Dependent on employees knowing what change is necessary and acting independently Non-linear and dynamic in nature, versus a static process

ANS: A, E Complexity science posits that interactions of the parts within a system are more important than the individual parts. Complexity science, however, recognizes that organizational processes are often non-linear and unpredictable. Through the dynamic interplay of negative and positive feedback an organization is able to make changes to keep abreast of the environmental context. The autocratic top-down decision making and mandates do not create a sustainable change. Being dependent on employees knowing what change is necessary and acting independently lacks interaction of leadership to stimulate change and adaptation among employees.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Concept 40: Ethics Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient suffered a brain injury from a motor vehicle accident and has no brain activity.

The patient has a living will which states no heroic measures. The family requests that no additional heroic measures be instituted for their son. The nurse respects this decision in keeping with which principle? a. Accountability b. Autonomy c. Nonmaleficence d. Veracity ANS: B Patients and families must be treated in a way that respects their autonomy and their ability to express their wishes and make informed choices about their treatment. Accountability is inherent in the nurse’s ethical obligation to uphold the highest standards of practice and care, assume full personal and professional responsibility for every action, and commit to maintaining quality in the skill and knowledge base of the profession. Nonmaleficence is a principle that implies a duty not to inflict harm. In ethical terms, nonmaleficence means to abstain from injuring others and to help others further their own well-being by removing harm and eliminating threats. Veracity means telling the truth as a moral and ethical requirement.

OBJ: NCLEX Client NeedsNCategory: Safe and Effective Care Environment: Management of Care 2. A male patient suffered a brain injury from a motor vehicle accident and has no brain activity. The spouse has come up to see the patient every day for the past 2 months. She asks the nurse, “Do you think when he moves his hands he is responding to my voice?” The nurse feels bad because she believes the movements are involuntary, and the prognosis is grim for this patient. She states, “He can hear you, and it appears he did respond to your voice.” The nurse is violating which principle of ethics? a. Autonomy b. Veracity c. Utilitarianism d. Deontology ANS: B Veracity is the principle of telling the truth in a given situation. Autonomy is the principle of respect for the individual person; this concept states that humans have incalculable worth or moral dignity. Utilitarianism is an approach that is rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Giving the spouse false reassurance is not a good consequence. Deontological theory claims that a decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty. Persons are to be treated as ends in themselves and never as means to the ends of others.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse is faced with an ethical issue. When assessing the ethical issue, which action should the nurse perform first? a. Ask, “What is the issue?” b. Identify all possible alternatives. c. Select the best option from a list of alternatives. d. Justify the choice of action or inaction.

ANS: A The first step in the situational assessment procedure is to find out the technical and scientific facts and assess the human dimension of the situation—the feelings, emotions, attitudes, and opinions. Trying to understand the full picture of a situation is time consuming and requires examination from many different perspectives, but it is worth the time and effort that is required to understand an issue fully before moving forward in the assessment procedure. Identifying alternatives is the second step in the situation assessment procedure.

A set of alternatives cannot be established until an assessment has been completed.

Selecting the best option is actually the third step in the situation assessment procedure.

Options cannot be selected until an assessment has been done to define the issue. Justifying the action or inaction is the final step in the situational assessment procedure. No justification can be made until the assessment and action phases have been completed.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nursing student is conductiNng a survey of fellow nursing students. Which ethical concept is the student following when calculating the risk-to-benefit ratio and concluding that no harmful effects were associated with a survey? a. Beneficence b. Human dignity c. Justice d. Human rights ANS: A Beneficence is a term that is defined as promoting goodness, kindness, and charity. In ethical terms, beneficence means to provide benefit to others by promoting their good.

Human dignity is the inherent worth and uniqueness of a person. Justice involves upholding moral and legal principles. Human rights are the basic rights of each individual.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A nurse on the unit makes an error in the calculation of the dose of medication for a critically ill patient. The patient suffered no ill consequences from the administration. The nurse decides not to report the error or file an incident report. The nurse is violating which principle of ethics? a. Fidelity b. Individuality c. Justice

d. Values clarification ANS: A Fidelity is the principle that requires us to act in ways that are loyal. In the role of a nurse, such action includes keeping your promises, doing what is expected of you, performing your duties, and being trustworthy. Individuality is something that distinguishes one person or thing from others. Injustice is when a person is denied a right or entitlement. Values clarification is a tool that allows the nurse to examine personal values in terms of ethical situations.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. An unconscious patient is treated in the emergency department for head trauma. The patient is unconscious and on life support for 2 weeks prior to making a full recovery. The initial actions of the medical team are based on which ethical principle? a. Utilitarianism b. Deontology c. Autonomy d. Veracity ANS: B Deontology is an approach that is rooted in the assumption that humans are rational and act out of principles that are consistent and objective and that compel them to do what is right.

Deontological theory claims that a decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty. Utilitarianism is an approach that is rooted in the assumption thatNan action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. An attempt is made to determine which actions will lead to the greatest ratio of benefit to harm for all persons involved in the dilemma. Autonomy is the principle of respect for the individual person. People are free to form their own judgments and perform whatever actions they choose. Veracity is defined as telling the truth in personal communication as a moral and ethical requirement.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A drug-addicted nurse switches a patient’s morphine injection with normal saline so that the nurse can use the morphine. The nurse is violating which principles of ethics? (Select all that apply.) a. Autonomy b. Utilitarianism c. Beneficence d. Dilemmas e. Veracity ANS: A, B, C, E

Beneficence is providing benefit to others by promoting their welfare. In general terms, to be beneficent is to promote goodness, kindness, and charity. By taking the patient’s pain medication and substituting saline, the nurse did harm, not good, for the patient. Autonomy is the principle of respect for the individual person; the nurse does not respect someone upon whom the nurse is inflicting harm. Utilitarianism is the principle that assumes that an action is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Because the patient’s pain medication was taken away, the consequences were all bad. Dilemmas are not included as a principle of ethics.

Veracity involves truth-telling.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Concept 41: Patient Education Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. What is the most appropriate resource to include when planning to provide patient education related to a goal in the psychomotor domain? a. Diagnosis-related support groups b. Internet resources c. Manikin practice sessions d. Self-directed learning modules ANS: C A teaching goal in the psychomotor domain should be matched with teaching strategies in the psychomotor domain, such as demonstration, practice sessions with a manikin, and return demonstrations. Diagnosis-related support groups would be most effective with goals in the affective domain. Internet resources would be most effective for goals in the cognitive domain. Self-directed learning modules would be most effective for goals in the cognitive domain.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse educator would identify a need for additional teaching when the student lists which example as a type of learning?

N a. Affective b. Cognitive c. Psychomotor d. Self-directed ANS: D Self-directed is one approach to learning but is not considered a type or domain of learning.

Self-directed would be a cognitive way of learning. Affective (feelings/attitude), cognitive (knowledge), and psychomotor (skills/performance) are the main domains of learning.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that involves which quality? a. Addresses group needs b. Follows formalized plans c. Has standardized content d. Often occurs one-to-one ANS: D

Informal teaching is individualized one-on-one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes.

Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse is preparing to implement a teaching plan. Which factor might be considered to be a barrier to patient education? a. Family resources b. High school education c. Hunger and pain d. Need perceived by patient ANS: C A patient who is hungry or in pain has limited ability to concentrate or learn. Family resources would be considered in developing a plan of care and could be an asset or a barrier to patient education. The patient’s educational level would be considered in planning teaching strategies but would not be a barrier to education. A need perceived by a patient would provide motivation for learning and would not be a barrier.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. A nurse has prepared a dischaNrge teaching plan for an adult patient who is not being compliant. Which strategy should the nurse include to help increase compliance with following discharge instructions? a. Individualized handout b. Instructional videos c. Internet resources d. Self-help books ANS: B An instructional video would provide a visual/auditory approach for discharge instructions.

Repeatedly not following written instructions is a clue that the patient may not be able to read or understand the information. While assessing the literacy level of an adult patient can be challenging, the information that they have not been able to follow previous written instructions would suggest that the nurse use an alternate strategy that does not require a high degree of literacy. An individualized handout would be written, very similar to previous instructions, and would not address a concern about literacy. Internet resources generally require an individual to be able to read, and although videos are available through the Internet, this is not the best response. Self-help books would be appropriate for an individual who reads. There is a question about whether this patient is literate, so these would not be the best choice.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. When planning to evaluate a patient’s satisfaction with a teaching activity, what is the most appropriate strategy? a. Include a survey instrument. b. Observe for level of skill mastery. c. Present information more than one time. d. Provide for a return demonstration.

ANS: A A survey or questionnaires can be used to measure affective behavior change as well as patient satisfaction with the teaching experience. Observing for level of skill mastery would evaluate achievement of a psychomotor goal rather than satisfaction with the experience.

Repeating information more than one time or in more than one way may be appropriate strategies to include in the teaching plan but would provide no evaluation data. Providing for a return demonstration would help in evaluating achievement of a psychomotor goal, not satisfaction with the activity.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. A nurse manager is reviewing interrelated concepts to the professional nursing role. Which factor should the nurse manager consider when addressing concerns about the quality of patient education? a. Adherence b. Developmental level c. Motivation d. Technology ANS: D N The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 42: Health Promotion Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Which tertiary prevention measure should be included in the health promotion plan of care for a patient newly diagnosed with diabetes? a. Avoiding carcinogens b. Foot screening techniques c. Glaucoma screening d. Seat belt use ANS: B Foot screening is considered a tertiary prevention measure, one that minimizes the problems with foot ulcers, an effect of diabetic disease and disability. Avoiding carcinogens is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Glaucoma screening is considered secondary screening—measures designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Seat belt use is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. When teaching a patient withNa family history of hypertension about health promotion, the nurse describes blood pressure screening as which type of prevention? a. Illness b. Primary c. Secondary d. Tertiary ANS: C Blood pressure screening is considered secondary prevention. It is a measure designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Illness prevention is considered primary prevention. Primary prevention measures are those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Tertiary prevention measures are those that minimize the effects of disease and disability.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The primary healthcare nurse would recommend screening based on known risk factors, because of which action? a. Eliminate the possibility of developing a condition. b. Identify appropriate treatment guidelines. c. Initiate treatment of a condition or disease. d. Make a substantial difference in morbidity and mortality.

ANS: D Screenings are typically indicated and recommended if the effort makes a substantial difference in morbidity and/or mortality of conditions, and they are safe, cost-effective, and accurate. Ideally a screening measure will accurately differentiate individuals who have a condition from those who do not have a condition 100% of the time; however, there may be a false-negative result, or the patient may develop a condition after the screening was conducted. A screening does not specify treatment guidelines; the screen provides results, and the healthcare provider identifies the treatment. The goal of screening is to identify individuals in an early state of a disease so that prompt treatment can be initiated. The screening results are used for this purpose.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. At the well-child clinic, how does the nurse correctly teach a mother about health promotion activities and describe immunizations? a. Unique for children b. Primary prevention c. Secondary prevention d. Tertiary prevention ANS: B Immunizations/vaccinations are considered primary prevention measures, those strategies aimed at optimizing health and disease prevention in general. Immunizations/vaccinations are primary prevention measures for individuals across the lifespan, not just children.

Secondary prevention measures are those designed to identify individuals in an early state of a disease process so that pro mNpt treatment can be started. Tertiary prevention measures are those that minimize the effects of disease and disability.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. The nurse in a newly opened community health clinic is developing a program for the individuals considered at greatest risk for poor health outcomes. How should the nurse consider this group? a. Global community b. Sedentary society c. Unmotivated population d. Vulnerable population ANS: D Vulnerable populations refer to groups of individuals who are at greatest risk for poor health outcomes. The entire world is the global community. Sedentary refers to the lifestyles of people worldwide who have epidemic rates of obesity and many other related chronic diseases. Unmotivated population refers to the individuals who have not demonstrated interest in changing.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. When there is evidence that supports a screening for an individual patient but not for the general population, the nurse would expect the United States Preventive Services Task Force Grading (USPSTF) to be what? a. No recommendation for or against b. Recommends c. Recommends against d. Strongly recommends ANS: A The USPSTF Grading is an example of how evidence is used to make guidelines and determine priority. When there is evidence that supports a screening for an individual patient but not for the general population, there is no recommendation for or against screening the general population. Recommends is the grading when there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Recommends against is the grading when there is moderate or high certainty that the intervention has no net benefit or that the harms outweigh the benefits. Strongly recommends is the grading when there is high certainty that the net benefit is substantial.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. A nurse manager is reviewing interrelated concepts to professional nursing. Which concepts should the nurse manager consider when addressing concerns about the quality of health promotion? (Select all that apply.) a. Culture N b. Development c. Evidence d. Nutrition e. Health policy ANS: C, E The interrelated concepts to professional nursing include evidence, healthcare economics, health policy, and patient education. Culture is a patient attribute concept. Development is a patient attribute concept. Nutrition is a health and illness concept.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 43: Communication Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient states, “I had a bad nightmare. When I woke up, I felt emotionally drained, as though I hadn’t rested well.” Which response by the nurse would be an example of interpersonal therapeutic communication? a. “It sounds as though you were uncomfortable with the content of your dream.” b. “I understand what you’re saying. Bad dreams leave me feeling tired, too.” c. “So, all in all, you feel as though you had a rather poor night’s sleep?” d. “Can you give me an example of what you mean by a ‘bad nightmare’?”

ANS: D The technique of clarification is therapeutic and helps the nurse examine meaning. The distracters focus on patient feelings but fail to clarify the meaning of the patient’s comment.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. The nurse is admitting a patient to the medical/surgical unit. Which communication technique would be considered appropriate for this interaction? a. “I’ve also had traumatic life experiences. Maybe it would help if I told you about them.” b. “Why do you think you had so much difficulty adjusting to this change in your life?” c. “You will feel better afterNgetting accustomed to how this unit operates.” d. “I’d like to sit with you for a while to help you get comfortable talking to me.”

ANS: D Because the patient is newly admitted to the unit, allowing the patient to become comfortable with the setting is a technique that can assist in establishing the nurse-patient relationship. It helps build trust and conveys that the nurse cares about the patient. The nurse should not reveal their life experiences as this is not therapeutic. Asking why the patient is having difficulty may provide insight; however, this would be best saved for an established relationship with the patient. Assuring the patient that they will feel better may not be true depending on the reason for the admission.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is seeking clarification of a statement that was made by a patient. What is the best way for the nurse to seek clarification? a. “What are the common elements here?” b. “Tell me again about your experiences.” c. “Am I correct in understanding that …” d. “Tell me everything from the beginning.”

ANS: C

Clarification ensures that both the nurse and the patient share mutual understanding of the communication. The distracters encourage comparison rather than clarification and present implied questions that suggest the nurse was not listening.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. A nurse is conducting a therapeutic session with a patient in the inpatient psychiatric facility. Which remark by the nurse would be an appropriate way to begin an interview session? a. “How shall we start today?” b. “Shall we talk about losing your privileges yesterday?” c. “Let’s get started discussing your marital relationship.” d. “What happened when your family visited yesterday?”

ANS: A The interview is patient centered; thus, the patient chooses issues. The nurse assists the patient by using communication skills and actively listening to provide opportunities for the patient to reach goals. In the distracters, the nurse selects the topic.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. The nurse and the patient are conversing face to face. What communication technique is being demonstrated? a. Linguistic b. Paralinguistic c. Explicit N d. Metacommunication ANS: A Conversing face to face, reading newspapers and books, and even texting are all common forms of linguistic communication. Paralinguistics include less recognizable but important means of transmitting messages such as the use of gestures, eye contact, and facial expressions. Explicit communication is not a therapeutic communication technique.

Metacommunication factors that affect how messages are received and interpreted would include internal personal states (such as disturbances in mood), environmental stimuli related to the setting of the communication, and contextual variables (such as the relationship between the people in the communication episode).

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE 1. The nurse is working with a patient diagnosed with posttraumatic stress disorder related to childhood sexual abuse. The patient is crying and states, “I should be over this by now; this happened years ago.” Which response(s) by the nurse will facilitate communication? (Select all that apply.) a. “Why do you think you are so upset?” b. “I can see that this situation really bothers you.” c. “The abuse you endured is very painful for you.”

d. “Crying is a way of expressing the hurt you’re experiencing.” e. “Let’s talk about something else, since this subject is upsetting you.”

ANS: B, C, D Reflecting and giving information are therapeutic techniques. “Why” questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 44: Collaboration Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A newly licensed nurse is assigned to an experienced nurse for training on a medical unit of a hospital. What type of nurse-to-nurse collaboration does this assignment demonstrate? a. Interprofessional b. Shared governance c. Interorganizational d. Mentoring ANS: D Mentoring is a collaborative partnership between a novice nurse and an expert nurse to help transition a nurse through career development, personal growth, and socialization into the profession. Interprofessional collaboration is working with several disciplines. Shared governance is a type of management for nursing. Interorganizational collaboration often includes teams from inside and outside an organization to meet a common goal.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse is presenting an in-service on the importance of collaborative communication.

The nurse includes which critical event identified by the Joint Commission as an outcome of poor communication among healthcare team members? a. The occurrence of a patieNnt event resulting in death or serious injury b. Decreased ability to document expenses of care provided c. Longer time to begin surgical cases d. Increased time to discharge patients to outpatient care ANS: A The Joint Commission has identified that poor communication is the primary factor in the occurrence of sentinel events, or events resulting in unintended death or serious injury to patients. Lack of documentation, longer time to begin surgery, and increased delays in discharge all contribute to the management of health care, but do not result in critical patient outcomes.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A nurse is reviewing the concept of professional collaboration. Which patient scenario should the nurse identify as the best example of professional collaboration? a. The nurse, physician, and physical therapist have all visited separately with the patient. b. The nurse, physical therapist, and physician have all developed separate care plans for the patient. c. The nurse mentions to the physical therapist that the patient may benefit from a muscle strengthening evaluation. d. The nurse and physician discuss the patient’s muscle weakness and initiate a

referral for physical therapy.

ANS: D Professional collaboration includes team management and referral to needed providers to meet patient needs. Each discipline retains responsibility for their own scope of practice but recognizes the expertise of other providers. Working separately does not develop a comprehensive plan of care. Casual mentioning of patient needs does not follow professional communication channels and frequently delays needed interventions.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A registered nurse (RN) is reviewing the concept of collaboration. Which statement correctly describes the RN nursing’ role in collaboration? a. State boards of nursing mandate that collaboration can only occur in hospitals. b. Collaboration should occur only with physicians. c. Collaboration occurs only between nurses with the same level of education. d. Collaboration may occur in health-related research.

ANS: D RNs collaborate with many different persons, including patients, managers, educators, and researchers. Collaboration does not occur only with physicians or nurses of equivalent educational background, but with anyone who is working toward meeting patient goals.

Collaboration occurs in any healthcare setting as well as community and home settings.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

N 5. A nurse manager is looking to promote a culture of safety on the medical unit. Which action should the nurse manager implement? a. Focus on the number of medication errors occurring on the unit. b. Focus on adapting system changes. c. Providing incentives to nurses who don’t make any medication errors. d. Placing nurses on restricted duty who have made medication errors.

ANS: B The Institute of Medicine (IOM) and QSEN initiative have switched their perspective from medication errors to systematic changes that focus on safety aspects. The nurse manager should not use rewards or incentives to motivate change of behavior as that would not promote a culture of safety if individuals feared retaliation or were treated differently for safe behavior practices.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. The nurse and physician are explaining that home care that will be needed by a patient after discharge. The patient’s spouse states angrily that it will not be possible to provide the care recommended. What is the best response by the nurse? a. “Let me review what is needed again.” b. “It is important that you do what the physician has prescribed.” c. “What concerns do you have about the prescribed care?”

d. “I can come back after you talk with your spouse about the care.”

ANS: C The patient needs to be the focus of developing care plans, and communication is an important part of collaboration with the patient to discover barriers for the patient to follow recommendations. It is important to either provide solutions to the barriers or present other options. Reviewing the care again does not demonstrate willingness to have the patient be part of the team. Insisting that the patient do what is prescribed is autocratic and does not recognize the role the patient has in their care. Leaving the patient and spouse with the situation unresolved fosters distrust and more anger.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. The nurse is caring for a patient with a progressive, degenerative muscle illness. The patient states that she would like to remain in her home with her daughter as long as possible. What action should the nurse take? a. Teach the patient muscle strengthening and stretching exercises. b. Tell the patient to make plans to move to an assisted-living facility. c. Discuss resources to help the patient and make appropriate referrals. d. Ask the patient to come in for daily physical therapy.

ANS: C To honor the patient’s request to stay at home the nurse should make appropriate referrals for needed evaluation and assistance. Most nurses will not have the expertise to teach appropriate exercises for degenerative illness. Asking the patient to move to an assisted-living facility does not account for the patient’s request. The patient has not been assessed for the need of dailyNtherapy, and it is not likely that a patient with a degenerative illness will be able to make daily appointments for treatment as the illness progresses.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

8. A patient has been admitted to an acute care hospital unit. The nurse explains the hospital philosophy that the patient be an active part of planning their care. The patient verbalizes understanding of this request when they make which statement? a. “I will have to do whatever the physician says I need to do.” b. “Once a plan is developed, it cannot be changed.” c. “My insurance will not pay if I don’t do what you want me to do.” d. “We can work together to adjust my plan as we need to.”

ANS: D Treatment plans need to be developed, evaluated, and adapted as needed based on the patient status and willingness to complete the prescribed care. Stating that the patient has to do whatever the care provider prescribes does not include the principle of collaboration.

Care plans can be altered based on patient status. Insurance providers do not determine a patient’s ability to complete prescribed care, although they do reimburse for standard care given.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

9. The management of a community hospital is trying to encourage a more collaborative environment among staff members. Which concept is most important for management to develop first? a. Post educational posters about how well collaboration is being performed b. Highlight that no single profession can meet the needs of all patients c. Provide meetings for each department on how their role affects patients d. Begin implementing evaluations of collaborative skills on annual performance reviews ANS: B Recognizing that collaboration needs all professions to provide patient-centered care is an important first step to implementing a different philosophy in the hospital. Posting an evaluation of performance before education will not encourage participation. Collaboration requires an understanding of more than your own discipline. It is unfair to evaluate staff on a requirement that they have not been introduced to.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. Which activities are appropriate for the nurse to collaborate with a patient? (Select all that apply.) a. Prescribing a new medication dose b. Health promotion activities c. End-of-life comfort decisions N d. Interpreting laboratory results e. Lifestyle changes to improve health ANS: B, C, E Nurses should include patients and their families when exploring health promotion activities, end-of-life decisions, lifestyle changes, and treatment options. Prescribed medication doses are initiated by educated professionals, although the patient gives feedback on the effectiveness of medications. Patients are not trained to interpret lab results, but patients rely on health professionals to explain results to them.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 45: Safety Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A sentinel event refers to which situation? a. An event that could have harmed a patient, but serious harm didn’t occur because of chance b. An event that harms a patient as a result of underlying disease or condition c. An event that harms a patient by omission or commission, not an underlying disease or condition d. An event that signals the need for immediate investigation and response ANS: D A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof called sentinel, because it signals the need for immediate investigation and response. A near-miss refers to an error or commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance. Harm that relates to an underlying disease or condition provides the rationale for the close monitoring and supervision provided in a healthcare setting. An adverse event is one that results in unintended harm because of the commission or omission of an act.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. The nurse is caring for a patieNnt experiencing an allergic reaction to a bee sting who has an order for diphenhydramine (BenaDRYL). The only medication in the patient’s medication bin is labeled BenaZEPRIL. The nurse contacts the pharmacy for the correct medication to avoid what type of error? a. Communication b. Diagnostic c. Preventive d. Treatment ANS: D The nurse avoided a treatment error, giving the wrong medication. Benazepril is an ace inhibitor used to treat blood pressure. The Institute of Medicine (IOM) report referred to Leape’s identification of four types of errors. Treatment errors occur in the performance of an operation, procedure, or test; in administering a treatment; in the dose or method of administering a drug; or in avoidable delay in treatment or in responding to an abnormal test. Communication errors refer to those that occur from a failure to communicate.

Diagnostic errors are the result of a delay in diagnosis, failure to employ indicated tests, use of outmoded tests, or failure to act on results of monitoring or testing. Preventive errors occur when there is inadequate monitoring or failure to provide prophylactic treatment or follow-up of treatment.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

3. A nurse administers an incorrect medication to a patient. In reviewing this medication error, the nurse finds out that incorrect medication was placed in the Pyxis system. What type of error has the nurse committed? a. Latent error b. Blunt end c. Did not follow nursing process d. Latent error resulting in active error ANS: D The situation described is a latent error which resulted in an active error as incorrect medication was placed in the Pyxis system. Latent errors are also referred to as blunt end whereas active errors are applied as occurring at the sharp end. There is no provided information to suggest that the nurse did not follow nursing process.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Prior to drug administration the nurse reviews the seven rights, which include right patient, right medication, right time, right dose, right education, right documentation, and what other right? a. Room b. Route c. Physician d. Manufacturer

N

ANS: B The right route (e.g., oral or intramuscular) is an essential component to verify prior to the administration of any drug. The patient does not need to be in a specific location. There may be a number of physicians caring for a patient who prescribe medications for any given patient. A similar drug may be made by a number of different companies, and checking the manufacturer is not considered one of the seven rights. However, the nurse will want to be aware of a difference, because different companies prepare the same medication in different ways with different inactive ingredients, which can affect patient response.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. Which nursing action indicates that a nurse is more likely to incur a medication error during medication administration? a. Checks the original medication order on the patient’s chart b. Asks the patient to state his/her name and date of birth c. Does not scan the barcode of the patient prior to administering the medication d. Does not provide the patient with a glass of water ANS: C

Use of barcode scanning of both the medication and the patient’s hospital band is critical to maintaining safe practice during medication administration. The nurse by not scanning the barcode is not maintaining the required elements and as a result is more likely to incur a medication error. Checking the original order and asking the patient to provide identification are required elements. Not providing a glass of water to the patient is not related to a medication error but does not represent best practice unless the patient is NPO except meds which would require sips of water.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. To promote safety, the nurse manager sensitive to point of care (sharp end) and systems level (blunt end) exemplars works closely with staff to address which point of care exemplar? a. Care coordination b. Documentation c. Electronic records d. Fall prevention ANS: D The most common safety issues at the sharp end include prevention of decubitus ulcers, medication administration, fall prevention, invasive procedures, diagnostic workup, recognition of/action on adverse events, and communication. These are the most common issues the staff nurse providing direct patient care encounters. Each of the other options is classified as systems level exemplars.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. Aspects of safety culture that contribute to a culture of safety in a healthcare organization include which component? a. Communication b. Fear of punishment c. Malpractice implications d. Team nursing ANS: A Aspects that contribute to a culture of safety include leadership, teamwork, an evidence base, communication, learning, a just culture, and patient-centered care. Fear of professional or personal punishment and concern about malpractice implications are considered barriers to a culture of safety. No model of nursing care has been related to a culture of safety.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A staff nurse reports a medication error due to failure to administer a medication at the scheduled time. What is the charge nurse’s best response? a. “We’ll conduct a root cause analysis.” b. “That means you’ll have to do continuing education.”

c. “Why did you let that happen?” d. “You’ll need to tell the patient and family.”

ANS: A In a just culture the nurse is accountable for their actions and practice, but people are not punished for flawed systems. Through a strategy such as root cause analysis the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences. Requiring continued education may be an appropriate recommendation but not until data is collected about the event. Telling the patient is part of transparency and the sharing and disclosure among stakeholders, but it is generally the role of risk management staff, not the staff nurse.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 9. To promote a culture of safety, the nurse manager preparing the staff schedule considers the anticipated census in planning the number and experience of staff on any given shift. Which is the human factor primarily addressed with this consideration? a. Available supplies b. Interdisciplinary communication c. Interruptions in work d. Workload fluctuations ANS: D Including an adequate number of staff members with experience caring for anticipated patients is a strategy to manage the workload and potential fluctuations. A safety culture requires organizational leaderNship (e.g., the nurse manager) that gives attention to human factors such as managing workload fluctuations. This strategy also applies principles of crew resource management in that it addresses workload distribution. Lack of supplies can create a challenge for safe care but could not be addressed with the schedule. Concerns with communication and coordination across disciplines, including power gradients, and excessive professional courtesy can create hazards but would not be the best answer.

Strategies to minimize interruptions in work are essential but would not be the best answer in this situation.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 46: Technology and Informatics Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The staff nurse who uses informatics in promoting quality patient care is most likely to access data in which domain? a. Certified clinical information systems (CIS) b. Clinical healthcare informatics c. Public health/population informatics d. Translational bioinformatics ANS: B Clinical healthcare informatics and the subset, nursing informatics, provides for the development of direct approaches to patients and their families which can be used by the staff nurse to promote quality patient care. Certified CIS refers to the tools for achieving quality outcomes, including electronic health records, clinical data repositories, decision support programs, and handheld devices—not the data. Public health/population informatics is the domain which relates information, computer science, and technology to public health science to improve the health of populations; this domain would provide data for the nurse working with communities. Translational bioinformatics refers to the research science domain where biomedical and genomic data are combined; it is a new term that describes the domain of where bioinformatics meets clinical medicine, generally for healthcare research rather than direct patient care.

OBJ:

NCLEX Client NeedsNCategory: Health Promotion and Maintenance

2. When discussing the purposes of healthcare informatics with a nurse during orientation, the nurse educator would be concerned if the nurse orientee stated that which is one purpose of informatics? a. Develop a cognitive science. b. Improve disease tracking. c. Improve the health provider’s work flow. d. Increase administrative efficiencies.

ANS: A Cognitive science is one of the theories that play a role in the implementation of informatics.

Its development is not a purpose, and the nurse educator would use this incorrect response of the orientee to plan additional teaching about the purposes of healthcare informatics.

Purposes of information health technology include to improve health provider work flow, improve healthcare quality, prevent medical errors, reduce healthcare costs, increase administrative efficiencies, decrease paperwork, and improve disease tracking.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. To design and implement a decubitus ulcer risk management protocol in the electronic health record, the informatics nurse would first perform which action? a. Build the screens in the electronic health record.

b. Determine evidence supporting decubitus ulcer risk management. c. Develop the training program for staff. d. Select the appropriate standardized language.

ANS: B Collecting the evidence related to the issue is the first step in addressing a problem (remember the nursing process, the foundation of nursing practice). Based on the evidence, an assessment tool or tools and data needed from a patient perspective would be identified.

The screens in the electronic record would be based on the workflow surrounding the patient assessment. A training program could not be developed until the protocol is adopted. The appropriate standardized language is selected based on what needs to be documented and what has been approved for use by the agency (e.g., ANA recognized terminologies).

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The application of information processing that deals with the storage, retrieval sharing, and use of healthcare data, information, and knowledge for communication and decision making is the definition of which area? a. Computer science b. Health informatics c. Health information technology d. Nursing informatics ANS: C This is the definition of health information technology. Computer science is a branch of engineering that studies compNutation and computer technology, hardware, software, and the theoretical foundations of information and computation techniques. Health informatics is a discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. The nurse manager of a medical/surgical unit wants to increase the use of healthcare technology on the unit and is working with an ANA-certified informatics nurse to reduce which barriers to health information exchange? a. Basic informatics knowledge and skills b. Offering the best set of tools c. Privacy and security policies d. Unit-specific terminology ANS: D

Unit-specific terminology would be a barrier to sharing health information because there could be confusion about terms. Standardized terminology within the electronic health record is critical for communicating care to the interprofessional team and exchanging health information. Competency in informatics including basic informatics knowledge and skills could facilitate the use of informatics; lack of competency could be a barrier. Offering the best set of tools could promote the ease of data entry and access. Privacy and security policies reduce legal and ethical concerns about sharing data, thus reducing barriers to health information exchange.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse is reviewing concepts related to documentation in the electronic health record.

Which statement best represents the concept of “meaningful use”? a. Allows for privacy of information b. Uses individualized log on for access c. Completes charting in a timely manner d. Meets established criteria related to technological use ANS: D The concept of “meaningful use” refers to the establishment of criteria related to technological use of the electronic health record as determined by federal guidelines.

HIPAA policy mandates privacy of personal information and patient medical records. Use of an individualized log on to access relates to security concerns. Completing charting in a timely manner is an expectation of prudent practice.

OBJ: NCLEX Client NeedsNCategory: Safe and Effective Care Environment: Management of Care 7. Which are exemplars of the health informatics concept? a. Clinical research informatics b. Hardware and software c. Privacy and security d. Standard terminology ANS: A Exemplars of the health informatics concept include clinical healthcare informatics, clinical research informatics, public/population health informatics, and translational bioinformatics.

Hardware and software, privacy and security, and standardized information systems and terminology are considered attributes related to the concept, not exemplars.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 47: Evidence Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. One of the first nurse researchers to document evidence-based practice for nursing was Florence Nightingale. What did Nightingale incorporate into her practice that made her practice different from her colleagues? a. Nightingale gathered scientific data. b. Nightingale calculated statistics to report her findings. c. Nightingale communicated her findings to powerful others. d. Nightingale based her nursing practice on her findings.

ANS: D Florence Nightingale had tried to develop the role of researcher by using evidence from her practice and implementing these findings. Evidence-based practice (EBP) includes conducting quality studies, synthesizing the study findings into the best research evidence available, and using that research evidence effectively in practice. Although gathering scientific data, calculating statistics to report findings, and communicating findings to powerful others are all important components of conducting research, Nightingale’s action that most appropriately reflects the current nursing research priority is that she based her nursing practice on her findings.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N 2. The nurse administrator is doing a study that entails gathering data about new employees over a 10-year period. Which research method would be the best one to use for this type of study? a. Quantitative longitudinal cohort b. Qualitative longitudinal c. Qualitative interview d. Qualitative case study ANS: A Quantitative research has been defined as being “focused on the testing of a hypothesis through objective observation and validation.” The types of studies that make up this category include randomized controlled studies, cohort studies, longitudinal studies, case-controlled studies, and case reports. The other options are examples of quantitative, not qualitative, studies.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse in the outpatient setting would like to conduct a research study that compares patients who take tramadol (Ultracet) to patients who take oxycodone hydrochloride and acetaminophen (Percocet) for managing back pain. Which quantitative research method should yield the best results? a. Longitude study

b. Randomized controlled study c. Systematic reviews/meta-analysis d. Survey study ANS: B A randomized controlled study is a type of quantitative research that seeks to control and examine the variables to determine effectiveness. In this case, the variables would be those that were administered tramadol (Ultracet) and those that were administered hydrochloride and acetaminophen (Percocet) for managing back pain. Correlational research methods help determine association between or among variables. A longitudinal study examines variables over a designated course of time. A systematic review/meta-analysis is a type of literature review and not a research method. A survey study is a type of qualitative research method.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The nurse in the psychiatric unit is involved in a research study for a depression medication.

In the study, patients are randomly assigned to one depression medication and the other group is receiving no medication to treat the depression. What method of research are the patients involved with? a. Descriptive b. Correlational c. Quasi-experimental d. Experimental ANS: D Experimental tests an interveN ntion and includes both a control group and random assignment. This research study tests an intervention and includes both a control group and random assignment. Descriptive defines the magnitude of a concept and its characteristics.

Correlational determines association between or among variables. Quasi-experimental tests an intervention and lacks either a control group or random assignment.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. How does the Iowa model transcend mere nursing care? (Select all that apply.) a. It includes formalized internal feedback loops. b. Its triggers can have their origins practically anywhere. c. It generates change in practice solely through research. d. It implies a layer of policy development. e. It addresses multiple disciplines’ impacts on quality.

ANS: A, B, D, E

The triggers addressed within the Iowa model process can be problem focused and evolve from risk management data, process improvement data, benchmarking data, financial data, and clinical problems. The triggers can also be knowledge focused, such as new research findings, change in a national agency’s or an organization’s standards and guidelines, expanded philosophy of care, or questions from the institutional standards committee.

Because the Iowa model is often implemented at a fairly high level of nursing or hospital administration, it scrutinizes the input of nursing and other disciplines in its process. Its output is applied as widely as possible throughout the organization, and it can affect policy within a multihospital system and even across systems. The success of EBP is determined by all involved, including healthcare agencies, administrators, nurses, physicians, and other healthcare professionals.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. Which statements are true about the Iowa model of EBP? (Select all that apply.) a. It addresses utilization of research findings at an individual level. b. It addresses the relevance of the question to the organization. c. Individual nurses enact an Iowa decision tree when they examine risk management data. d. It identifies triggers capable of posing hazard or benefit. e. It reiterates that innovators embrace change far earlier than laggards.

ANS: B, D The Iowa model of EBP provides direction for the development of EBP in a clinical agency and as such focuses on the relevance of the question to the organization. In a healthcare agency, there are triggers t h a N t initiate the need for change, and the focus should always be to make changes based on best evidence. The Iowa model of EBP was revised in 2015 to provide additional feedback loops, detailed instructions, and inclusion of patient preferences.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse is conducting a review of the literature for pain management techniques. Which of the following should the nurse consider when conducting research that yields solid EBP? (Select all that apply.) a. Search the literature to uncover evidence to answer the question. b. Evaluate the outcome. c. Use the nursing process to evaluate evidence. d. Evaluate the evidence found. e. Develop an answerable question. f. Develop a question that has not been answered. g. Apply the evidence to the practice situation.

ANS: A, B, D, E, G To facilitate the use of evidence, steps have been developed to systematically approach a question of patient care. The steps are outlined as follows: • Develop an answerable question.

• Search the literature to uncover evidence to answer the question.

• • • •

Evaluate the evidence found.

Apply the evidence to the practice situation.

Evaluate the outcome.

The nursing process is a method of problem solving and can be used to develop a plan of care. Formulating a question that has not been answered in the research would be considered primary research. Therefore, there is no evidence in which to draw from.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Concept 48: Health Care Quality Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Which statement is true regarding the patient’s perception of his or her care? a. Patent perception is just as important as the outcome of care. b. Patient perception is insignificant compared to the outcome of care. c. Patient satisfaction has no relation to quality of care. d. Patient satisfaction is insignificant compared to the outcome of care.

ANS: A The patient’s perception of his or her care is just as important as the outcome of the care. If the patient perceives the care as meeting the aspects of quality, then patient satisfaction increases.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. Two nurses are discussing health-care quality. They agree which event contributes to increased health-care quality? a. Magnet status hospitals b. Fewer adverse events c. Collaboration of multiple health-care agencies d. Increased patient education ANS: C N Multiple health-care agencies are able to collaborate and provide better outcomes for health-care personnel and patients. Magnet status hospitals may be good, but the status does not always mean a quality outcome. Fewer adverse events and increased patient education are good, but they may be the result of other variables and not just quality of care rendered.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A student nurse is talking with his instructor. The student asks how quality of care is evaluated. What is the best response by the instructor? a. “By the patient getting well.” b. “On the basis of process and outcomes.” c. “By the physician’s assessment.” d. “By the patient’s satisfaction.”

ANS: B Quality of care is evaluated by process and outcomes. If the outcomes are achieved, then the care has achieved what is was designed to do. The patient getting well may be an action of the body doing what it is supposed to do and not quality of care; the same can be said of the physician’s assessment. The patient’s satisfaction is subjective according to his or her perceptions and not the quality of care.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. What are two major foci of The Joint Commission (TJC) in the delivery of health care? a. Cost containment, safety b. Safety, quality c. Quality, assessment d. Assessment, evaluation ANS: B The focus of TJC is quality and safety for patient care. TJC does not address cost containment, assessment of care, or evaluation of care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A student nurse and clinical instructor are discussing quality in health care. The instructor knows the student understands when the student makes which statement? a. “Quality is apparent in all health care.” b. “Quality is an outcome of health care.” c. “Quality is seen and unseen in health care.” d. “Quality is achieved by collaboration in health care.”

ANS: C Quality in health care is tangible and intangible. Quality in health care is not apparent in all health care, as many areas of health care are lacking. Quality of care does not always affect the outcome of care; the patient may recover no matter what care is given. Quality is not always achieved by collaboration.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. The focus of quality health care should be on which of the following items? (Select all that apply.) a. Excellent services b. Comprehensive communication c. Private hospital rooms d. Health team collaboration e. Culturally competent care ANS: A, B, D, E Excellent services, communication, collaboration, and culturally competent care bring quality to the health care delivered to the patient. Private hospital rooms may be a preference by some patients, but they do not add to the quality of care.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. What are the major attributes of health-care quality? (Select all that apply.) a. Conforms to standards b. Sound decision making

c. High acuity patients d. Low health-care costs e. Identifies adverse events ANS: A, B, E Major attributes of health-care quality include conformation to standards set by regulatory agencies, sound decision making regarding care, and identifying potential adverse events.

High acuity of patients does not contribute to quality health care, because the care demand is increased, and low health-care costs mean fewer services may be available.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Concept 49: Care Coordination Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Student nurses are being questioned by the nursing instructor about the health-care coordination system. The instructor knows the students understand health-care delivery when making which statement? a. “Health care is available for everyone at every time.” b. “Health-care needs are best met with a collaborative effort.” c. “Health care is adequately meeting the needs of the homeless populations.” d. “Health care needs are mostly in third world countries.”

ANS: B Health-care needs many times are not met by one discipline. When a collaborative effort is used, the patient is better served. Health care is not available for everyone, nor is it meeting the needs of the homeless population. Health-care needs are worldwide, not just in third world countries.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. For children and teens, which model includes school-based services? a. Social b. Integrated c. Medically-oriented N d. Nurse-oriented ANS: A The social models focus on community-based services, and the other models do not.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. Which statement is true regarding the concept of care coordination? a. There is minimal risk for individuals across the life cycle. b. Due to enhanced technological ability, services are able to be provided to all those in need. c. Most vulnerable populations have the highest need. d. Costs of services are easily maintained.

ANS: C The concept of care coordination is an important aspect for all individuals as there is the potential for everyone to experience a risk at one time that may require at best a temporary need for coordination of services. Although technological advances have advanced, there are still limitations and barriers to providing coordination of care services to all in need.

Vulnerable populations have the highest need and costs of services are cost-intensive.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. The nurse is discussing care coordination with a patient. The patient asks the nurse to explain care coordination. What is the nurse’s best response? a. “Care coordination is a cost effective method created by the community.” b. “Care coordination forces the health-care facilities in the community to work together.” c. “Care coordination exists for the children and uninsured in the community.” d. “Care coordination allows health-care services to work together in the community.”

ANS: D Care coordination allows all health-care/community services to work together so that patient and family needs can be met. Care coordination does not focus on cost methods. Cost coordination does not exist just for children or the uninsured. No one service is forced to work with another service.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. Nurses work to serve the population, and they know that which priority population needs to be served by care coordination? a. Most vulnerable and the frail b. Uninsured and the very young c. Underinsured and the elderly population d. Whole population of the community ANS: A The priority population is the most vulnerable and the frail, because they have the most health-care needs. Other popuNlations do need health care, but they do not always have immediate need of the health-care system.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nursing instructor is talking about care coordination with nursing students. The instructor stresses which of the following to the students concerning care coordination? a. “A patient must ask for what they need in order to coordinate care.” b. “The nurse does most of the work in care coordination.” c. “Medical diagnoses are an integral part of care coordination.” d. “Collaboration is a significant part of care coordination.”

ANS: D Collaboration is a big part of care coordination. Without the collaboration, there would be no care coordination. Patients asking for their needs to be met does not collaborate care.

Nurses do not do all the work in care collaboration. Medical diagnoses are one small part that drives the need for care collaboration.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. Care coordination models should be adopted in health-care facilities. If models are not put into practice, the shortcomings of the health-care system may display which of the following items? (Select all that apply.) a. Decrease in patients b. Fragmented services c. Low birth weight newborns d. Cost inefficiencies e. Poor health outcomes f. Increased pharmacy costs ANS: B, D, E Fragmented services, cost inefficiencies, and poor health outcomes may be some of the shortcomings seen in health care without the proper model in place to guide the health-care delivery system.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 50: Caregiving Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The community health nurse is assessing a family who has a chronically ill child. The child needs special care, and the nurse has to coordinate the care for the home setting. What behavior will the nurse assess for to know that the family can care for the child? a. The family is willing to learn about the care and share the caregiving needs. b. The mother is going to care for the child and the family herself. c. The older siblings are going to care for the child while the parents are at work. d. An outside agency will be coming to the home three times a week to give care.

ANS: A The nurse will look for a family who is willing to provide care plus support each other in this need. Having a situation where just siblings or a mother or an outside agency give care puts an undue burden on the caregiver and brings disharmony to the family.

OBJ:

NCLEX Client Needs Category: Physiological Integrity

2. A young wife is talking with the nurse about her husband who is returning from the military.

The wife confides that her husband is physically okay but is behaving differently. What is the nurse’s best response? a. “He is just trying to adjust to civilian life again; he’ll be okay.” b. “You should observe him closely, because he could attack you.” c. “Many times people needNcare for emotional trauma.” d. “Talk with your physician to get medication, and then put it in his food.”

ANS: C The nurse is alerting the young wife to the fact that people who have experienced emotional trauma need care too. The nurse does not know how the husband is adjusting so the other options are incorrect.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is counseling a woman who is caring for her 83-year-old father. The father has had mental changes and is becoming more confused. The father lives with the daughter in her home. The nurse knows the daughter understands the father’s care needs when she states which of the following? a. “Dad will only need my help for a short time, and then he will get better.” b. “I can leave dad alone during the day; I’ll just deadbolt the door.” c. “I can send dad to the adult daycare; that way I can work and care for him at night.” d. “Dad misses mom since she passed; he will be okay in a few weeks.”

ANS: C

The father will be cared for at the adult daycare, and it is a nice alternative for the daughter.

She will be able to work and know that her father is safe during the day. The daughter thinking the father will be okay in a few days is not realistic, nor can she deadbolt the door and lock him in the house.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. Many middle-aged adults are called the “sandwich” generation because they are caring for their children and their aging parents. What is the priority reason for aging parents needing care? a. Mental clarity b. Immobility c. Blindness d. Multiple chronic illnesses ANS: D Multiple chronic illnesses come with the aging process. Middle-aged adults are becoming the caregivers for the generation before them and the one after them. Mental clarity is a positive aspect of aging and does not need care. Immobility and blindness do not always mean that the person needs direct care.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. A mother is talking with the community-based nurse concerning her adult son. The son is mentally challenged and not able to live on his own. The mother is concerned about her son’s welfare when she is no longer able to care for him. What is the best response by the N nurse? a. “Let’s look into the community resources that are available to assist you.” b. “You have raised your son well, and he will be okay on his own.” c. “Contact your distant relatives to see if anyone would take your son.” d. “There are places for mentally challenged adults; let’s place him there.”

ANS: A The mother, with the assistance of the nurse, can research resources in the community that will service and care for her son when she is no longer able to do so. How the son is raised does not mean that he will be okay on his own. Distant relatives may not want or be able to care for the son, so this may not be a viable option. Placing the son is too general of an option, and he may not do well in this setting.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE 1. Many grandparents today are caring for grandchildren in place of a parent. Identify the reasons why this phenomenon is happening. (Select all that apply.) a. Children prefer living with their grandparents. b. Parents are incarcerated. c. Parents are deceased. d. Grandparents are better caregivers.

e. Parents are mentally ill. f. Parents are substance abusers.

ANS: B, C, E, F Grandparents are usually caring for children because the parents are deceased, in prison, substance abusers, or mentally ill and cannot care for the children. The fact that children prefer to live with the grandparents or the grandparents may be better caregivers is not a main reason for this phenomenon to happen.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity 2. Caregivers are often categorized by their relationship to the person being cared for. Which of the following are the roles? (Select all that apply.) a. Grandparent b. Spouse c. Parent d. Adult children e. Neighbor/friend f. Young children ANS: A, B, C, D, E All of these options can provide care whether it is on a temporary or permanent basis.

Young children do not provide care.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 51: Palliative Care Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Palliative care is used in the management of a patient with symptomatic chronic obstructive pulmonary disease (COPD). Which option does the nurse identify as being accurate? a. Palliative care is used when the patient is beginning to die. b. Palliative care is used to help manage the symptoms that often accompany COPD. c. Hospice nurses must be involved to provide palliative care in a cancer patient. d. Patient must be enrolled into the Medicare Hospice Benefit to receive palliative care.

ANS: B Palliation is the relief or management of symptoms without providing a cure. To palliate is to reduce the severity of an actual or potential life-threatening condition or a chronic debilitating illness. Palliation is not equivalent to cure, but it is the reduction of undesirable effects resulting from the incurable disease or condition.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. Today most patients are living for several years before dying with multiple chronic conditions, such as COPD, congestive heart failure, diabetes, and obesity. These concomitant diseases contribute to multiple symptoms that interfere with the patient’s quality of life. What type of care would you consider for this patient?

N a. End-of-life care b. Supportive care c. Comfort care d. Palliative care ANS: D Palliative care provides optimal symptom management in the setting of multiple chronic conditions. The relief and management of these symptoms help to promote improved quality of life for the patient and help to maintain physical functioning.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

3. What is the most prominent goal of palliative care? a. Integrate into chronic disease management sooner rather than later. b. Enroll the patient into the Medicare Hospice Benefit. c. Ensure that the patient has a 6-month prognosis. d. Reserve this type of care until the patient is actively dying.

ANS: A The goal of palliative care is to integrate symptom management interventions earlier into the course of chronic disease sooner rather than later. This helps to promote optimal quality of life.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The student demonstrates a lack of understanding of palliative care when making which statement? a. “Palliative care is designed to promote comfort.” b. “Palliative care is designed to reduce disease exacerbations.” c. “Palliative care is designed to decrease acute care hospital admissions.” d. “Palliative care is designed to promote a cure for chronic disease.”

ANS: D Palliation is the reduction of symptoms without elimination of the cause. Palliative care refers to the provision of care for patients who are diagnosed with a disease or condition without a cure.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort 5. Which is one of the biggest challenges facing current nursing practice? a. The number of aging Americans living with chronic disease b. The number of patients entering into hospice programs c. The number of cancer patients receiving supportive care d. Reduced length of stay in hospice care ANS: A Millions of Americans are living with one or more chronic debilitating diseases, and 7 out of 10 can expect to live with their diseases several years before dying. When coupled with the advancing age of the eight million baby boomers who now qualify for Medicare, this will soon create a huge demand on health-care resources and community-based services.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. When considering the trajectory of a specific disease, what is the most important concept? a. Hospital admissions b. Physical functioning c. Quality of life d. Symptom management ANS: B The disease trajectory occurs from the onset of a life-limited diagnosis until death. Physical functioning determines the decline in the patient’s physical status. Decline in status is used to determine when to intervene with palliative and end-of-life care.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The interprofessional core team includes members from which disciplines? a. Nursing, medicine, volunteers, and nutrition b. Medicine, nursing, social work, and clergy c. Medicine, nursing, physical therapists, and volunteers d. Nursing, home health aides, volunteers, and clergy ANS: B

An interprofessional team approach involving healthcare professionals from different disciplines is central to optimal palliative care practice and quality outcomes. The interdisciplinary core team includes members from medicine, nursing, social work, and clergy. Ancillary disciplines are also included. Volunteering is not considered a discipline in health care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Concept 52: Health Disparities Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for a Chinese patient diagnosed with cancer who is suffering from pain, yet refuses analgesia administration. What type of health disparities is this patient exhibiting? a. Avoidable and acceptable b. Avoidable and unacceptable c. Unavoidable and acceptable d. Unavoidable and unacceptable ANS: B Health disparities that are avoidable and unacceptable unfortunately occur in healthcare settings and these are the targets of interventions. For example, a disparity in cancer pain management exists between Asians and Whites. This difference is attributable to Asian cultural values and attitudes related to cancer pain and pain medication distinguished from the cultural values of Whites. The disparity is avoidable if Asian cancer patients are adequately educated and instructed on cancer pain management strategies including pain medication and complementary and alternative medicine. Also, this disparity is unacceptable because this gives an unnecessary burden of pain to Asian cancer patients that could be easily managed by using existing strategies.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management N of Care 2. An experienced nurse tells the student nurse, “I have found that most Hispanic immigrants live in unsanitary conditions but are hard workers.” How should the student nurse best classify this statement? a. Stereotyping b. Prejudice c. Discrimination d. Misinformed ANS: A Stereotyping often leads to biased clinical decision making. Stereotyping refers to the process by which people use social categories (e.g., gender or race/ethnicity) in acquiring, processing, and recalling information about others. Both implicit and explicit negative attitudes and stereotypes of healthcare providers significantly shape interactions with patients, influence how information is recalled, and guide expectations and inferences in systematic ways. Stereotyping often occurs subconsciously, unlike prejudice or discrimination. Prejudice, which refers to unjustified negative attitudes based on a person’s group membership, is another source of biased clinical decision making. Discrimination refers to the actual mistreatment of individuals based on race, gender, ethnicity, etc. The nurse is not misinformed as the nurse has practiced for some time and made a statement based on observation and experience.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment: Management

of Care 3. Which type of health disparities are most frequently encountered by nurses in clinical and community settings? a. Avoidable and acceptable b. Avoidable and unacceptable c. Unavoidable and acceptable d. Unavoidable and unacceptable ANS: B Although there are many types of health disparities, the avoidable and unacceptable health disparities are the ones that healthcare providers, including nurses, frequently encounter in clinical and community settings. Furthermore, these are the health disparities that healthcare providers need to target to intervene.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The nurse is caring for diverse population groups at a health clinic. Which of the following patients demonstrates a potential health disparity group? a. A 26-year-old woman who is receiving follow-up after a car accident b. A 30-year-old immigrant who does not speak English c. A 28-year-old man who needs a tetanus booster d. A 12-month-old with an appointment for immunizations ANS: B Poor health literacy skills areNan example of a health disparity that limits an individual’s ability to access or communicate about healthcare needs. Patients who are receiving needed care are not experiencing a gap between health need and actual care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Which is the best strategy the nurse manager should include when working to reduce healthcare disparities on a medical-surgical unit? a. Less diverse workforce b. Increase interpreter availability c. Authoritarian leadership d. Annual staff training ANS: B Key elements are cultural competence that can reduce health disparities including: a diverse workforce; interpreter availability; finding common ground versus authoritarian leadership; frequent staff training and updating staff as needed throughout the year.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A new nurse requires further teaching when failing to identify which practice as a health disparity?

a. b. c. d.

Annual mammogram Early prenatal care Blood pressure screening Frequent fast food meals

ANS: D Preventive care, screening, and health promotion activities are not considered health disparities. Examples include mammograms, prenatal care, and blood pressure checks.

Frequent fast food meals, containing high fat content, are considered a health disparity due to possible lack of money or access to healthy meals.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. Before beginning work on a culturally diverse hospital unit, the nurse should perform which action first? a. Improve self-awareness of one’s own biases. b. Attend an anti-discrimination rally or march. c. Build rapport and trust with the patients. d. Take a foreign language class.

ANS: A Before working with culturally diverse groups, the nurse should first identify own biases and assumptions in order to objectively and competently care for patients. Attending a rally or march may not raise awareness of various biases. The nurse should establish rapport and trust when working with patients, after self-awareness is appreciated. Taking a foreign language may be helpful; how Neve r the first step is self-awareness.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

8. The nurse who has been hired to work on an oncology unit identifies which group of women as being at highest risk of developing breast cancer? a. African b. Caucasian c. Asian d. Hispanic ANS: C Breast cancer is the most common cancer in Asian women in the United States, but Asian women have relatively lower rates of breast cancer screening than African American and white women in the United States. Furthermore, disparities in breast cancer screening reportedly result from low income, lack of a local mammography center, lack of transportation to a mammography center, lack of a usual healthcare provider, lack of a recommendation from a healthcare provider to get mammography screening, lack of awareness of breast cancer risks and screening methods, and cultural and language differences.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE 1. A healthcare provider whose native country is India is explaining the treatment plan to a patient. The patient tells the nurse she is having trouble understanding the provider but is embarrassed about asking to repeat the information over and over. The nurse should assess for which results due to this disparity in provider-patient communication? (Select all that apply.) a. Patient dissatisfaction b. Optimal health outcome c. Poor adherence d. Increased patient confidence e. Improved communication ANS: A, C When sociocultural differences between healthcare providers and patients are not appreciated or communicated effectively in clinical encounters, patient dissatisfaction, poor adherence, poorer health outcomes, and racial/ethnic disparities in healthcare easily happen.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse in the immunization clinic should place emphasis on educating and reaching which groups about the disease preventing effects of immunizations? (Select all that apply.) a. Caucasian b. All individuals living below the federal poverty level regardless of race or ethnicity N c. Low income d. Parents of children e. High income ANS: B, C, D It is important to reach out to all individuals living below the federal poverty level (parents and children) as they are most likely not to have completed the specified immunization schedule. Research obtained from the Center for Disease Control (CDC) in 2014 suggests that those living below the federal poverty level were less likely to have the full series of vaccination coverage.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

Concept 53: Population Health Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse is reviewing the concept of population health. Which statement best represents the concept? a. Individuals who live in the United States b. Individuals with common characteristics related to health co-morbidities c. Individuals who use emergent care facilities as their primary source of health care d. Individuals with no symptoms of disease ANS: B Population health refers to individuals who reside in a geographic area that have similar characteristics related to health. Population by itself refers to a specific group location.

Choice of emergent care facilities as their primary source of health care does not define population health. Individuals within the population may have symptoms of disease.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse is reviewing the concept of population health. What method should the nurse utilize in order to maintain health equity for a given population? a. Ask each member of the group if they need an interpreter. b. Calculate group statistics for delivery of healthcare services. c. Make sure that all documN entation is accurate. d. Offer health screenings to all group members.

ANS: D The concept of population health is to maintain/improve health status, reduce disparities and create health equity. By offering health screenings to all group members, this allows for primary prevention. There is no information provided that indicates there is a language barrier, so asking each member of the group if they need an interpreter is not necessary.

While it is important to obtain statistical information relative to the group, this in itself does not provide for health equity. Making sure that documentation is accurate is important in the context of health care but it does not help to maintain health equity.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 3. A public health nurse is caring for a patient in the community who has been exposed to tuberculosis. What aspect of care is the public nurse providing? a. Health protection b. Health promotion c. Disease prevention d. Community nursing ANS: C

A nurse working as a public health nurse, who is providing care to a patient who has been exposed to a disease such as tuberculosis, would be providing disease prevention. Health protection would include providing educational materials to patients. Health promotion would include providing healthy educational programs. Community nursing is considered a specialty area of practice not an aspect of care.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. A parent asks the nurse to explain the term “herd immunity.” How should the nurse respond? a. “As long as your child receives his/her immunizations, they will be protected by this concept.” b. “It is important for 90% of the population to maintain their vaccination status for herd immunity to be effective.” c. “The term applies to individuals who have decided not to immunize but instead use isolation practices to maintain health.” d. “The term relates to individual groups of patients who are immunized.”

ANS: C The concept of herd immunity refers to 90% of the population being immunized in order for it to be effective on a population level. Although it is important for individual children to be immunized, the overall population must maintain a high immunization status to be effective.

Immunization is the key to the concept and the term does not relate to individual groups.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 5. A nurse is reviewing factors tNh a t lead to prevention of non-communicable diseases. Which intervention would be most effective for the nurse to implement for a group of patients? a. Check the patient’s immunization records. b. Maintain scheduled appointments with their healthcare provider. c. Offer information related to smoking cessation. d. Check patient’s medication record.

ANS: C Health promotion is an essential aspect of population health. Offering information related to smoking cessation would be most effective. Although it is important to check the patient’s immunization record, this relates to communicable diseases. Checking the patient’s medication record and maintaining scheduled appointments with their healthcare provider are important as well but in terms of health promotion, providing smoking cessation information would be more important.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A nurse is reviewing health promotion strategies with regard to population health. Which non-communicable disease processes linked to high morbidity and mortality can be addressed through health promotion? (Select all that apply.) a. Cardiac disease

b. c. d. e.

Diabetes End stage renal disease Stroke Chronic lower respiratory disease

ANS: A, B, C, D, E Of the ten leading causes of death, five of them are linked to non-communicable diseases: heart disease, diabetes, end stage renal disease, stork and chronic lower respiratory disease.

Each of which can be addressed via health promotion measures.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 54: Health Care Organizations Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse is interviewing at an agency owned by a national religious organization that serves homeless and uninsured patients. A large poster display shows a proposed addition that would add 16 beds to the facility that will be funded from profits of the previous 3 years of operation. The nurse recognizes that the agency is most likely what type of agency? a. For-profit b. Not-for-profit c. Publicly-owned d. Investor-owned ANS: B Many religious organizations are privately owned and administer not-for-profit health facilities, where profits are returned into the facility for improvements or equipment.

For-profit agencies distribute profits to shareholders. Publicly-owned facilities are government supported and not linked to religious organizations. Investor-owned agencies would be for-profit agencies with profits distributed to investors.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nurse is reported for taking prescribed patient medications for their personal use. Who has direct authority over decidingNif the nurse may keep their professional license to continue practicing as a nurse? a. The hospital where the nurse is currently employed b. The American Nurses Association c. The National League for Nursing d. The State Board of Nursing who issued the license ANS: D Decisions related to practice are the responsibility of the licensing body, or State Board of Nursing, who is charged with protecting the public. The hospital does not determine who is eligible for a professional license. The National League for Nursing is active in nursing education standards. The American Nurses Association helps develop standards of care and is politically active, but it does not enforce standards for individuals.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The annual report for a hospital shows that external environment factors are affecting the amount of new staff hired. What is a likely factor contributing to this outcome? a. The recent implementation of becoming a not-for-profit institution b. The implementation of a hospital electronic medical record system c. A national recession that has been occurring for 3 years d. The closure of a hospital-based school of nursing due to lack of funding

ANS: C External environmental factors that affect organizations are conditions or events that occur outside the control of the agency, such as new health laws, governmental regulations, or economic trends. Internal environmental factors occur within the organizational structure and include such factors as technology issues, changes in personnel roles, or the implementation of new policies.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse manager recognizes that systems theory identifies that there is a social component within an organization that affects the overall functioning of the system. What indicator would demonstrate to the nurse manager that the social needs of an organization are being met? a. Most employees from the organization attend an annual holiday celebration. b. Separate eating areas for each discipline are set up in the cafeteria. c. Nurse managers are planning to move to a centralized area away from the care units. d. The summer softball teams are canceled due to lack of interest.

ANS: A Systems theory focuses on the needs and desires of people who work in the organization.

Good attendance at a work-sponsored function indicates that staff enjoy interacting and are meeting social and relationship roles. Separating disciplines does not foster a sense of team.

Moving administration away from staff limits interaction and informal conversations that build trust. Lack of participation in sponsored events such as a softball team indicates that staff relationships are not stroNng, and a social component is not being achieved within the work environment.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A hospital organization is working to improve a feeling of being valued and respected among all staff members. Which action by administration would reinforce the feeling of being valued? a. Create professional pathways that require advanced education for any advancement of staff. b. Seek staff input when planning a remodeling project of patient rooms. c. Form committees that consist of upper management to plan organizational goals. d. Consistently schedule required staff meetings at the same time each month.

ANS: B Including staff at all levels of an organization in planning and projects demonstrates respect for the intelligence and creativity of the individual. Requiring advanced education for any advancement limits those with barriers to attending additional schooling; advancement should be available in a variety of ways to show the value of the individual. Committees that only consist of upper management cause a feeling of disconnect between staff and administration. Scheduling meetings at the same time does not consider those who work shifts and either have to come in on their day off or must disrupt sleep to attend.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A quality improvement committee is reviewing discharge surveys. Results show that patients and their families have difficulty finding departments and areas of the hospital.

What action by the committee would best address this concern for the organization? a. Continue to review future surveys to monitor the situation. b. Give additional training to the receptionists and switchboard personnel to give better directions. c. Form a multidisciplinary committee to identify options to help travel through the hospital. d. Send a work order to the maintenance department requesting that brighter lights be installed.

ANS: C Successful organizations respect the input of all disciplines when searching for solutions for problems. Continuing to gather data delays solving a problem. There is no indication that verbal directions will solve the problem; additional measures may be required. Merely providing additional light may not solve the problem—multi-language signs or even remodeling may be identified by the committee as being needed.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse manager finds an unsigned note reporting that patient care standards are not consistently being followed. Within the organizational structure, what is the best action for N the manager? a. Schedule a staff meeting to ask staff who left the note. b. Send an email reminder that all staff need to review the policy and procedure book. c. Wait for a staff member to come forward who is willing to be identified. d. Form a small group to explore why staff are not comfortable reporting errors.

ANS: D There are significant problems in an organization where staff are not willing to openly discuss problems, especially problems that affect patient care. A focus group can help identify what is preventing a sense of comfort to reveal problems. Scheduling a meeting is unlikely to have the person admit to complaining about care provided by coworkers in front of coworkers. A request to review policies and procedures is so broad the staff will not be able to identify a specific problem that needs to be corrected. Unless organizational changes are made, it is unlikely that staff will decide to come forward when they would not do so in the first place.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A hospital is experiencing a drop in patient admissions, resulting in the implementation of a hiring freeze. What is a potential critical consequence of this internal organizational decision? a. A decrease in the availability of future nurses to hire b. A savings of salaries and benefits

c. Increased scholarships to nursing students from the local high school d. Increased cross-training of current staff ANS: A In an economic climate where hospitals are not hiring, nursing schools may limit enrollment which will limit the availability of future nurses available to be hired when the current nurses retire or reduce their hours. Salary savings is minimal as the number of patients, staffing, and revenue are closely aligned. Scholarships will decrease as hiring commitments to scholarship holders will no longer be in effect. Cross-training may occur, but it is not a critical consequence of a hiring freeze.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A hospital organization is applying for Magnet© status to show excellence in nursing practice. What components would indicate that the hospital is meeting Magnet© principles?

(Select all that apply.) a. The education budget for nursing has been cut to provide for new laboratory equipment. b. On average, 40% of new nurses are leaving within 1 year of hire. c. Nurses are active participants on all major hospital committees. d. Quality improvement projects are planned and evaluated by nurses. e. Patient care outcome data are reported in the annual executive board meeting.

N ANS: C, D To gain Magnet© status, an organization must show that nurses are active participants in the organization administrative structure, fully involved in quality improvement projects, and are recognized as a valuable resource.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 58: Health Care Economics Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. What do the economics of health care include? a. Medicare and Medicaid dollars b. Patients’ rights c. Equal distribution of health care d. Nurse salaries ANS: C The economics of health care include the equal distribution of healthcare services so everyone may be served when services are needed. Medicare and Medicaid, patients’ rights, and nurse salaries do not factor into the economics of health care; they are only parts of the healthcare system.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A student asks the instructor about healthcare economics. The instructor knows the student understands when the student makes which statement? a. “The elderly population uses most of the healthcare services.” b. “Everyone should have health insurance to obtain services.” c. “Healthcare dollars should be partitioned by the government.” d. “Resources will be needeN d to serve healthcare issues.”

ANS: D Every healthcare issue needs resources to bring it to fruition. Without the resources, the healthcare issue would not be served. The elderly are a large part of the population, but that does not change the economics of health care. Everyone does not have health insurance so that statement would not enter into healthcare economics. Last, all health care dollars are not partitioned by the government; third party payers exist.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The U.S. healthcare system is different from that of other countries in which way? a. The United States charges money from the private sector only. b. U.S. health care is funded from private organizations. c. The U.S. healthcare system is not entirely government funded. d. The U.S. healthcare treats the older person first.

ANS: C

Other countries fund the healthcare system so that every citizen may have health care. In addition they provide the option that citizens may purchase private health care too. The United States has a combination of private companies and government agencies funding health care, so money is not coming from just the private sector. The older person in the population receives care according to the insurance coverage they have, but the care is not before anyone else.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. Which of the following statements is true about health care in the United States? a. The United States spends more money on health care than any other nation. b. The United States provides health care to every citizen. c. The United States relies on government funding to treat most citizens. d. The United States spends less money on pediatric care than other nations.

ANS: A The United States spends more money on health care than any other country. The United States does not provide health care to every citizen, nor does it rely entirely on government funding. The United States does not spend less money on pediatric care but usually more than other countries.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Two nurses are discussing managed healthcare organizations. The two nurses know which to be true about managed h eaNl t h care? a. Care is mostly provided by nurses. b. Prices for care are negotiated by the patient. c. Providers may encounter additional cost if care provided exceeds reimbursement. d. Patients can select any healthcare provider for treatment without additional costs.

ANS: C Managed healthcare organizations include both PPO (Preferred Provider Organizations) and HMO (Health Maintenance Organizations). Fees are determined by the insurance company with a provided listing of healthcare providers who are in-network. Delivery of care is physician based. Additional costs to the patient may be incurred if the patient decides to see an out-of-network healthcare provider. Providers are paid a preset reimbursement for each patient and may suffer losses if their cost exceeds this stipulated amount.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A student nurse is discussing Medicare coverage with the clinical instructor. The instructor knows the student understands Medicare when the student makes which statement(s)?

(Select all that apply.) a. Medicare covers all patients while they are in the hospital.

b. c. d. e.

Medicare is funded by the federal government.

Medicare is for persons 65 years old and older.

Medicare is partially funded by private third-party payers.

Medicare is for patients who are disabled and/or have end-stage renal disease.

ANS: B, C, E Medicare is funded by the federal government. It covers people who are 65 years old and older, disabled people, and patients who have end-stage renal disease. It does not cover all patients in the hospital, because some patients do not qualify for Medicare. It is not funded by third-party payers.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. An Accountable Care Organization (ACO) seeks to deliver which of the following aspects of health care? (Select all that apply.) a. Lessen Medicare payments b. Integrate care c. Enhance evidence-based practices d. Manage acute conditions e. Support hospice charges ANS: B, C ACOs work to integrate care, manage chronic conditions, and enhance the use of evidence-based practices. They do not have any involvement with Medicare payments, the management of acute conditions, or hospice care.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 59: Health Policy Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A definition of health policy includes which of the following elements? a. Funding for public education b. Appropriation of funds for roadwork c. Selection of congressional members of committees d. Public policy made to support health-related goals ANS: D Health policy is defined as public policy pertaining to health that is the result of an authoritative public decision-making process. Public education funding, appropriation of funding for roads, and selection of members of committees are not part of healthcare policy.

They are under a different funding arm of the government.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. Which branch of government is responsible for the execution of laws passed by legislatures? a. Legislative b. Judicial c. Executive d. Local

N

ANS: C The executive branch of federal and state governments is responsible for execution of laws passed. The legislative branch is responsible for passing laws. The judicial branch of government determines if rights are being upheld. Local governments are not considered a branch of the government.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. Which level of government is responsible for the regulation of a nurse’s license? a. Federal government b. State government c. Local government d. International coalition ANS: B State boards of nursing oversee the regulation of nursing practice. These agencies are established by legislatures to implement and enforce laws through a rule-making process.

Federal, local, and international coalitions are not correct, because they do not have control of the state boards of nursing.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

4. Which of the following components are included in health policy at the state level? a. Americans with Disabilities Act of 1990 b. Scope of nursing practice c. Health Insurance Portability and Accountability Act (HIPAA) of 1996 d. Patient Safety and Quality Improvement Act of 2005 ANS: B The scope of nursing practice is correct, because it is controlled at the state level by state boards of nursing. The Americans with Disabilities Act of 1990, the HIPAA of 1996, and the Patient Safety and Quality Improvement Act of 2005 are all regulated at the national level.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Which of the following is the intent of HIPAA? a. Release patient information for purposes of insurance reimbursement. b. Prevent healthcare providers from billing for procedures done for the insured person. c. Protect patients from reviewing their own medical records. d. Limit the ability of healthcare providers to sell patient information to outside sources.

ANS: D The intent of HIPAA is to protect patient information and prevent it from being sold to outside agencies. The right ofNheath care providers to bill for services is necessary for patient payment and is not prohibited. Patients have the right to view their own patient information.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. Nurses can be health advocates in which of the following ways? (Select all that apply.) a. Supporting their professional nursing organization when discussing upcoming legislation b. Discussing the upcoming classes with a neighbor c. Rallying for coverage for childhood immunizations d. Arranging for a patient to meet with case management for home health care e. Discussing a patient they are concerned about with a fellow student in the public cafeteria ANS: A, C, D

Supporting a professional nursing organization, rallying for coverage for childhood immunizations, and arranging for a patient to meet with case management are examples of how nurses can be a positive influence on healthcare policy. Discussing an upcoming class with a neighbor is not effective because it could be determined to be negative. Talking about a patient in a public area is an example of inappropriate communication between healthcare workers and is a violation of patient confidentiality.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nursing student is preparing a care plan for an assigned patient. When accessing the electronic medical record, what is acceptable information to view? (Select all that apply.) a. Laboratory data of the assigned patient b. Admission diagnosis for a patient who is a former neighbor c. The patient’s age, date of birth, and gender d. The history and physical of the assigned patient e. A classmate’s brother’s chest x-ray report ANS: A, C, D The laboratory data, age, date of birth, gender, history, and physical of an assigned patient are necessary for identification and care of the patient so it is acceptable to view this information in the electronic medical record. The patient information in the medical record, whether electronic or print, is only to be viewed by those who have a legitimate role in the patient’s care. Viewing information on patients other than the assigned patient is not appropriate, because the student does not have a need to view the information for patient care. These are violations of patient privacy.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 60: Health Care Law Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The new nurse correctly defines a law when stating which information? a. “Law is a fundamental concept for healthcare professionals.” b. “Law’s rule is developed by the employee’s organization.” c. “Law’s rule is enacted by a government agency that defines what must be done in a given circumstance.” d. “Law is a mandate from the Joint Commission or other accrediting agency.”

ANS: C This is the correct definition of a law.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. Which of the following is true about healthcare legislation? a. The U.S. Constitution addresses healthcare law specifically to give the federal government the ability to license professionals and institutions. b. The power of the U.S. Constitution does not have a direct relationship to health care and reserves most of the power to the states. c. State laws are considered the highest source of healthcare law and trump the federal laws. d. The federal government aNsserts its power over healthcare legislation through the U.S. Constitution.

ANS: B The power of the U.S. Constitution does not have a direct relationship to health care and reserves most of the power to the states. The other statements are false. The U.S. Constitution does not address health care specifically. Either state or federal laws can be considered the highest source of law depending on which law has the stricter regulation or rule.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. Which is an example of the regulatory power to make law? a. Joint Commission establishing a medication reconciliation standard b. Centers for Disease Control and Prevention (CDC) developing recommendations for childhood immunizations c. Institute of Medicine (IOM) defining the approximate number of medication errors that result in significant patient harm or death d. Centers for Medicare and Medicaid Services (CMS) enacting rules for restraint and seclusion for participating hospitals ANS: D

The Centers for Medicare and Medicaid Services (CMS) enacting rules for restraint and seclusion for participating hospitals refers to the enactment of law, while the other answers discuss the development of standards and recommendations that do not have the authority of law. There are some healthcare rules that may define expected behavior, but if these rules were not created by a government entity with legal authority, then they are not healthcare laws.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. What is one of the major attributes of healthcare law? a. It defines the expected behavior of persons in the business of health care. b. The law or rule is easy to interpret and comply with. c. It is established by any healthcare authority. d. The creator must be an expert in health care.

ANS: A A healthcare law or rule defines expected behavior of persons in the business of health care or in healthcare relationships. Healthcare law is not easy to interpret or comply with and can only be established by organizations with legal authority for law making. Creators of healthcare law are often not experts in health care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. The Board of Nursing (BON) is reviewing a nurse’s practice based on a reported violation of the Nurse Practice Act. W hNa t action can the BON take if the complaint is found to be unsupported? a. Censure the nurse. b. Assess a penalty in the form of monetary cost. c. Reinstate the nurse’s license. d. Dismiss the complaint.

ANS: D The Board of Nursing (BON) in each state defines and interprets the Nurse Practice Act. The BON is responsible for investigating and providing actions based on complaints and/or violations of the Nurse Practice Act. If the BON finds that the complaint is not supported by evidence, then the complaint will be dismissed with no disciplinary action taken. Actions allowable by the BON with a supported complaint and/or violation range from censure, talking additional courses, paying a fine/penalty, probation, suspension, and revocation to denial of licensure.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. Which of the following is an example of a nurse violating the Health Insurance Portability and Accountability Act (HIPAA) of 1996? a. The nurse asks the unit clerk to look up lab values for her relative recently admitted to the hospital. b. A group of fellow employees are discussing a patient’s clinical status in a public

place. The nurse manager requests that they step into private room to complete the discussion. c. After entering the progress notes on a patient’s electronic medical record, the nurse logs off the computer to allow her coworker to use the terminal. d. As a family approaches the nursing desk, the nurse removes the patient census sheet from view on the counter.

ANS: A When the nurse asks the unit clerk to look up lab values for her relative recently admitted to the hospital, the nurse is accessing protected health information not required for the nurse to perform his or her job. This is a violation of privacy even if it is a relative. The other choices are all actions that are consistent with protecting a patient’s privacy right as defined by HIPAA. OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. In which of the following answers is the hospital in compliance with the Consolidated Omnibus Budget Reconciliation Act and Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA)? a. The emergency department staff asks a patient to stay in the waiting room until the patients with insurance are treated. b. The emergency registration personnel explain to a patient that they must have proper identification to receive treatment. c. A patient with chest pain is triaged directly to a room for evaluation and registration information is obtained after the patient is stabilized. d. The emergency departmeN nt physician discharges and instructs a patient who is actively suicidal to go to the neighborhood facility that has psychiatric services.

ANS: C EMTALA requires that any hospital that operates an emergency department and receives Medicare funds provide an appropriate screening exam to anyone who presented and stabilize any emergency medical condition prior to transfer to another facility. The other choices are in conflict with EMTALA because a medical screening exam must be provided without consideration of the patient’s insurance, whether the patient has identification, or the facility’s services.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

8. Which of the following is false regarding state licensure laws? a. These laws establish the requirements for licensure to practice. b. Licensure is not necessary if the individual has completed training. c. The state regulatory agencies such as the state board of nursing are responsible for creating and enforcing these rules. d. The scope of practice defines what the professional can and cannot do within the scope of their licensure.

ANS: B

Licensure is required to practice after the completion of all required training for the profession. The state laws establish the requirements to practice and the state regulatory agencies are responsible for creating and enforcing the rules. The scope of practice defines what activities the professional is legally authorized to perform.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

9. The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b. identifies a need for physical therapy. c. is a developmental screening tool. d. provides a framework for health teaching.

ANS: C The Denver II is the most commonly used measure of developmental status used by healthcare professionals; it is a screening tool. Screening tools do not provide a diagnosis.

Diagnosis requires a thorough neurodevelopment history and physical examination.

Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

10. To plan early intervention a n Nd care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b. autism. c. attention-deficit/hyperactivity disorder (ADHD). d. failure to thrive.

ANS: D Failure to thrive is also a physical development exemplar. Cerebral palsy is an exemplar of motor/developmental delay. Autism is an exemplar of social/emotional developmental delay. ADHD is an exemplar of a cognitive disorder.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

11. To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition.

ANS: C

Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes); hence determination of development would be the focus of preventive interventions. Environment is considered to significantly affect development. Nutrition is considered to significantly affect development.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

12. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychological evaluation. The nurse’s best initial response is to a. refer the child to a psychologist immediately. b. explain that playing make believe is normal at this age. c. complete a developmental screening using a validated tool. d. separate the child from the mother to get more information.

ANS: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time.

OBJ:

NCLEX Client NeedsNCategory: Health Promotion and Maintenance

13. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. b. rebel against rules. c. regress because of stress. d. want to know everything.

ANS: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors.

An adolescent may want to “know everything” with their logical thinking and deductive reasoning, but that would not explain why they would act like a child.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

Concept 02: Functional Ability Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is assessing a patient’s functional ability. Which patient best demonstrates the definition of functional ability? a. Considers self as a healthy individual; uses cane for stability b. College educated; travels frequently; can balance a checkbook c. Works out daily, reads well, cooks, and cleans house on the weekends d. Healthy individual, volunteers at church, works part time, takes care of family and house ANS: D Functional ability refers to the individual’s ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, healthy individual, church volunteer, part time worker, and the patient who takes care of the family and house fully meets the criteria for functional ability.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. The nurse is assessing a patient’s functional performance. What assessment parameters will be most important in this assessment? a. Continence assessment, gait assessment, feeding assessment, dressing assessment, N transfer assessment b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Health and well-being, amount of community volunteer time, working outside the home, and ability to care for family and house ANS: A Functional impairment, disability, or handicap refers to varying degrees of an individual’s inability to perform the tasks required to complete normal life activities without assistance.

Height, weight, BMI, and vital signs are part of a physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient’s functional ability. What question would be the most appropriate? a. “Are you able to shop for yourself?” b. “Do you use a cane, walker, or wheelchair to ambulate?” c. “Do you know what today’s date is?” d. “Were you sad or depressed more than once in the last 3 days?”

ANS: B

“Do you use a cane, walker, or wheelchair to ambulate?” will assist the nurse in determining the patient’s ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient? a. Eating and drinking, personal cleansing and dressing, working and playing b. Toileting, transferring, dressing, and bathing activities c. Sleeping, expressing sexuality, socializing with peers d. Maintaining a safe environment, breathing, maintaining temperature ANS: D The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service after left knee replacement. Which tool is the best for the nurse to utilize? N a. Minimum Data Set (MDS) b. Functional Status Scale (FSS) c. 24-Hour Functional Ability Questionnaire (24hFAQ) d. The Edmonton Functional Assessment Tool ANS: C The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is assessing a patient’s functional abilities and asks the patient, “How would you rate your ability to prepare a balanced meal?” “How would you rate your ability to balance a checkbook?” “How would you rate your ability to keep track of your appointments?” Which tool would be indicated for the best results of this patient’s perception of their abilities? a. Functional Activities Questionnaire (FAQ) b. Mini Mental Status Exam (MMSE) c. 24hFAQ d. Performance-based functional measurement ANS: A

The FAQ is an example of a self-report tool which provides information about the patient’s perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is used to assess functional ability in postoperative patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient’s risk for falls so that falls prevention can be implemented if necessary.

Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence ANS: B, D, E, F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Taking meNdications to treat hypertension that may lead to hypotension and dizziness is a fall risk. Dizziness does contribute to falls.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Concept 03: Family Dynamics Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions and lack of family support for a patient would be to a. enforce hospital visiting policies. b. monitor the dysfunctional interactions. c. notify the primary care provider. d. role model appropriate support.

ANS: D Nurses can, at times, role model more appropriate interactions or provide suggestions for improving communication and interactions among family members. If the nurse determines that the number of visitors has a negative impact on the patient, hospital policy may be to limit visitors, but that would not be the initial action. Monitoring the dysfunctional interactions would not be an adequate response. The primary care provider should certainly be notified, but that would not be the initial response.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. The nurse caring for a patient would identify a need for additional interventions related to family dynamics when a. extended family offers to help. b. family members express cNoncern. c. the ill member demands attention. d. memories are shared.

ANS: C It is not uncommon for the ill family member to become demanding and indicate that they deserve special treatment and care, and the supportive family may need assistance in understanding the dynamics of the illness in order to continue to be supportive. Offers from extended family to help can be indicative of positive dynamics. Concern expressed by family members can be indicative of positive dynamics. Sharing of family memories can be indicative of positive dynamics.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. Two women have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of a baby. The nurse identifies them as which type of family? a. Cohabiting b. Nuclear c. Same-sex d. Single parent ANS: C

This family would be considered a same-sex family. Cohabiting refers to a couple who live together with no legal bond. Nuclear refers to the traditional male and female core family with one or more children. Single parent refers to a family with one adult and one or more children.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. The nurse identifies the family with a child graduating from college as having which effect on the family life cycle? a. Minimal impact b. Considered to be a negative impact on the family unit c. Leads to role confusion d. Expectation of role change ANS: D The family life cycle developmental theory focuses on the growth and development of changes in role relationships during transitional periods. A child graduating from college is an example of a transition which requires a role change. As this is a transition, one would expect to see a change so minimal impact would not be expected. Graduation does not imply that it will be a negative change on the family life cycle or lead to role confusion.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of which aspect of the family?

N a. Development b. Function c. Political views d. Structure ANS: C An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nurse is planning to assess the structure of a family. Which question should the nurse ask? a. “Who lives with you in this home?” b. “Who does the grocery shopping?” c. “Who provides support in your family?” d. “How old are the members of your family?”

ANS: A

The structure of the family includes who is in the family and what their relationship is.

“Who does the shopping?” would provide information about family functioning. “Who provides support?” would provide information about family functioning. “How old are the members?” would provide information about family development.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. Which factors which would alert the nurse to negative/dysfunctional family dynamics? a. Aging of family members b. Chronic illness of a family member c. Disability of a family member d. Intimate partner violence ANS: D Intimate partner violence is an exemplar of negative/dysfunctional family dynamics. Aging of family members is an exemplar of changes to family dynamics. Chronic illness of a family member is an exemplar of changes to family dynamics. Disability of a family member is an exemplar of changes to family dynamics.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 04: Culture Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for an older Chinese adult male who is grimacing and appears restless after abdominal surgery. What is the nurse’s best action? a. Ask the patient if he is anxious about his hospital stay. b. Ask a translator to conduct a FACES pain scale assessment. c. Ask the patient about pain and assess vital signs. d. Ask the patient about any history of depression or anxiety.

ANS: C In the Chinese culture, elderly Chinese people believe that they must be stoic about pain and there is a stigma about talking about any mental health problems. The nurse should ask the patient about pain and also assess vital signs for physiological signs of pain, since the patient may not admit to any pain. Assuming the patient is depressed or anxious is not the best action when considering individual cultural differences and the risk of pain after major surgery. The registered nurse should never delegate assessment to any unlicensed member of the healthcare team such as a translator. The translator may assist with communication, but the nurse is responsible for the pain assessment.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. Understanding cultural differN ences in health care is important because it will help the nurse to understand the manner in which people decide on obtaining treatments and medical care.

In independent cultures an individual will a. put himself first. b. consult family members for advice. c. ask for a second opinion. d. travel great distances to receive the best care.

ANS: A In independent cultures, an individual will put himself first in the case of a life-threatening illness, whereas even in dire circumstances, members of collectivist cultures may still consult other family members for the best course of action. In independent cultures, an individual will not consult with other family members, ask for a second opinion, or travel great distances to receive the best care.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the patient nodding yes to everything that is being said. With a better understanding of cultural interdependence in self-concept, a nurse should immediately a. write everything down for the patient to refer to later. b. prompt further to elicit additional questions or concerns. c. call the recognized elder for this patient. d. call the oldest male relative for help with decision making.

ANS: B When a nurse provides nutritional education to a patient who is from a culture that values greater power distance, it might appear that the patient is willing to accept all that the nurse suggests, when further prompting would elicit additional questions or concerns. The patient from a collectivist culture will usually consult family members for a best course of action. It is not acceptable for nurses to take it upon themselves to call the recognized elder or oldest male relative for help with decision making. While writing everything down may be OK for some cultures, with Asian patients it may be best to prompt further to elicit additional questions or concerns.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. Women who are given the job of caretaker for aging relatives are subject to caregiver strain due to a. feminine attributes. b. unequal gender. c. fixed gender roles. d. female inequality.

ANS: C In cultures with more fixed gender roles, women are usually given the role of caretaker for aging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers to harmonious relationships, modesty, and taking care of others. Unequal gender refers to roles of males and females being unevenly distributed. Female inequality refers to female gender and roles being less than or unequal to male roles.

N OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. A 60-year-old Italian immigrant presents for an annual physical. He is counseled about diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and pneumococcal vaccination. His reply is “If it ain’t broke, don’t try to fix it.” When developing a plan of care, the nurse should consider which cultural orientation for this patient? a. Short term b. Long term c. Leisurely term d. Noncommittal ANS: A Short-term cultural orientation focuses on the present or past and emphasizes quick results.

Long-term cultural orientation focuses the future and long-term rewards.

Long-term-oriented cultures favor thrift, perseverance, and adopting to changing circumstances. Leisurely term and noncommittal are undefined in cultural orientation.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. The emphasis on understanding cultural influence on health care is important because of a. disability entitlements. b. HIPAA requirements.

c. increasing global diversity. d. litigious society.

ANS: C Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. What interrelated constructs facilitate a nurse to become culturally competent? a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge b. Cultural desire, self-awareness, cultural knowledge, and cultural identity c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity d. Cultural desire, self-awareness, cultural knowledge, and cultural skill ANS: D The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and histoNrical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

Concept 05: Spirituality Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is assessing a patient's spirituality and observes the patient meditating before any treatments. What is the nurse’s best action? a. Document that the patient is not religious. b. Offer the patient a copy of the Bible to read. c. Arrange for quiet time for the patient as needed. d. Limit the time patient can meditate before procedures.

ANS: C The nurse can best promote the patient’s spirituality practices by arranging for the patient to be left alone when possible to meditate. Meditation is an exemplar of spirituality, not necessarily of the Christian faith. The Bible is most often read by believers in the Christian faith. Meditation does not imply that the patient is not religious. Time for meditation should not be limited, whenever possible.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Health Promotion and Maintenance 2. When conducting a spiritual assessment of a hospitalized patient, the nurse should remain aware of which potential barrier to effective communication? a. Clarifying the meaning of a patient’s statement. b. Multi-tasking while talkinNg to the patient. c. Listening to patients’ complete statements. d. Discussing patient’s feelings while hospitalized.

ANS: B Several barriers may result in the nurse’s inability to be totally present and communicate effectively with the patient. First, the nurse may be distracted by other things and may not pay attention to the patient. Multi-tasking while trying to listen to a patient may be a barrier to effective communication. Second, the nurse may miss the meaning of the patient’s message because of failure to clarify the meaning of a word, a phrase, or a facial expression.

Third, the nurse may interject personal feelings and reactions into the patient’s situation rather than allow the patient to explore and discuss his own feelings and reactions. The last barrier occurs when the nurse is busy formulating a response while the patient is still talking. In this instance, the nurse never hears the patient’s message.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity 3. A patient uses rosary beads and attends mass once a week. This expression of spirituality is best described with which term? a. Religiosity b. Faith c. Belief d. Authenticity

ANS: A There are a few similar and related terms to spirituality worth mentioning to provide distinction and clarification. Faith, as defined by Dyess, refers to an “evolving pattern of believing, that grounds and guides authentic living and gives meaning in the present moment of inter-relating.” Religiosity, another similar term, is an external expression (public or private), in the form of practicing a belief or faith, whereas spirituality is an internalized spiritual identity (or experiential). Specifically, religiosity is defined as “the adherence to religious dogma or creed, the expression of moral beliefs, and/or the participation in organized or individual worship, or sacred practices.”

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity 4. When developing a plan of care, the nurse should consider which attribute of the concept of spirituality? a. Spirituality is not a well-known universal concept. b. Chronic versus acute illnesses affect spirituality. c. Convincing patients to pray is a priority intervention. d. Referrals may be needed to spiritual counselors.

ANS: D The attributes of the concept of spirituality in the context of nursing care are described below.

• Spirituality is universal. All individuals, even those who profess no religious belief, are driven to derive meaning and purpose from life.

• Illness impacts spirituNality in a variety of ways. Some patients and families will draw closer to God or however they conceive that higher Power to be in an effort to seek support, healing, and comfort. Others may blame and feel anger toward that Higher Power for any illness and misfortune that may have befallen a loved one or their entire family. Still others will be neutral in their spiritual reactions.

• There has to be willingness on the part of patient and/or family to share and/or act on spiritual beliefs and practices.

• The nurse needs to be aware that specific spiritual beliefs and practices are impacted by family and culture.

• The nurse needs to be willing to assess the concept of spirituality in patients and families and based on this ongoing assessment to integrate the spiritual beliefs of patients and families into care.

• The nurse needs to be willing to refer the patient or family to a Spiritual Expert i.e., a Minister, Priest, Rabbi, an Imam.

• Community-based religious organizations can provide supportive care to families and patients and nurses need to be aware of these resources.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity MULTIPLE RESPONSE

1. When completing the FICA tool for spiritual assessment, which questions should the nurse ask the patient? (Select all that apply.) a. What things do you believe in that give meaning to life? b. Are you connected with a faith center in your community? c. How has your illness affected your personal beliefs? d. When was the last time you have been to church? e. What can I do for you?

ANS: A, B, C, E The FICA tool for spiritual assessment stands for Faith or beliefs, Importance and influence, Community, and Address. “When was the last time you have been to church?” is not a question included in the FICA assessment. The patient may attend community activities, besides church, that foster his/her spiritual well-being.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. Which are true statements about the definition of spirituality in nursing? (Select all that apply.) a. Patient’s quality of life, health, and sense of wholeness are affected by spirituality. b. An exact definition was developed and adopted in the late 1980s. c. Encompasses principle, an experience, attitudes, and belief regarding God d. Head knowledge affects spirituality more than heart knowledge. e. Mind, body, spirit, love, and caring are interconnected.

ANS: A, C, E The concept of Spirituality is an elusive concept to define. Authors who write about spirituality in nursing advocaNte the position that a patient’s quality of life, health, and sense of wholeness are affected by spirituality, yet still the profession of nursing struggles to define it. Why? There are a number of explanations for this. One explanation is that spirituality represents “heart” not “head” knowledge and “heart” knowledge is difficult to encapsulate into words. A second explanation is that spirituality is unique to each person so a precise definition is somewhat elusive. The definitions of spirituality encompass the following: a principle, an experience, attitudes and belief regarding God, a sense of God, the inner person. Most descriptions of spirituality include not only transcendence but also the connection of mind, body, and spirit, plus love, caring, and compassion and a relationship with the Divine.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Health Promotion and Maintenance 3. Which life events should the nurse recognize as being spiritually life changing? (Select all that apply.) a. Births b. Weddings c. Medical diagnoses d. Career day to day job duties e. Loss of independence ANS: A, B, C, E

The meaning and significance of the event might only be experienced by one individual; others who might be participants in the event might be left virtually untouched and unchanged. These life changing spiritual events include just about any occurrence that has intense and personal relevance to those involved in the event. Examples of spiritually life changing events include births, deaths, weddings, divorces, illnesses, diagnoses, and loss of abilities, loss of independence, death and so many more. These events, having the power to change individuals and families, also have the power to draw people toward the transcendent—for many people that transcendent is known as God but this is not universal.

Day-to-day activities are not the best examples of spiritually life changing events.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity

N

Concept 06: Adherence Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? a. The patient will select the type of learning materials they prefer. b. The patient will verbalize an understanding of the importance of following the regimen. c. The patient will demonstrate coping skills needed to manage hypertension. d. The patient will verbalize the side effects of treatment.

ANS: A Adults learn best when given information they can understand that is tailored to their learning styles and needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. After the nurse implements a teaching plan for a newly diagnosed patient with hypertension, the patient can explain the information but fails to take the medications as prescribed. What is the nurse’s next action? a. Reeducate the patient, be N c ause learning did not occur because the patient’s behavior did not change. b. Assess the patient’s perception and attitude toward the risks associated with not taking their anti-hypertensives. c. Take full responsibility for helping the patient make dietary changes. d. Ask the provider to prescribe a different medication, because the patient does not want to take this medication.

ANS: B Although the patient behavior has not changed, the patient’s ability to explain the information indicates that learning has occurred. The nurse would need to ask what the patient’s perceptions are of taking the medications to determine if the patient understands the ramifications of not taking the medication. The patient may be in the contemplation or preparation state (see Health Belief Model). The nurse should reinforce the need for change and continue to provide information and assistance with planning for change.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. A diabetic patient presents to the diabetes clinic with A1c levels of 7.5%. The nurse has met this patient for the first time. When applying principles of Theory of Planned Behavior (TPB), which teaching strategy by the nurse is most likely to be effective? a. Provide information on the importance of blood glucose control in maintenance of long-term health and evaluate how the patient has been following the prescribed regime.

b. Establish a rapport with the patient by complimenting them on what they did correctly, and ask what strategies they have tried thus far. c. Refer the patient to a certified diabetic educator, because the educator is an expert on management of diabetes complications. d. Have the patient explain what medications they are on and what diet they should be following.

ANS: B Principles of a TPB indicate that the patient will need to establish a good rapport with the nurse in order to talk about nonadherence. If the patient finds it difficult to discuss their diabetes self-management and adherence with the nurse, the patient may not open up to the nurse. Although a referral to an educator is a good idea, it would be better to use this resource as a follow-up for this visit. Having the patient verbalize medications and diet is not part of the TPB method.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. The nurse is assessing a newly diagnosed diabetic, and the patient’s readiness to learn about glucose monitoring. Before planning teaching activities, which approach would be most effective? a. Assist the patient with long-term goals and plan teaching according to these goals. b. Provide the patient with all the latest research from the Internet on glucose monitoring. c. Refer the patient to the diabetic specialist who can assist the patient with the glucometer. d. Assist the patient in developing realistic short-term goals.

N

ANS: D Concordance reflects development of an alliance with patients based on realistic expectations. Providing the patient with the research will not help with the practical skill of using the glucometer. Long-term goals are useful; however, the goals need to be immediate with a newly diagnosed patient learning a new skill. Referring the patient would be useful if the patient has not been able to grasp the concept after several attempts.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse is developing a care plan for a patient who has low motivation and nonadherence with blood glucose monitoring. Which statement by the patient would indicate to the nurse that the patient is not motivated and will most likely not comply? a. “I do not like to test my sugar, but I do it because my wife nags me.” b. “I forget to check my sugar once in a while.” c. “I don’t see or feel any different when I do keep my blood sugars under control.” d. “I have no idea what the signs of low blood sugar are.”

ANS: C If patients do not perceive any benefit from changing their behavior, sustaining the change becomes very difficult. Having someone remind the patient is more likely to reinforce compliance. Forgetting to check glucose occasionally may indicate the patient needs memory cues or joggers. The patient who does not know the signs of low glucose will need further teaching.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is preparing a discharge teaching plan for a patient who has peripheral vascular disease and has poor circulation to the feet. Which learning goal should the nurse include in the teaching plan? a. The nurse will demonstrate the proper technique for trimming toenails. b. The patient will understand the rationale for proper foot care after instruction. c. The nurse will instruct the patient on appropriate foot care before discharge. d. The patient will post reminder stickers on the calendar to check feet every day and record scheduled appointments with podiatrist.

ANS: D To improve the patient adherence to treatment, it will be important to help them develop reminder strategies that fit into their lifestyle. Options A and C describe actions that the nurse will take, rather than behaviors that indicate that patient learning has occurred. Option B is too vague and nonspecific to measure whether learning has occurred.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. A patient with hypertension is prescribed a low-sodium diet. The patient’s teaching plan includes this goal: “The patient will select a 2-gram sodium diet from the hospital menu for the next 3 days.” Which intervention would be most effective at increasing the patient’s compliance with the diet? a. Check the sodium content of the patient’s menu choices over the next 3 days. b. Ask the patient to identify which foods on the hospital menus are high in sodium. c. Have the patient list favo N r ite foods that are high in sodium and foods that could be substituted for these favorites. d. Compare the patient’s sodium intake over the next 3 days with the sodium intake before the teaching was implemented.

ANS: C Including a patient’s favorite foods will most likely increase compliance, because the patient is not being deprived. Checking the sodium will be useful for teaching strategies but will not be the most effective means of increasing adherence.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 8. The nurse is evaluating the need to refer a patient with osteoarthritis for a home care visit to be sure the patient can function in accomplishing daily activities independently. What is the nurse’s first priority? a. Determine if the patient has had home visits before and if the experience was positive. b. Check the patient’s ability to bathe without any assistance the next day. c. Have the patient demonstrate the learned skills at the end of the teaching session. d. Arrange a physical therapy visit before the patient is discharged from the hospital.

ANS: A

To begin the assessment of adherence, it is first important to clarify with the patient (a) their beliefs and perceptions about their health risk status, (b) their existing knowledge about cardiovascular disease risk reduction, (c) any prior experience with healthcare professionals, and (d) their degree of confidence with controlling the disease. The other actions allow evaluation of the patient’s short-term response to teaching.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

9. A 73-year-old male patient is seen in the home setting for a routine physical. The nurse notes which behavior as the most reassuring sign that the patient has been following the treatment plan for the diagnoses of hypertension, diabetes, and hyperlipidemia? a. The patient has a list of glucose readings for the past 10 days. b. The patient has a list of medications along with newly refilled meds. c. The patient has a list of all foods and beverages for a 3-day period. d. The patient verbalizes the side effects of all his medications.

ANS: B Confirming how often a patient renews or refills his/her prescriptions is a measurement of the patient’s persistence with continuation of the treatment. Having a list of glucose readings or verbalizing side effects does not necessarily mean that the patient is compliant unless the readings were all normal, which is not indicated. Listing foods may not indicate the patient is following the treatment plan.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

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Concept 07: Self-Management Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is developing a plan of care for a newly diagnosed hypertensive patient who is being discharged on medications and given the Dietary Approaches to Stop Hypertension (DASH) diet to follow. What statement by the patient signals to the nurse that the patient is motivated to learn? a. “I am sure the medications will help to bring down my blood pressure.” b. “I can’t wait to try the new recipes, and I’m hopeful I will lose weight.” c. “Do I really need to follow the diet and take medications?” d. “I have my parents to blame for this. They both have high blood pressure.”

ANS: B A patient who is motivated will see what the benefits of following the teaching will do for them and will most likely be able to manage their own care. The patient who believes medications are the only solution may not be motivated to follow the prescribed diet.

Blaming the parents for their condition does not show accountability or motivation for change.

OBJ: NCLEX Client Needs Category: Physiological Integrity | NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is assessing a patient’s readiness to be discharged and ability to manage care at home. What is the most approNpriate question for the nurse to ask to determine the patient’s learning needs before planning teaching activities? a. “What are your hobbies and occupation?” b. “What do you need to know before you go home from the hospital?” c. “Do you have any cultural or religious beliefs that you would like incorporated into your plan of care?” d. “What were your grades and learning style when you were in school?”

ANS: B Motivation and readiness to learn depend on what the patient values. The other questions are also important but do not address what information interests the patient most at present and will assist the patient in managing his own care.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. Which acute medical event should the nurse identify as requiring self-management when planning care for a patient? a. Prenatal care b. Depression c. Diabetes d. Femur fracture ANS: D

A femur fracture is considered an acute medical event. Pregnancy is an expected and normal life event/condition. Depression and diabetes are considered disease states.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. An 8-year-old child is newly diagnosed with asthma. Which nursing intervention best promotes self-efficacy for the parents to help the child follow the prescribed treatments? a. Ask parents to list all possible triggers for asthma. b. Request a spacer for the metered dose inhaler. c. Suggest the parents enforce a strict exercise regimen. d. Recommend replacing carpeting in the home with wood flooring.

ANS: B The most realistic and helpful interventions will promote self-management. A spacer is helpful for children learning to use inhaled medication. Listing all the triggers for asthma may be overwhelming. The parents should focus on the individual triggers for the child.

Enforcing a strict exercise regimen is restrictive and will not promote self-management.

Environmental changes must be feasible and cost-effective. Replacing carpeting is optimal but may not be affordable.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. When developing a plan of care to promote self-management, which patient is least likely to be affected by depression? a. A 55-year-old employed female b. A 35-year-old Hispanic male c. A 40 year old with 5th grN ade education d. A 42 year old with private insurance ANS: D Individuals most affected by depression are midlife adults ages 45–64, women, minorities, individuals without a high school education, and individuals without health insurance.

Treatment for depression includes the use of medication and psychological therapy.

Additionally, patients must learn to manage moods including suicidal thoughts, recognize triggers and relapse, and set goals for behavioral management of their disease.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is assisting an older adult patient, diagnosed with type 2 diabetes, with self-injection of insulin. What is the most appropriate intervention for this patient at discharge? a. Arrange daily home visits for injections. b. Request an insulin pen prescription. c. Recommend upper arm injection sites. d. Supply patient with 100 unit insulin syringes.

ANS: B

An insulin pen will be the most effective method for injection for an older adult secondary to reduced eyesight and dexterity compared to using syringes. A 100 unit syringe has very small calibration marks and numbers, making it more difficult for older adults to see the appropriate doses. Daily home visits are not usually paid for by insurance. Most patients must learn to administer medications themselves. The upper arm subcutaneous site is too difficult for self-administration and may not be feasible for an older adult.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. The nurse is developing a teaching plan for a patient diagnosed with congestive heart failure. Which are the most appropriate teaching points to include that will assist in self-management of the disease? (Select all that apply.) a. Side effects of medications b. Activity restrictions c. Daily weights d. Increased sodium intake e. Blood pressure monitoring ANS: A, B, C, E Congestive heart failure (CHF) is one of the most common complications of coronary artery disease in which the heart fails to pump efficiently enough to meet the metabolic demands of the body. Fluid overload is a common complication. As with most chronic conditions, patients with CHF benefit from education about their disease and self-managing diet, physical activity, weight, andNmedication adherence. Fluid retention occurs with increased sodium intake; therefore sodium is usually restricted in a congestive heart failure diet.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

Concept 08: Fluid and Electrolytes Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which physician order should the nurse question? a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr b. Furosemide (Lasix) 20 mg PO now c. Oxygen via face mask at 8 L/min d. KCl 20 mEq PO two times per day ANS: A A patient with decompensated heart failure has extracellular fluid volume (ECV) excess.

The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to t hNe physician? a. Swollen ankles in patient with compensated heart failure b. Positive Chvostek sign in patient with acute pancreatitis c. Dry mucous membranes in patient taking a new diuretic d. Constipation in patient who has advanced breast cancer ANS: B Positive Chvostek sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek sign.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it.

Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a. Weight gain of 2 pounds since last week b. Dry mucous membranes and skin tenting c. Urine output 8 mL/hr

d. Blood pressure 98/58 ANS: C Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. An overnight weight gain indicates a fluid gain.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a. Vomiting all day and not replacing any fluid b. Tumor that secretes excessive antidiuretic hormone (ADH) c. Tumor that secretes excessive aldosterone d. Tumor that destroyed the posterior pituitary gland ANS: B ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia.

The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.

OBJ:

NCLEX Client NeedsNCategory: Physiological Integrity: Reduction of Risk Potential

5. The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a. Development of ankle or sacral edema b. Increased skin tenting and dry mouth c. Postural hypotension and tachycardia d. Decreased level of consciousness ANS: D Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a. Severe hemorrhage b. Diabetes insipidus c. Oliguric renal disease d. Adrenal insufficiency

ANS: C When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. The patient’s laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the priority nursing intervention? a. Raise bed side rails due to potential decreased level of consciousness and confusion. b. Examine sacral area and patient’s heels for skin breakdown due to potential edema. c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

ANS: D Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

N

1. The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all that apply.) a. Bilateral ankle edema b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau sign e. Flat neck veins when upright f. Decreased patellar reflexes ANS: B, C, D Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient?

(Select all that apply.) a. Test for skin tenting. b. Measure rate and character of pulse. c. Measure postural blood pressure and heart rate. d. Check Trousseau sign. e. Observe for flatness of neck veins when upright. f. Observe for flatness of neck veins when supine.

ANS: A, B, F ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

Concept 09: Acid–Base Balance Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse’s teaching about the acid-base imbalance has been effective? a. “To prevent another problem, I should eat less sodium during diarrhea.” b. “My blood became too acid because I lost some base in the diarrhea fluid.” c. “Diarrhea removes fluid from the body, so I should drink more ice water.” d. “I should try to slow my breathing so my acids and bases will be balanced.”

ANS: B Diarrhea causes metabolic acidosis through loss of bicarbonate, which is a base. Eating less sodium during diarrhea increases the risk of ECV deficit. Although diarrhea does remove fluid from the body, it also removes sodium and bicarbonate which need to be replaced.

Rapid deep respirations are the compensatory mechanism for metabolic acidosis and should be encouraged rather than stopped.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see? a. pH high, PaCO2 high, HCO3– high b. pH low, PaCO2 low, HCO3– low O 3 – high c. pH low, PaCO2 high, HCN d. pH low, PaCO2 high, HCO3– normal ANS: C Type B COPD is a chronic disease that causes impaired excretion of carbonic acid, thus causing respiratory acidosis, with PaCO2 high and pH low. This chronic disease exists long enough for some renal compensation to occur, manifested by high HCO3–. Answers that include low or normal bicarbonate are not correct, because the renal compensation for respiratory acidosis involves excretion of more hydrogen ions than usual, with retention of bicarbonate in the blood. High pH occurs with alkalosis, not acidosis.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to perform in order to detect development of the highest risk acid-base imbalance? a. Urine output and color b. Level of consciousness c. Heart rate and blood pressure d. Lung sounds in lung bases ANS: B

Thyroid hormone increases metabolic rate, causing a patient with severe hyperthyroidism to have high risk of metabolic acidosis from increased production of metabolic acids.

Metabolic acidosis decreases level of consciousness. Changes in urine output, urine color, and lung sounds are not signs of metabolic acidosis. Although metabolic acidosis often causes tachycardia, many other factors influence heart rate and blood pressure, including thyroid hormone.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. The nurse is making a home visit to a child who has a chronic disease. Which finding has the most implication for acid-base aspects of this patient’s care? a. Urine output is very small today. b. Whites of the eyes appear more yellow. c. Skin around the mouth is very chapped. d. Skin is sweaty under three blankets.

ANS: A Oliguria decreases the excretion of metabolic acids and is a risk factor for metabolic acidosis. Jaundice requires follow-up but is not an acid-base problem. Perioral chapped skin needs intervention but is not an acid-base issue. With three blankets, diaphoresis is not unusual.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first? a. “Is there a place that I canNdispose of my unused morphine pills?” b. “I want to lose at least 20 pounds without getting sick this time.” c. “I think I have asthma because I cough when dogs are near.” d. “I ran out of money and am cutting my insulin dose in half.”

ANS: D Decreasing an insulin dose by half creates high risk of diabetic ketoacidosis, and this patient has the highest priority. The other patients have less priority due to lower risk situations with longer time course before development of an acid-base imbalance. The coughing when dogs are near is not a sign of a severe asthma episode that causes respiratory acidosis, although this patient does need attention after the insulin situation is handled. Disposing of morphine properly helps prevent respiratory acidosis from opioid overdose. Guidance regarding weight loss helps prevent starvation ketoacidosis.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Management: Management of Care MULTIPLE RESPONSE 1. The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.) a. Skin pale and cold b. Tingling of fingertips

c. Heart rate of 102 d. Numbness around mouth e. Cramping in feet ANS: B, D, E Hyperventilation is a risk factor for respiratory alkalosis. Respiratory alkalosis can cause perioral and digital paresthesias and pedal spasms. Pallor, cold skin, and tachycardia are characteristic of activation of the sympathetic nervous system, not respiratory alkalosis.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 2. Which statements said by patients indicate that the nurse’s teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.) a. “Baking soda is an effective and inexpensive antacid.” b. “I should take my insulin on time every day.” c. “My aspirin is on a high shelf away from children.” d. “I have reliable transportation to dialysis sessions.” e. “Fasting is a great way to lose weight rapidly.”

ANS: B, C, D Taking insulin as prescribed helps prevent diabetic ketoacidosis. Safeguarding aspirin from children prevents metabolic acidosis from increased acid intake. Regular dialysis reduces the risk of metabolic acidosis from decreased renal excretion of metabolic acid. Baking soda is sodium bicarbonate and should not be used as an antacid due to the risk of metabolic alkalosis. Fasting without carbohydrate intake is a risk factor for starvation ketoacidosis.

OBJ:

NCLEX Client NeedsNCategory: Health Promotion and Maintenance

Concept 10: Thermoregulation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Which newborn should the nursery nurse identify as being at significant risk for hypothermic alteration in thermoregulation? a. Large for gestational age b. Low birth weight c. Born at term d. Well nourished ANS: B Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well-nourished infant is not at significant risk.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about the temperature. What is the nurse’s best response? a. Older people have a diminished ability to regulate body temperature because of active sweat glands. b. Older people have a diminished ability to regulate body temperature because of N increased circulation. c. Older people have a diminished ability to regulate body temperature because of peripheral vasoconstriction. d. Older people have a diminished ability to regulate body temperature because of slower metabolic rates.

ANS: D Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older adults have reduced circulation.

The body conserves heat through peripheral vasoconstriction, and older adults have a decreased vasoconstrictive response, which impacts ability to respond to temperature changes.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates which assessment finding? a. Decreased respirations b. Low pulse rate c. Red, sweaty skin d. Slow capillary refill ANS: C

With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. What is the priority nursing action for a patient suspected to be hypothermic? a. Assess vital signs. b. Hydrate with intravenous (IV) fluids. c. Provide a warm blanket. d. Remove wet clothes.

ANS: D The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. Which strategies should the nurse include in a community program for senior citizens related to dealing with cold winter temperatures? a. Avoiding hot beverages b. Shopping at an indoor mall c. Using a fan at low speed d. Walking slowly in the p a N rk ANS: B Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is recommended to conserve body temperature.

Physical activity can increase body temperature, and if the senior is going to walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a. Impaired cognition b. Occupational exposure c. Physical agility d. Temperature extremes ANS: C

Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation? a. Oral thermometer b. Rectal thermometer c. Temporal thermometer scan d. Tympanic membrane sensor ANS: B The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

8. Which similar exemplar should the nurse consider when planning care for a patient with hypothermia?

N a. Heat exhaustion b. Heat stroke c. Infection d. Prematurity ANS: D Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

In Stage 1 (N1 or Non-REM Stage 1), referred to as light sleep, the individual can be awakened easily. In this stage, brain waves slow and, on EEG, the slower wave pattern known as alpha waves appears. The individual at this point is likely to drift in and out of sleep and can be awakened easily. Sensations known as hypnagogic hallucinations can occur during this stage. A common sensation of this type is the feeling of falling.

Uncontrolled muscle jerks sometimes occur at this stage along with sudden movements that can startle the individual and restore wakefulness.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

4. The nurse must awaken a patient from Stage 4 non-rapid eye movement sleep in order to prepare the patient for a procedure. The patient is disoriented. What is the nurse’s best action? a. Notify the healthcare provider. b. Re-assess the patient’s orientation. c. Administer an anti-anxiety medication. d. Cancel the patient’s procedure.

ANS: B Stage 3 (N3) and Stage 4 (N4) are the periods of deep sleep. N3 is characterized by very slow brain waves called delta waves interspersed with smaller, faster waves. In Stage 4 (N4), the EEG shows almost exclusively delta waves. In this type of sleep it is difficult to awaken the individual and muscle activity is very limited or may be completely absent. A person awakened from Stage 3 or 4 of sleep could be disoriented for a brief period of time before regaining awareness.

OBJ:

NCLEX Client NeedsNCategory: Physiological Integrity: Basic Care and Comfort

5. A patient complains of not being able to fall asleep at night and asks the nurse if there is a safe, non-prescription medication he can try. After consulting the healthcare provider, the nurse should recommend which naturally occurring hormone? a. Melatonin b. Cortisol c. Luteinizing hormone d. Estrogen ANS: A A rise in the hormone melatonin at the onset of sleep helps to promote and maintain sleep, and a drop in levels leads to eventual awakening. The immune system is enhanced as well during sleep as proteins associated with fighting illness are produced. The circadian rhythm, or the typical 24 hour (more or less) cycle through which the body passes, including both awake and sleep cycles, is responsible for regulating all of the physiologic processes in the body. An adequate amount and quality of sleep, therefore, is essential to all of the regulatory mechanisms that take place in the body.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

6. A mother tells the nurse she is concerned because her 8-month-old infant sleeps all day and night and is only awake about 2–3 hours per day. What is the nurse’s best response? a. “This sleep pattern is very normal for an infant at this age.”

b. “Adding an additional feeding will keep the child awake more.” c. “I recommend that you notify the child’s pediatrician.” d. “Be sure you are laying the child on his back to sleep at night.”

ANS: C By approximately 6 months of age, the infant should sleep through the night with at least one nap during the day. 2–3 hours of wakefulness per day is not an expected finding at age 8 months and should be reported to the pediatrician to determine the underlying cause. An additional feeding may be warranted; however the pediatrician should be notified first.

Lying on infant on the back to sleep is recommended to prevent sudden infant death syndrome; however the priority concern is the length of time the child is sleeping.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. The nurse is caring for a child with tonsillar enlargement. What is the nurse’s priority concern? a. Low oxygen saturation b. Daytime fatigue c. Increased temperature d. Antibiotic administration ANS: A Tonsillar enlargement in children often leads to obstructive sleep apnea which can cause decreased oxygen saturation levels. Low oxygen is a priority concern which carries the highest safety risk to the child. Obstructive sleep apnea occurs in an estimated 1–3% of children, though the causative factors may differ with tonsillar enlargement being a significant component in chilNdren. Infection that leads to an increased temperature and requires antibiotic therapy is a concern, but the priority health concern is low oxygen levels.

Obstructive sleep apnea can interfere with sleep patterns and lead to daytime fatigue, but the highest priority of care is low oxygen.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is caring for a patient who received a recent bone marrow transplant. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a. Mucositis b. Confusion c. Depression d. Mild temperature elevation ANS: D The earliest sign of infection in an immunosuppressed patient can be a mild fever.

Mucositis, confusion, and depression are possible clinical manifestations but are representative of less life-threatening complications.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? a. Being a woman b. Family history of hypertension c. Cigarette smoking as a teenager d. Advancing age ANS: D Aging is a non-modifiable risk factor for the development of cancer with an associated increase seen with aging. In terms of gender and age, lifetime risk is higher for males than females. Family history of c oN- morbidities such as hypertension is not directly correlated with cancer development. Cigarette smoking as a teenager for the patient is a risk factor but may have mitigated impact at this point in time based on the patient’s stated age and length of time as a non-smoker.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. In caring for a patient admitted with lung cancer, which of the following should the nurse expect to find on assessment? a. No use of accessory muscles during respirations b. Orthostatic hypotension upon change of positioning c. Clear sputum d. Weight loss compared to last admission ANS: D Common signs/symptoms of lung cancer include coughing, hemoptysis, and weight loss, shortness of breath and chest pain. The nurse should expect to see weight loss and altered breathing patterns. Clear sputum and orthostatic blood pressure changes would not be seen.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A female patient complains of a “scab that just won’t heal” under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What is the nurse’s best action?

a. Continue to conduct a symptom analysis to better understand the patient’s symptoms and concerns. b. End the appointment and tell the patient to use skin protection during sun exposure. c. Suggest further testing with a cancer specialist and provide the appropriate literature. d. Tell her to put a bandage on the scab and set a follow-up appointment in 1 week.

ANS: A A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague. The nurse should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

8. A patient with prostate cancer is taking hormonal therapy to control tumor growth. He reports that his left calf is swollen and painful. Which of the following would be the nurse’s best action? a. Instruct the patient to keep the leg elevated. b. Measure the calf circumference and compare the measurement with the right calf circumference measurement. c. Apply ice to the calf after a 10-minute massage of the area. d. Document assessment findings as an expected response with estrogen therapy.

ANS: B N A nurse should be aware of potential complications from hormonal therapy such as the development of thrombus formation. Massaging a calf that is swollen and painful is never correct, because this action might break a clot, causing formation of an embolus, which could then travel to the lungs.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

9. A patient being evaluated for breast cancer is not certain whether she and her family should participate in a genetic screening plan since no one can guarantee the results. What is the nurse’s best response? a. “If you have a family history of breast cancer, the chances for you to have this type of cancer increases.” b. “The decision is up to you in the final analysis.” c. “If there is no family history, then there is no need to go through the process.” d. “If your insurance will pay for the screening, then there is no associated risk.”

ANS: A

Individuals with a family history of breast cancer (especially 1st degree relatives) are at increased risk for disease occurrence. The nurse should inform the patient of the outcome measures of the screening plan. The nurse should not dissuade the patient from the process based on stating there is no family history, as there is no evidence that an adequate family history has been obtained. Similarly, to correlate the need for genetic testing with insurance and no implied risk cannot be stated equivocally. Although the decision is up to the patient in the final analysis, that response does not address relevant information about the purpose of genetic screening.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

10. A nurse is reviewing assessment findings for a female patient admitted to the oncology unit.

Which finding should alert the nurse to contact the physician? a. Blood pressure 130/88 b. Noticeable difference in circumference of lower legs c. Presence of goiter previously identified on prior admission d. Negative guaiac test ANS: B Examination findings relative to oncology patients and neoplastic growth manifest as visible lesions, physical asymmetry, palpable masses, abnormal sounds or the presence of blood on screening tests. A blood pressure of 130/88 is within normal range as is a negative guaiac test. Observation of a previous goiter which is consistent with a prior admission is not a concern. The detection of physical asymmetry as seen by a difference in circumference should be reported to the physician.

OBJ:

NCLEX Client NeedsNCategory: Physiological Integrity: Physiological Adaptation

Concept 13: Intracranial Regulation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient with increased intracranial pressure (ICP). Which action would be considered to be a collaborative intervention? a. Decreasing perfusion b. Administering an osmotic diuretic c. Assessing orientation d. Assessing for edema ANS: B Collaborative interventions are aimed at preventing secondary injury by improving cerebral perfusion. This would include decreasing edema by administering an osmotic diuretic which in turn would lead to decreased ICP and improved oxygenation. Assessing orientation and for the presence of edema would not be considered as a collaborative intervention.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation? a. Change in level of consciousness b. Inability to focus visually c. Loss of primitive reflexes N d. Unequal pupil size ANS: A A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refer to those reflexes found in a normal infant that disappear with maturation.

These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS. OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. When caring for a patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings? a. Hypertension and bradycardia b. Hypertension and tachycardia c. Hypotension and bradycardia d. Hypotension and tachycardia ANS: A

Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushing triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. Which components of the Glasgow Coma Scale (GCS) should the nurse use to assess a patient after a head injury? a. Blood pressure b. Cranial nerve function c. Head circumference d. Verbal responsiveness ANS: D Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale.

Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N 5. The nurse is teaching a patient about head injuries. Which information should the nurse include as a primary prevention strategy to reduce the occurrence of head injuries? a. Blood pressure control b. Smoking cessation c. Maintaining a healthy weight d. Violence prevention ANS: D Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.

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NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse preparing to care for a patient after a suspected stroke would question which order? a. Antihypertensive b. Antipyretic c. Osmotic diuretic d. Sedative

ANS: A Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure.

Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand.

Long-acting sedatives would be avoided to provide times for periodic neurologic assessments.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. After shunt procedure, the nurse would monitor the patient’s neurologic status by using which test? a. Electroencephalogram b. Glasgow Coma Scale c. National Institutes of Health Stroke Scale d. Monro-Kellie doctrine ANS: B The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This scale is an example of one type of specific tool for nurses to use when assessing a patient following stroke. The Monroe-Kellie doctrine is not an assessment or monitoring strategy; it describes the interrelationship of volume and compliance of the three cranial components, brain tissue, cerebral spinal f lNui d, and blood.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 14: Hormonal Regulation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient presents to the emergency room complaining of vomiting with severe back and leg pain. The patient’s home medications include daily oral corticosteroids. Vital signs reveal a low blood pressure and there are peaked T waves on the electrocardiogram. What is the nurse’s priority intervention? a. Start an intravenous line b. Collect urine specimen c. Administer antiemetic d. Administer narcotic analgesia ANS: A The patient is exhibiting signs of adrenal insufficiency (Addison disease) given the regular use of corticosteroids. Cortisone, hydrocortisone (Cortef), prednisone, and fludrocortisone (Florinef) are used for the treatment of adrenocorticoid deficiency. Treatment of Addisonian crisis includes administration of hydrocortisone, saline solution, and sugar (dextrose) to correct the insufficiency. The priority intervention is to start an intravenous line so that appropriate treatments may be administered. A urine specimen may be collected but is not the priority intervention. Since the patient is vomiting, administration of antiemetics or analgesia would be given through an intravenous line. The nurse should also assess for changes in the level of consciousness; so administration of analgesia may be contraindicated if any decrease in level of consciousness occurs.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. Which important teaching point should the nurse include in the plan of care for a patient diagnosed with Cushing disease? a. Daily weight using same scale b. Wash hands frequently c. Use exfoliating soaps when bathing d. Avoid yearly influenza vaccine ANS: B Cushing syndrome is characterized by chronic excess glucocorticoid (cortisol) secretion from the adrenal cortex. This is caused by the hypothalamus, or the anterior pituitary gland, or the adrenal cortex. Cushing syndrome can also be caused by taking corticosteroids in the form of medication (such as prednisone) over time—referred to as exogenous Cushing syndrome. Regardless of the cause, excess secretion of cortisol has a systemic affect affecting immunity, metabolism, and fat distribution (truncal obesity), reduced muscle mass, loss of bone density, hypertension, fragility to microvasculature, as well as thinning of the skin. Washing hands is important because the patient’s immune system is suppressed due to the excess glucocorticoid level. Daily weights are not indicated. Exfoliating soaps may damage thin skin. The patient should receive vaccinations due to being immunocompromised.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse is caring for a patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What is the nurse’s best action? a. Encourage increased fluid and water intake b. Teach about risk for malignancies c. Monitor for changes in level of consciousness d. Assess labwork for potassium level changes ANS: C As the name suggests, SIADH is a condition in which antidiuretic hormone (ADH) is secreted despite normal or low plasma osmolarity, resulting in water retention and dilutional hyponatremia. In response to increased plasma volume, aldosterone secretion increases and further contributes to sodium loss. Hyponatremia frequently manifests with changes in level of consciousness from confusion to coma. A large number of clinical conditions can cause SIADH including malignancies, pulmonary disorders, injury to the brain, and certain pharmacologic agents. Malignancies often lead to SIADH versus SIADH causing malignant conditions. Water intoxication can lead to hyponatremia, therefore water intake is restricted.

The most affected electrolyte from SIADH is sodium versus potassium.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. Following a parathyroidectomy, which electrolyte should the nurse most closely monitor? a. Potassium b. Sodium c. Magnesium d. Calcium

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ANS: D Because the parathyroids are located on the thyroid gland, similar concerns for postoperative monitoring apply. Additionally, calcium levels are monitored to avoid hypocalcemic crisis.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. Radioactive iodine is indicated for the treatment of hyperthyroidism. Which item should the nurse include in the plan of care? a. Isolation is required for 6–8 weeks. b. Continued thyroid monitoring is required. c. Thyroid replacement therapy is prescribed. d. An overnight hospital stay is required.

ANS: B Radioactive iodine (RAI) is indicated for the treatment of hyperthyroidism. It is given as an oral preparation, usually as a single dose on an outpatient basis. The radioactive iodine makes its way to the thyroid gland where it destroys some of the cells that produce thyroid hormone. The RAI is completely eliminated from the body after about 4 weeks. The extent of thyroid cell destruction is variable, thus the patient has ongoing monitoring of thyroid function. If thyroid production remains too high a second dose may be needed. The goal of this procedure is to destroy thyroid hormone producing cells; additional thyroid hormone is not prescribed.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The nurse is caring for a patient who has undergone a thyroidectomy. Which patient complaint is highest priority requiring further evaluation? a. Pain at surgical site b. Thirst c. Hoarseness d. Nausea ANS: C Thyroidectomy involves a surgical incision in the anterior neck. Hoarseness may be a sign of airway edema. A patent airway is always a priority of care for any post-operative patient.

General anesthesia is used for this surgery requiring insertion of an artificial airway, therefore throat irritation and thirst is expected. Nausea may be a side effect from anesthesia. Pain is expected at the surgical site.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. Which statement made by a student nurse indicates the need for additional teaching about pituitary insufficiency? a. “Synthetic human growth hormone may be prescribed for children who are small for gestational age.” b. “Testosterone supplements may be prescribed for women with gonadotropin deficiency.” c. “Estrogen is known to regulate the action of growth hormone in men and women.” d. “Chronic kidney disease tNreatment may include synthetic growth hormone replacement.”

ANS: B Synthetic human growth hormone (HGH) is used for growth hormone deficiencies caused by pituitary insufficiency, as well as other conditions such as Turner syndrome, chronic kidney disease, and children small for gestation age. Testosterone is used as supplement for men with gonadotropin deficiency. Estrogen and progesterone supplements, also referred to as hormone replacement therapy (HRT), are indicated for women with gonadotropin deficiency and for the relief of post-menopausal symptoms. Estrogen is also known to regulate secretion and action of GH in men and women.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end-stage renal disease. Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be filtered into the urine.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. What is the nurse’s best response about developing diabetes to the patient whose father has type 1 diabetes mellitus? a. “You have a greater susceptibility for development of the disease because of your family history.” b. “Your risk is the same as the general population, because there is no genetic risk for development of type 1 diabetes.” c. “Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore the risk for becoming diabetic is 50%.” d. “Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual development of the disease. However, your brothers will become diabetic.”

ANS: A Even though type 1 diabetes does not follow a specific genetic pattern of inheritance, those with one parent with type 1 diabetes are at an increased risk for development of the disease.

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NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse recognizes which pNatient as having the greatest risk for undiagnosed diabetes mellitus? a. Young white man b. Middle-aged African-American man c. Young African-American woman d. Middle-aged Native American woman ANS: D The highest incidence of diabetes in the United States occurs in Native Americans. With age, the incidence of diabetes increases in all races and ethnic groups.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? a. Decreased hunger sensation b. Report of no urine output c. Increased respiratory rate d. Decreased thirst ANS: C

Ketoacidosis decreases the pH of the blood, stimulating the respiratory control area of the brain to buffer the effects of the increasing acidosis. The rate and depth of respirations are increased (Kussmaul respirations) to excrete more acids by exhalation. Usually polydipsia (increased thirst), polyphagia (increased hunger), and polyuria (increased urine output) are seen with hyperglycemia and ketoacidosis.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) a. Tremors b. Nervousness c. Extreme thirst d. Flushed skin e. Profuse perspiration f. Constricted pupils ANS: A, B, E When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.

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NCLEX Client NeedsNCategory: Physiological Integrity: Physiological Adaptation

A low sodium diet will prevent water retention which could increase blood pressure.

Patients with hypertension would not be on a regular diet due to sodium content. A pureed diet is indicated for stroke patients who may have impaired swallowing. A low sugar diet is indicated for patients with diabetes.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

4. During a nutritional assessment, the nurse calculates that a female patient’s BMI is 27. The nurse would advise the patient to follow which of these recommendations? a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. b. This measurement indicates that the patient is underweight and will need to take measures to gain weight. c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery. d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.

ANS: A A BMI of 25–29.9 is in the overweight range. A BMI of <18.5 is in the underweight range.

A BMI of 30–34.9 is obesity class I, a BMI of 35–39.9 is obesity class II, and a BMI of >40 is obesity class III (morbid obesity). A BMI of 19–24 is in the normal range.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a Nquick screening tool to assess dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall ANS: D A 24-hour recall is useful as a quick screening tool to assess dietary intake. A food diary provides detailed information, but it is not convenient and requires a follow-up visit. A calorie count requires several days to collect data and requires a trained dietician to analyze the results. A comprehensive diet history may provide more accurate reflection of nutrient intake, but it is time-consuming to acquire and requires a trained/skilled dietary interviewer.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

6. During a physical examination, the nurse notes that the patient’s skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein ANS: C

Dry and scaly skin is a manifestation of essential fatty acid deficiency. Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae. Vitamin B deficiency is too large a category to consider. Specific categories of vitamin B deficiency have been identified, such as pyridoxine and thiamine. Protein deficiency causes decreased pigmentation and lackluster hair.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. During a physical examination, the nurse notes that the patient’s skin is dry and flaking.

What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves and numbness and tingling in extremities d. Fissures and inflammation of the mouth ANS: A Hair loss (alopecia) and hair that is easily removed from the scalp (easy pluckability), like dry, flaking skin, is caused by essential fatty acid deficiency. Inflammation of the tongue (glossitis) and fissured tongue are manifestations of a niacin deficiency. Inflammation of peripheral nerves (neuropathy) and numbness and tingling in extremities (paresthesia) are manifestations of a thiamin deficiency. Fissures of the mouth (cheilosis) and inflammation of the mouth (stomatitis) are manifestations of a pyridoxine deficiency.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

N MULTIPLE RESPONSE 1. An African American is at an increased risk for which of the following? (Select all that apply.) a. Vitamin D deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome ANS: A, D, E, F Type 1 diabetes and celiac disease are more common in Northern European heritage.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

Concept 17: Elimination Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient who was diagnosed with senile dementia has become incontinent of urine. The patient’s daughter asks the nurse why this is happening. What is the nurse’s best response? a. “The patient is angry about the dementia diagnosis.” b. “The patient is losing sphincter control due to the dementia.” c. “The patient forgets where the bathroom is located due to the dementia.” d. “The patient wants to leave the hospital.”

ANS: B Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity: Physiological Adaptation 2. The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient’s elimination status. What is the nurse’s best action? a. Speak with the patient’s family about food choices. b. Establish a bowel and bladder program for the patient. c. Speak with the patient about past elimination habits. d. Establish a bedtime ritual for the patient.

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ANS: B Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

3. The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a. Large intestine b. Stomach c. Small intestine d. Pancreas ANS: C Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3–4 minutes. The patient asks the nurse why this is happening. What is the nurse’s best response? a. “Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel.” b. “Some people have a slower bowel than others, and this is nothing to be concerned about.” c. “The foods you eat contribute to peristalsis, so you should eat more fiber in your diet.” d. “Bowel peristalsis is slow because you are not walking. Get more exercise during the day.”

ANS: A Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. What is a primary prevention tool used for colon cancer screening? a. Abdominal x-rays b. Blood, urea, and nitrogen (BUN) testing c. Serum electrolytes d. Occult blood testing ANS: D Occult blood testing will reveNal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening.

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NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a. Increase fiber intake. b. Increase water consumption. c. Decrease physical exercise. d. Refrain from alcohol. e. Refrain from smoking.

ANS: A, B Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on the quality of bowel movements.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. When conducting a health history assessment, which information would be viewed as most important as related to the patient’s elimination status? (Select all that apply.) a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine c. Time of day patient defecates d. Discomfort or pain with elimination e. List of medications taken by patient f. Patient’s preferences for toileting ANS: A, B, D, E Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Personal preferences are not the most important data the nurse needs to collect.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

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Concept 18: Perfusion Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student makes which statement? a. “Central perfusion is monitored only by the physician.” b. “Central perfusion involves the entire body.” c. “Central perfusion is decreased with hypertension.” d. “Central perfusion is toxic to the cardiac system.”

ANS: B Central perfusion does involve the entire body as all organs are supplied with oxygen and vital nutrients. The physician does not control the body’s ability for perfusion. Central perfusion is not decreased with hypertension. Central perfusion is not toxic to the cardiac system.

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NCLEX Client Needs Category: Health Promotion and Maintenance

2. A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse’s best response? a. “Hypertension happens to everyone sooner or later. Don't be concerned about it.” b. “Hypertension can happen from eating a poor diet, so change what you are eating.” c. “Hypertension can happen from arterial changes that block the blood flow.” d. “Hypertension happens wNhen people do not exercise, so you should walk every day.”

ANS: C Hardening of the arteries from atherosclerosis can cause hypertension in the patient.

Hypertension does not happen to everyone. Changing the patient’s diet and exercising may be a positive life change, but these answers do not explain to the patient how the disease could have happened.

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NCLEX Client Needs Category: Health Promotion and Maintenance

3. The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse’s best response? a. “It stimulates the heart to beat in a normal rhythm.” b. “It protects the heart from atherosclerotic changes.” c. “It provides the heart with oxygenated blood.” d. “It protects the heart from infection.”

ANS: A The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with oxygenated blood.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? a. Mental alertness b. Perfusion c. Pain d. Reaction to medications ANS: B Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A patient’s serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? a. Tissue ischemia b. Brain malformations c. Intestinal blockage d. Cardiac dysrhythmia ANS: D Cardiac dysrhythmia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nurse is explaining the concept of perfusion to a student nurse. The nurse knows the student understands the concept of perfusion when the student makes which statement? a. “Perfusion is a normal function of the body, and I don't have to be concerned about it.” b. “Perfusion is monitored by the physician.” c. “Perfusion is monitored by vital signs and capillary refill.” d. “Perfusion varies as a person ages, so I would expect changes in the body.”

ANS: C The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

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NCLEX Client Needs Category: Health Promotion and Maintenance

7. The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a. Elevated blood pressure b. Bounding pedal pulses

c. Night blindness d. Reflux disease ANS: A Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes.

This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

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Concept 19: Gas Exchange Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange? a. Blood glucose of 350 mg/dL b. Anticoagulant therapy for 10 days c. Hemoglobin of 8.5 g/dL d. Heart rate of 100 beats/min and blood pressure of 100/60 ANS: C The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential | NCLEX Client Needs Category: Physiological Adaptation 2. The nurse is reviewing the patient’s arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b. Tachycardia and decreaseNd blood pressure c. Increased anxiety and irritability d. Hyperventilation and lethargy ANS: A The patient is experiencing respiratory acidosis (pH and PaCO2) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO 2.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem? a. Peripheral arterial disease of the lower extremities b. Chronic obstructive pulmonary disease (COPD) c. Chronic asthma d. Severe anemia secondary to chemotherapy ANS: A Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is assessing a patient’s differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient’s gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. Eosinophil count will assist to identify the presence of a respiratory infection. c. White cell count will differentiate types of respiratory bacteria. d. Level of neutrophils provides guidelines to monitor a chronic infection.

ANS: A Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patient’s gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? a. Chronic lung disease with increased carbon dioxide retention b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention c. Decreased cardiac output with increased serum lactic acid production d. Gastric drainage with increased removal of gastric acid ANS: A N Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen? a. Hemoglobin level of 8.0 b. Bronchoconstriction and mucus c. Peripheral arterial disease d. Decreased thoracic expansion ANS: A Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a. The infant is becoming more active. b. There is an increase in intake of breast milk or formula. c. The infant is unable to maintain an adequate iron intake. d. A depletion of fetal hemoglobin occurs.

ANS: D Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2–3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

8. Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a. Decreasing venous stasis and risk for pulmonary emboli b. Implementation of strict hand washing routines c. Maintaining current vaccination schedules d. Prevention of pneumonia in patients with chronic lung disease ANS: D Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation,Nimmunizations, and prevention of postoperative complications.

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NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. Endocrine system c. Pulmonary system d. Immune system e. Cardiovascular system f. Hepatic system ANS: A, C, E The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange.

The immune system primarily protects the body against infection.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. Oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.

ANS: B, E, F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

N

The cilia in the tubes are stimulated by high estrogen levels, which propel the ovum toward the uterus. Without estrogen, the ovum won’t reach the uterus. The results of a series of events occurring in the ovary cause an expulsion of the oocyte from the ovarian follicle known as ovulation. The ovarian cycle is driven by multiple important hormones: (1) gonadotropic hormone, (2) follicle-stimulating hormone (FSH), and (3) luteinizing hormone (LH). The cilia in the tubes are stimulated by high (4) estrogen levels, which propel the ovum toward the uterus. The zona pellucida (inner layer) and corona radiata (outer layer) form protective layers around the ovum. If an ovum is not fertilized within 24 hours of ovulation by a sperm, it is usually reabsorbed into a woman’s body. A patient who is hypoestrogenic would not have excess circulating estrogen. A patient with low estrogen would not be classified as hyperestrogenic. Without sufficient estrogen, there can be no fertilization of the ovum.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. An obstetric multipara with triplets is placed on bed rest at 24 weeks’ gestation. Her perinatologist is managing intrauterine growth restriction with serial ultrasounds. This prescribed treatment is an example of which type of care? a. Antenatal diagnostics b. Primary prevention c. Secondary prevention d. Tertiary prevention ANS: C An example of secondary prevention relating to reproductive health would be managing fetal intrauterine growth restriction by serial ultrasounds. This type of diagnostic maternal/fetal monitoring is pNerformed to determine the best time for delivery due to potential fetal nutritional, circulatory, or pulmonary compromise. A cesarean section (operative delivery) may be performed if maternal or fetal conditions indicate that delivery is necessary. Antenatal diagnostics refers to prior to pregnancy. An example of primary prevention is teaching a high school class about reproductive health. An example of tertiary prevention would be aimed at improving health following an illness and/or rehabilitation.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

7. A female patient comes to the clinic after missing one menstrual period. She lives in a house beneath electrical power lines which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest implication for this patient’s plan of care? a. Electrical power lines are a potential hazard to the woman and her fetus. b. Living near an oil field may mean the water supply is polluted. c. Alcohol exposure should be avoided during pregnancy due to teratogenicity. d. Eating sweets may cause gestational diabetes or miscarriage.

ANS: C

Stages of development include ovum, embryonic, and fetal. The beginning of the fourth week to the end of the eighth week comprise the embryonic period. Teratogenicity is a major concern because all external and internal structures are developing in the embryonic period. A pregnant woman should avoid exposure to all potential toxins during pregnancy, especially alcohol, tobacco, radiation, and infections during embryonic development. Living in a house beneath power lines is not the greatest implication in this patient’s plan of care as there are no definite risks to the developing fetus. Living near an oil field has no definite risks to the fetus. Eating sweets may contribute to maternal obesity, large for gestational age fetus, and maternal gestational diabetes but does not have the immediate implication of a daily beer drinker which can cause fetal alcohol syndrome.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

Based on the patient’s reported complaint and obstetrical history, it may be likely that the patient has a pelvic prolapse. Therefore, a vaginal exam would be indicated to help identify possible anatomical changes. There is no clinical data that supports a potential pelvic mass and inspection alone would not confirm this finding. Obtaining vital signs as well as a urine culture may be needed, but the focus should be on determination of physical findings related to the pelvic area.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. An adult patient comes for a well-check up to the primary care provider’s office. In completing the office admission form, the patient does not indicate gender on the form and seems somewhat agitated when providing the form back to the nurse. How should the nurse respond? a. Ask the patient to complete all of the information at this time. b. Ask the patient if you can assist with completing the form. c. The nurse should just indicate which gender she/he thinks is appropriate. d. Tell the patient that if the form is not completed, then the doctor will not see you.

ANS: B Gender identity is defined by the individual patient. The nurse should not designate this description or identity nor should the nurse tell the patient that if the form is not completed, that the patient will not be seen by the healthcare provider. Asking the patient to complete the information without acknowledging that the patient is exhibiting signs of distress is not therapeutic. The nurse should offer to provide assistance to the patient.

OBJ:

NCLEX Client Needs Category: Psychological Integrity

N 5. A nurse is working with a male patient being treated for erectile dysfunction. Which statement indicates that additional teaching is needed? a. “I like to go walking around my community each night after dinner.” b. “I have a few drinks during the week when I go out after work.” c. “I have maintained my weight for the past 5 years after losing 20 pounds.” d. “I monitor my blood pressure at home using a portable cuff.”

ANS: B Erectile dysfunction (ED) is a common problem affecting the male population and can be chronic or transient in nature. Alcohol use can affect ED, so the patient’s reported alcohol intake indicates that additional teaching is warranted. Exercise, maintaining a healthy weight and monitoring of blood pressure are examples of appropriate activities.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nursery nurse performing the first physical assessment of the newborn observes that there is no clear identification of genitalia as being either female or male. How should the nurse identify this newborn? a. Gender neutral b. Bisexual c. Observation of intersex d. Asexual

ANS: C Intersex represents a group of conditions where the external genitalia of an infant does not appear as either male or female and/or is not consistent with genetic sex or organs. The nurse cannot attribute sexual preference such as asexual or bisexual. Gender neutral does not apply to this clinical situation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A nurse working with a family whose child has recently told them that he identifies with the LGBTQ community asks the nurse to explain how this happened considering the fact that the child was raised as a male and played with appropriate toys. What is the best nursing response to the family’s concerns? a. Tell them that there is no need for concern for their child has shared this information with them. b. Ask the parents if they ever noticed something different about their son as he was growing up. c. Explain that sexual orientation changes can occur over time. d. Suggest that this behavior may be temporary.

ANS: C Sexual orientation and gender identification is now thought of as a fluid concept, with the term sexual fluidity being used to convey this meaning for individuals who identify with other than heterosexual relationships. The nurse should respond to the parent’s concerns and not minimize their reaction but rather let them know that it is the chosen response of their child. Relating the sexual orientation or gender identification to how one was raised indicates an implied bias. Telling the family that the behavior may be temporary is not N correct.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

Concept 22: Immunity Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient’s discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques c. The importance of wearing a face mask in public d. Limiting contact with the general population ANS: B The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes Nt ha t the child’s growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition? a. Primary immunodeficiency b. Secondary immunodeficiency c. Cancer d. Autoimmunity ANS: A Primary immunodeficiency is a risk for patients with two or more of the listed problems.

Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12–24 hours post operation dependent on which condition? a. His immune system is functioning properly. b. He is properly vaccinated. c. He has an infection. d. The suppressor T-cells in his body are activated.

ANS: A Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the body’s response to intentional tissue impairment. The redness and swelling at the incision site in the first 12–24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement? a. “My body will treat the new kidney like my original kidney.” b. “I will have to make sure that I avoid being around people.” c. “The medications that I take will help prevent my body from attacking my new kidney.” d. “My body will only have a problem with my new kidney if the donor is not directly related to me.”

ANS: C Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will n o Nt treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they don’t have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient’s respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition? a. Suppressed immune response b. Hyperimmune response c. Allergic reaction d. Anaphylactic reaction ANS: D

The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication.

These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA).

The nurse should explain which goal of treatment to the patient? a. Eradicate the disease b. Enhance immune response c. Control inflammation d. Manage pain ANS: C Medications for RA are intended to control the inflammation that results from the body’s hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response.

The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

N MULTIPLE RESPONSE 1. The parents of a newborn question the nurse about the need for vaccinations: “Why does our baby need all those shots? He’s so small, and they have to cause him pain.” The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) a. Are only required for infants b. Are part of primary prevention for system disorders c. Prevent the child from getting childhood diseases d. Help protect individuals and communities e. Are risk free f. Are recommended by the Centers for Disease Control and Prevention (CDC) ANS: B, D, F Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient won’t get the disease, but it decreases the potential to contract the illness. No medication is risk free.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

Concept 23: Inflammation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following? a. “The coating on these medications is irritating to my intestines.” b. “I need a more immediate response from my medications than can be obtained from enteric coated medications.” c. “Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue.” d. “I don’t need to use these medications because they cause diarrhea, and I have had enough trouble with diarrhea and rectal bleeding over the past weeks.”

ANS: C Enteric coatings on medications are designed to prevent breakdown and absorption of the medication until lower in the digestive tract, usually to prevent stomach irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with ulcerative colitis, the intestinal lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, enteric coated medications should be avoided. The coating is not irritating, but the medication can be. The response time of the medication is not a concern in this instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.

N

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. What is the nurse’s best response? a. “Use ice only when the ankle hurts.” b. “Ice should be applied for 15–20 minutes every 2–3 hours over the next 1–2 days.” c. “Wrap an ice pack around the injured ankle for the next 24–48 hours.” d. “Ice is not recommended for use on the sprain because it would inhibit the inflammatory response.”

ANS: B Ice is used on areas of injury during the first 24–48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2–3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. A patient is being treated with an antibiotic for an infected orthopedic injury. What explanation should the nurse give to the patient about this medication?

a. b. c. d.

“Antibiotics will decrease the pain at the site.”

“An antibiotic helps to kill the infection causing the inflammation.”

“An antibiotic inhibits cyclooxygenase, an enzyme in the body.”

“Antibiotics will reduce the patient’s fever.”

ANS: B Antimicrobials treat the underlying cause of the infection which leads to inflammation.

Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient’s wound. The nurse realizes what information about this fluid? a. Contains the materials used by the body in the initial inflammatory response b. Indicates that the patient has an infection at the site of the wound c. Is destroying healthy tissue d. Results from ineffective cleansing of the wound area ANS: A Exudate is fluid moved from the vascular spaces to the area around a wound. It contains the proteins, fluid, and white blood cells (WBCs) needed to contain possible pathogens at the site of injury. Exudate appears as part of all inflammatory responses and does not mean an infection is present. Exudate is part of normal inflammatory responses which contain self-monitoring mechanisms to help prevent damage to healthy tissue. Exudate appears at wound sites regardless of cleaNning done to the area of injury.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The nurse reviews the patient’s complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates what type of inflammatory response? a. Chronic b. Resolved c. Early stage acute d. Late stage acute ANS: C Elevated neutrophils and monocytes within normal limits are findings indicative of early inflammatory response. Neutrophils increase in just a few hours, while it takes the body days to increase the monocyte levels. Chronic inflammation results in varying elevations in WBCs dependent on multiple issues. Elevated neutrophils are not indicative of resolved inflammation. Elevations in monocytes occur later in the inflammatory response.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. What teaching should the nurse provide for this patient?

a. b. c. d.

“Don’t eat with the other students.”

“Avoid sharing razors and other personal items.”

“Have a complete blood count (CBC) checked monthly.”

“Disinfect showers and bathroom floors weekly after use.”

ANS: B Avoidance of sharing personal items like razors and hairbrushes can decrease the spread of pathogens that cause inflammation and infection. Not eating with the others in his college apartment won’t relieve or prevent the spread of infection. A CBC monthly will not treat or prevent inflammation. Showers should be disinfected before and after each use.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. The nurse assesses the patient and notes all of the following. Which of the findings indicates systemic manifestations of inflammation? (Select all that apply.) a. Oral temperature 38.6 C/101.5 F b. Thick, green nasal discharge c. Patient complaint of pain at 6 on a 0–10 scale on palpation of frontal and maxillary sinuses d. WBC 20 cells/McL  109/L e. Patient reports, “I’m tired all the time. I haven’t felt like myself in days.”

ANS: A, D, E Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise andNfatigue. Purulent exudates and pain are both considered local manifestations of inflammation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

hours d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours ANS: B The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A nurse is teaching a group of business people about disease transmission. The nurse knows that additional teaching is needed when one of the participants states which of the following? a. “When traveling outside of the country, I need to be sure that I receive appropriate vaccinations.” b. “Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has no resistance.” c. “If I don’t feel sick, then N I don’t have to worry about transmitted diseases.” d. “I need to be sure to have good hygiene practices when traveling in crowded planes and trains.”

ANS: C People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. In order to provide an intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide? a. Whether a patient has an infection. b. Where an infection is located. c. The type of cells that are being utilized by the body to attack an infection. d. The specific type of pathogen that is causing an infection.

ANS: D

People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.) a. Administration of protease inhibitors b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission d. Preventing visitors from entering the room e. Administration of intravenous fluids f. Strict monitoring of intake and output ANS: B, C, E, F Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the use of personal protectiveNequipment and teaching on methods to inhibit transmission to help break the chain of infection. Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of Clostridium difficile, because it causes diarrhea with fluid loss.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort | NCLEX Client Needs Category: Physiological Adaptation 2. Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a. Uninsured or underinsured status b. Easy access to health screenings c. High cost of medications d. Inadequate nutrition e. Mostly female gender ANS: A, C, D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection. Gender has not been shown to be an increased risk factor for infection in the lower socioeconomic population.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort |

NCLEX Client Needs Category: Psychosocial Integrity

N

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? a. “Patients must have a trapeze over the bed to move properly.” b. “Patients should move themselves in bed to prevent immobility.” c. “Patients should always have a two-person assist to move in bed.” d. “Patients must be moved correctly in bed to prevent shearing.”

ANS: D Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional if the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly. A patient may move himself or herself if he or she is able; but shearing may still occur.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement? a. “Patients with impaired bed mobility have an increased risk for pressure ulcers.” b. “Patients with impaired bed mobility like to have extra visitors.” c. “Patients with impaired bed mobility need to have a mechanical soft diet.” d. “Patients with impaired bed mobility are prone to constipation.”

N

ANS: A Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is instituted.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. What percentage of hip fractures is the result of falls? a. 50% b. 80% c. 90% d. 100% ANS: C About 90% of falls end with a hip fracture.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. The lack of weight bearing leads to what effects on the skeletal system? a. Demineralization, calcium loss b. Thickened bones c. Increased range of motion

d. Increased calcium deposition in the bones ANS: A Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium that strengthen it. Thickened bones will not occur with the lack of weight bearing. Range of motion may be decreased with a lack of weight bearing movements.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity.

The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevNent sunburn by replacing lost nutrients. d. Apply sunscreen 30 minutes prior to exposure.

ANS: D Wearing sunglasses and sunscreen are recommended by the National Cancer Institute.

Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for additional teaching? a. “I wear a hat and sit under the umbrella when not in the water.” b. “I don’t bother with sunscreen on overcast days.” c. “I use a sunscreen with the highest SPF number.” d. “I wear a UV shirt and limit exposure to the sun by covering up.”

ANS: B The sun’s rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism? a. Candida albicans b. Group A -hemolytic streptococci c. Staphylococcus aureus d. E. Coli ANS: C Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

8. A nurse is conducting community education classes on skin cancer. One participant says to the nurse: “I read that most melanomas occur on the face and arms in fair-skinned women.

Is this true?” How should the nurse respond? a. “That is not correct. Melanoma is more commonly found on the torso or the lower legs of women.” b. “That is correct, because the face and arms are exposed more often to the sun.” c. “That is not correct. Melanoma occurs on the top of the head in men but is rare in women.” d. “That is incorrect. Melanoma is most commonly seen in dark-skinned individuals.”

ANS: A Melanoma is more commonlyN found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

9. The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse’s teaching? a. Bathing and drying the skin vigorously to stimulate circulation b. Keeping the head of the bed elevated 30 degrees c. Limiting intake of fluid and offer frequent snacks d. Turning the patient at least every 2 hours ANS: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

10. A patient asks the nurse what the purpose of the Wood’s light is. Which response by the nurse is accurate? a. “We will put an anesthetic on your skin to prevent pain.” b. “The lamp can help detect skin cancers.” c. “Some patients feel a pressure-like sensation.” d. “It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions.”

ANS: D The Wood’s light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

your sense of smell.” b. “Notify your doctor immediately, because this is a concerning reaction to the medication.” c. “You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection.” d. “You should see an improvement in the next week or so. Call if this continues.”

ANS: D Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process.

Understanding of the instructions is evident when the daughter says which of the following? a. “I will make sure that dad always wears warm socks.” b. “Dad needs to wear his glasses so he can delay the onset of macular degeneration.” c. “I will ask the home health aide to carefully inspect dad’s feet every day when she helps him bathe.” d. “We will give him only warm foods, so that he doesn’t burn his mouth.”

ANS: C Diabetes increases risk of perNipheral neuropathy, and it is hard to inspect one’s own feet.

Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse’s best action to provide recreational activities during the rehabilitation phase? a. Place the television to the left or right of patient’s visual field. b. Encourage the patient to learn braille. c. Suggest use of talking books. d. Provide headphones for listening to music.

ANS: C Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the nurse’s priority action? a. Notify the physician. b. Document the finding in the records. c. Recheck the reflex after several hours. d. Monitor the eye movements and pupil reactions closely.

ANS: A The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? a. “I will take my child to the audiologist because he doesn’t seem to hear me except when I look directly at him.” b. “Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle.” c. “Making my child wear ear plugs when she goes to a rock concert may save her hearing!” d. “I see now why when my child has a cold, he complains about everything tasting blah!”

ANS: B Each person should always h Na v e their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

8. During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient’s wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure? a. Tympanoplasty b. Irrigation of the ear c. Pure tone test d. Otoscopic exam by a specialist ANS: B The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

Concept 28: Pain Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of what type of pain? a. Neuropathic pain b. Nociceptive pain c. Chronic pain d. Mixed pain syndrome ANS: B Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer.

Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A 19-year-old male has sustaN ined a transection of C-7 in a motor vehicle crash rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. What type of pain is this patient describing? a. Neuropathic pain b. Visceral pain c. Eudynic pain d. Nociceptive pain ANS: A Neuropathic pain results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Simply put, neuropathic pain is pathologic. Examples of neuropathic pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and post stroke pain syndrome. Patients with neuropathic pain use very distinctive words to describe their pain, such as “burning,” “sharp,” and “shooting.” Visceral pain arises from the body cavities and responds to stretching, swelling and decreased oxygen levels. Eudynic pain refers to the normal transmission of pain via nociceptive receptors. Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping or throbbing.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. Controlling pain is important to promoting wellness. Unrelieved pain has been associated with complication?

prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services ANS: B Mind-body therapies are designed to enhance the mind’s capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others.

Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the mind’s capacity to affect bodily function and symptoms.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. A 30-year-old male is admitted to the hospital with acute pancreatitis. He is in acute pain described as a 10/10, which is localized to the abdomen, periumbilical area, and some radiation to his back. The abdomen is grossly distended. He is restless and agitated, with elevated pulse and blood pressure. An appropriate pain management plan of care may include which medication(s)? a. IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen b. Norco 5/500 q 4 hours PO and Benadryl 25 mg PO q 6 hours c. Phenergan 25 mg IM q 6 hours d. Tylenol 325 mg q 6 hoursN ANS: A A variety of routes of administration are used to deliver analgesics. A principle of pain management is to use the oral route of administration whenever feasible. All of the first-line analgesics used to manage pain are available in short-acting and long-acting formulations.

For patients who have continuous pain, a long-acting analgesic, such as modified-release oral morphine, oxycodone, or hydromorphone, or transdermal fentanyl, is used to treat the persistent baseline pain. A fast-onset, short-acting analgesic (usually the same drug as the long-acting) is used to treat breakthrough pain if it occurs. When the oral route is not possible, such as in patients who cannot swallow or are NPO or nauseated, other routes of administration are used, including intravenous (IV), subcutaneous, transdermal, and rectal.

Norco, Benadryl, Phenergan, and Tylenol are not appropriate solo choices for acute pancreatitis with pain reported as 10/10.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. An 80-year-old male patient is in the intensive care unit has suffered a fractured femur. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioid doses q 4 hours. What is the nurse’s first action? a. Call the rapid response team to care for the patient immediately. b. Discontinue the opioids on the medication administration record.

c. Assess the patient’s blood pressure and pain level. d. Start a second intravenous line with a large bore catheter.

ANS: A After establishing unresponsiveness, the next action is to call a Rapid Response. The patient is not able to subjectively describe pain if unresponsive. Another IV line may be needed, but first the nurse should call for help. The opioids should be discontinued on the MAR; however the priority action is to call for help.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

The patient’s symptoms are most congruent with dehydration. Hypovolemia, due to dehydration, can lead to decreased perfusion to the kidneys resulting in acute renal failure.

Influenza symptoms include headache, fever, body aches, and fatigue. Mononucleosis can manifest as severe fatigue. Pneumonia presents with cough, respiratory distress, and decreases in oxygen saturation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is caring for a patient diagnosed with amyotrophic lateral sclerosis. The nurse should assess for which priority problem? a. Fatigue b. Bradypnea c. Hypertension d. Fall risk ANS: B Amyotrophic lateral sclerosis is a chronic condition that causes fatigue; however specific respiratory muscle fatigue leading to bradypnea is the priority safety risk. Respiratory muscle fatigue can lead to bradypnea, decreased ventilation, and eventually cessation of breathing which is the condition of highest importance with this illness. Hypertension is not a high priority problem specifically related to ALS. While the patient is a fall risk due to overall skeletal muscle fatigue, respiratory depression is the priority safety risk.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A patient with chronic kidney disease is most likely to complain of which symptom?

N a. Fatigue b. Thirst c. Constipation d. Excess bleeding ANS: A Erythropoietin is produced by the kidneys. A patient with chronic kidney disease produces less erythropoietin, resulting in anemia and fatigue as a common symptom. Thirst, or polydipsia, is a common sign of hyperglycemia and diabetes which can lead to chronic kidney disease. Constipation is not a common symptom of chronic kidney disease.

Excessive bleeding can result from a decrease in platelets and clotting factors that are produced by the liver, not the kidneys.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A patient has been recently diagnosed with chronic fatigue syndrome and asks the nurse about the cause of this illness. What is the nurse’s best response? a. “The provider will be able to tell you when the lab results are back.” b. “An exact cause may not be determined, but a treatment plan will be discussed.” c. “Stress is the main cause; a referral to a counselor may be helpful.” d. “This is considered a psychiatric illness requiring behavioral medicine.”

ANS: B

Chronic fatigue syndrome is considered an illness with an unknown etiology. There are no specific lab results that reveal chronic fatigue syndrome. Stress and mental illnesses may be contributing factors, but are not classified as exact causes of chronic fatigue syndrome.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. The nurse palpates swollen nodes in a patient’s neck who presented to the clinic with complaints of fatigue lasting at least 2 weeks. What is the nurse’s best action? a. Advise patient this finding is normal. b. Review patient’s thyroid lab work. c. Perform deep tendon reflexes. d. Notify the healthcare provider.

ANS: D The nurse should notify the healthcare provider for further evaluation. Palpation is indicated to assess for the presence of lymphadenopathy, thyroid nodules or goiter. These findings could implicate the need to test further for cancer, thyroid disease or infection. These conditions should be ruled out by the healthcare provider. Thyroid nodules or changes in size indicate the need for further assessment of the thyroid. Deep tendon reflexes are part of a neuro-muscular examination and are not directly related to cervical node enlargement.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. The nurse is assessing a patient for risk factors of chronic fatigue syndrome. Which factors N should the nurse identify as placing the patient at risk for chronic fatigue syndrome? (Select all that apply.) a. Feeling tired upon awakening b. Chronic migraines c. Tenderness under the jaw d. 5 episodes tonsillitis/past year e. Swollen, painful knees ANS: A, C, D, E The individual has severe chronic fatigue for 6 or more consecutive months that is not due to ongoing exertion or other medical conditions associated with fatigue (these other conditions need to be ruled out by a doctor after diagnostic tests have been conducted). The fatigue significantly interferes with daily activities and work. The individual concurrently has four or more of the following eight symptoms: • Post exertion malaise lasting more than 24 hours • Unrefreshing sleep • Significant impairment of short-term memory or concentration • Muscle pain • Multi-joint pain without swelling or redness • Headaches of a new type, pattern, or severity • Tender cervical or axillary lymph nodes • Frequent or recurring sore throat

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The occupational health nurse is making rounds in a factory. Which employees need further education about energy conservation strategies? (Select all that apply.) a. Workers reaching up to high shelf often to obtain cleaning supplies b. Workers bending over to lift boxes onto conveyer belt c. Workers who have delegated out parts of their activities d. Workers standing for long periods e. Workers standing at desks at waist level ANS: A, B, D The employee health nurse should provide teaching to employees about energy conservation strategies to protect workers from job-related injuries. These strategies include: placing frequently used items within reach; using proper body mechanics (not bending over and straining the back); and standing for long periods of time. Delegating parts of activities is an appropriate energy conserving strategy. When standing is necessary, it is important that desks or tables are at waist level of the employee to prevent excess reaching or straining.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. The nurse recognizes that which patients are at highest risk for physiologic fatigue? (Select all that apply.) a. Parents of a newborn b. Adolescent with anorexia c. 25-year-old pregnant female d. Grandmother who takes N mile walks e. Businessman who consumes six cups coffee/day ANS: A, B, C, E Physiologic causes of fatigue include: protein–calorie malnutrition, excessive physical activity, sleep deprivation, excessive caffeine or alcohol use, and pregnancy. Parents of a newborn are likely experiencing sleep deprivation. A patient with anorexia is likely not consuming adequate amounts of protein. Consumption of six cups of coffee/day is considered excessive. A mile walk is an appropriate exercise for an older adult and not considered excessive physical activity.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. Which are treatment related causes of fatigue? (Select all that apply.) a. Blood transfusion b. Chemotherapy c. Radiation therapy d. Surgery e. Side effects of medications ANS: B, C, D, E

Cancer treatments, such as chemotherapy and radiation, commonly cause fatigue. A risk of any surgery is blood loss, which can possibly lead to fatigue if the hemoglobin and hematocrit drop significantly. Fatigue is a side effect of many medications. A blood transfusion is more likely to lead to increased energy versus fatigue as the hematocrit and hemoglobin levels would be expected to rise with the transfusion.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

N

The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient’s vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110–120/76–84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30–60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

ANS: C The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Benson’s relaxation response) will counter the sympathetic nervous system’s arousal, normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his body. Other options do not address his physiologic response pattern as directly or immediately.

OBJ: NCLEX Client NeedsNCategory: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function? a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. b. Alter the internal state by modifying electronic signals related to physiologic processes. c. Replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities. d. Reduce catecholamine production and promote the production of additional -endorphins.

ANS: A When the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse, blood pressure, and respiratory rate. Relaxation is achieved when the sympathetic nervous system is quieted and the parasympathetic nervous system is operative. Modifying electronic signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the cognitive approach to stress management. Reducing catecholamine production is the basis for guided imagery’s effectiveness.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A patient tells the nurse, “I’m told that I should reduce the stress in my life, but I have no idea where to start.” Which would be the best initial nursing response? a. “Why not start by learning to meditate? That technique will cover everything.” b. “In cases like yours, physical exercise works to elevate mood and reduce anxiety.” c. “Reading about stress and how to manage it might be a good place to start.” d. “Let’s talk about what is going on in your life and then look at possible options.”

ANS: D In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. As a result, further assessment is indicated before potential solutions can be explored. Suggesting further exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. A patient tells the nurse “My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking.” Which response would be in keeping with the doctor’s recommendations? a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts b. Encouraging the patient to imagine being in calming circumstances c. Teaching the patient to use instruments that give feedback about bodily functions d. Provide the patient with a blank journal and guidance about journaling ANS: A N Meaning-focused coping leads the individual to focus on his/her own values and beliefs to modify the personal interpretation and response to a problem. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient’s manner of thinking.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

8. A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient’s wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

ANS: C

Objective measures tend to be the most reliable means of gauging progress. In this case, the patient’s elevated blood pressure, an indication of the body’s physiologic response to stress, has diminished. The wife’s observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patient’s report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 9. The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress.

Which action should the nurse implement to assist the patient? a. Identifying the cause of fear b. Accessing a community support group c. Identifying relaxation methods d. Reviewing an educational pamphlet ANS: A Identifying the cause of a negative perception is the first step in helping an individual to be able to utilize coping strategies. Accessing a community support group is an example of accessing resources to enhance coping. Identifying relaxation methods is an example of developing an action plan. Reviewing an educational pamphlet is an example of using education to enhance coping.

OBJ:

NCLEX Client NeedsNCategory: Psychosocial Integrity

10. The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy? a. Scheduling a regular exercise program b. Attending a seminar on treatment options c. Identifying a confidant to share feelings d. Attending a support group for families ANS: C Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing community resources or attending educational seminars.

Exercise, emotional support, and support groups are emotion-based strategies that create a feeling of well-being.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

11. The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population? a. Altered vital sign readings b. Inaccurate perceptions of stressors c. Increased risk for suicide d. Decreased access to alcoholic beverages

ANS: C Adolescents with poor coping have increased risk for drug and alcohol use, risky sexual behaviors, and suicide. Pulse, respiratory rate, and blood pressure may change during stress, but patient safety is the priority concern. Adolescents may have inaccurate perceptions of stressors, and this actually increases the risk for unsafe behaviors. Adolescents under stress are more at risk for increasing their access to alcohol and illegal drugs.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

12. A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient? a. Ask if there is another family member who can help at home while the patient is in the hospital. b. Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover. c. Coordinate an ambulance transfer of the family member to an alternate family member’s home. d. Ask social services to assess what the patient’s needs will be after discharge to home.

ANS: A The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the immediate need to provide care for the disabled family member. An Nambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person’s needs, availability to provide the care by another, and distance of the transfer. Assessing the patient’s needs after discharge does not address the immediate need to provide care for the disabled family person.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

13. After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff? a. Ask administration to require staff to meditate daily for at least 30 minutes. b. Have a staff psychologist available on the unit once a week for required counseling. c. Have training sessions to help the staff understand their new responsibilities. d. Ask support staff from other disciplines to complete some nursing tasks to provide help.

ANS: C

Feeling unprepared for work responsibilities contributes to stress and poor coping in the workplace. Administration cannot require that staff participate in meditation or counseling sessions, although these can be recommended and encouraged. Asking other disciplines to assume nursing tasks is not appropriate for their scope of practice.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

14. The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool? a. “This tool will let us compare your stress to other patients in the hospital.” b. “This tool is short because it only measures the negative stressors you are experiencing.” c. “You will need to ask your parents about stressors you had as a child to complete this tool.” d. “This tool will help assess recent positive and negative events you are experiencing.”

ANS: D Coping measurement tools measure recent positive and negative life events as perceived by the individual. There is no objective scale for comparison with other patients because each person reacts differently to stressors. Both negative and positive events are assessed.

Childhood stressors are not part of this type of evaluation as they are intended to measure recently occurring events.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N MULTIPLE RESPONSE 1. Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.) a. Assess for bradycardia. b. Ask about epigastric pain. c. Observe for increased appetite. d. Check for elevated blood glucose levels. e. Monitor for a decrease in respiratory rate.

ANS: B, C, D The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and elevation of blood glucose levels. Stress causes an increase in the respiratory and heart rates.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse is working with a patient who recently lost her spouse after a lengthy illness. The patient shares that she would like to sell her home and move to another state now that her spouse has passed away. Which of the following interventions would be considered a priority for this patient? (Select all that apply.) a. Notify the provider to evaluate for antidepressant therapy.

b. c. d. e. f.

Suggest that the patient consider a support group for widows.

Suggest that the patient learn stress reduction breathing exercises.

Suggest that the patient take prescribed antianxiety medications.

Assist the patient in identifying support systems.

Notify the provider to evaluate the need for antianxiety medications.

ANS: B, C, E Stress prevention management involves counseling, education, and implementation of techniques to manage problem-oriented and emotion-oriented stress. To prevent physical symptoms, relaxation and deep breathing are effective and individuals can learn to prevent the stress response through cognitive behavioral strategies. Medications are not indicated for patients with known stressors unless the stress is prolonged or the patient has ineffective coping mechanisms.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 31: Mood and Affect Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant.

After taking the new medication, the patient states, “This medication isn’t working. I don’t feel any different.” What is the best response by the nurse? a. “I will call your care provider. Perhaps you need a different medication.” b. “Don’t worry. You can try taking it at a different time of day to help it work better.” c. “It usually takes a few weeks for you to notice improvement from this medication.” d. “Your life is much better now. You will feel better soon.”

ANS: C Seeing a response to antidepressants takes 3–6 weeks. No change in medications is indicated at this point of treatment because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that their life is better does not acknowledge their feelings.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A patient who has been diagnNosed with depression is scheduled for cognitive therapy in addition to receiving prescribed antidepressant medication. The nurse understands that the goal of cognitive therapy will be met when what is reported by the patient? a. “I will tell myself that I am a good person when things don’t go well at work.” b. “My medications will make my problems go away.” c. “My family will help take care of my children while I am in the hospital.” d. “This therapy will improve my response to neurotransmitter impulses.”

ANS: A Cognitive therapy helps patients restructure their patterns of thinking to various events or thoughts in a more healthy way. Medication alters neurotransmitters but does not make problems go away. Family support is important but is not the goal of cognitive therapy.

Neurotransmitters are affected by medication and brain stimulation therapy, not by cognitive therapy.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes a monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient? a. Serum blood levels must be regularly monitored to assess for toxicity. b. To prevent side effects, the medication should be administered as an intramuscular injection. c. Eating foods such as blue cheese or red wine will cause side effects.

d. This medication class may only be used safely for a few days at a time.

ANS: C MAOIs have serious food interactions when ingested with tyramine-containing foods such as aged or processed foods. Serum levels are routinely monitored when mood stabilizers such as lithium carbonate are prescribed. It is not necessary to administer this class intramuscularly. This medication takes several weeks to show effectiveness and should not be stopped abruptly; short-term use will not be effective.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. A patient with a diagnosis of depression and suicidal ideation was started on an antidepressant 1 month ago. When the patient comes to the community health clinic for a follow-up appointment he is cheerful and talkative. What priority assessment must the nurse consider for this patient? a. The medication dose needs to be decreased. b. Treatment is successful, and medication can be stopped. c. The patient is ready to return to work. d. Specific assessment for suicide plan must be evaluated.

ANS: D Energy levels increase as depression lifts; this may increase the risk of completing a suicide plan. An increase in mood would not indicate a decrease or discontinuation of prescribed medication. The patient may be ready to return to work, but assessment for suicide risk in a patient who has had suicidal ideation is the priority assessment.

OBJ: NCLEX Client NeedsNCategory: Safe and Effective Care Environment: Safety and Infection Control 5. A patient who is taking prescribed lithium carbonate is exhibiting signs of diarrhea, blurred vision, frequent urination, and an unsteady gait. Which serum lithium level would the nurse expect for this patient? a. 0–0.5 mEq/L b. 0.6–0.9 mEq/L c. 1.0–1.4 mEq/L d. 1.5 or higher mEq/L ANS: D Diarrhea, blurred vision, ataxia, and polyuria are all signs of lithium toxicity, which generally occurs at serum levels above 1.5 mEq/L. Serum levels within the normal range of 0.8–1.4 mEq/L are not likely to cause signs of toxicity.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. A patient newly diagnosed with depression states, “I have had other people in my family say that they have depression. Is this an inherited problem?” What is the nurse’s best response? a. “There are a lot of mood disorders that are caused by many different causes.

Inheriting these disorders is not likely.” b. “Current research is focusing on fluid and electrolyte disorders as a cause for mood

disorders.” c. “All of your family members raised in the same area have probably learned to respond to problems in the same way.” d. “Members of the same family may have the same biological predisposition to experiencing mood disorders.”

ANS: D Research is showing a genetic or hereditary role in the predisposition of experiencing mood disorders. These tendencies can be inherited by family members. Fluid and electrolyte imbalances cause many problems, but neurotransmitters in the brain are more directly linked to mood disorders. Mood disorders are not a learned behavior, but are linked to neurotransmitters in the brain.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient? a. Assess for depression and ask directly about suicide thoughts. b. Ask the care provider to prescribe blood lab work to assess for depression. c. Focus on the presenting problems and refer the patient for a mental health evaluation. d. Interview the patient’s family to identify their concerns about the patient’s behaviors.

ANS: A Assessing directly for thoughts of harm to self or others is a priority intervention for any patient exhibiting signs of a mNe nt al health disorder. It is estimated that 50% of individuals who succeed in suicide had visited a healthcare provider within the previous 24 hours.

Currently there is no serum lab that identifies depression. The risk of self-harm is a priority safety issue that is monitored in all health care within the scope of the nurse. It is important to obtain information directly from the patient when possible, and then validate the information from family or other secondary sources.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

8. An older adult has experienced severe depression for many years and is unable to tolerate most antidepressant medications due to adverse effects of the medications. He is scheduled for electroconvulsive therapy (ECT) as a treatment for his depression. What teaching should the nurse give the patient regarding this treatment? a. There are no special preparations needed before this treatment. b. Common side effects include headache and short-term memory loss. c. One treatment will be needed to cure the depression. d. This treatment will leave you unconscious for several hours.

ANS: B Common side effects of ECT include headache, sleepiness, short-term memory loss, nausea, and muscle aches. Preparations before and after the procedure are the same as any operative procedure involving the patient receiving anesthesia. Treatment is typically three sessions a week for 4 weeks, not once. Patients are not unconscious after the procedure due to the use of precisely placed electrodes and the use of anesthesia.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE 1. A nurse is developing a plan of care for a patient admitted with a diagnosis of bipolar disorder, manic phase. Which nursing diagnoses address priority needs for the patient?

(Select all that apply.) a. Risk for caregiver strain b. Impaired verbal communication c. Risk for injury d. Imbalanced nutrition, less than body requirements e. Ineffective coping f. Sleep deprivation ANS: C, D, F Risk for injury, poor nutrition, and impaired sleep are priority needs of the patient experiencing mania related to their impulsivity, inability to attend to activities of daily living such as diet and hygiene, and disruption of sleep. Caregiver strain is important to be addressed but is not a priority need on admission for the patient. Verbal communication improves when the mania is managed, and racing thoughts return to normal patterns.

Ineffective coping will require stabilization of the acute phase along with cognitive therapy over time.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control N

Concept 32: Anxiety Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient complains of insomnia during his stay in the hospital. Which nursing diagnosis would be a top priority for this patient? a. Anxiety related to hospitalization b. Ineffective coping related to hospitalization c. Denial related to hospitalization d. High risk for insomnia related to hospitalization ANS: A The information about the patient indicates that anxiety is an appropriate nursing diagnosis.

The patient’s data do not support defensive coping, ineffective denial, or risk-prone health behavior as problems for this patient.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time? a. Massage b. Meditation c. Guided imagery N d. Relaxation breathing ANS: D Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practice and learn.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate? a. “How do you feel about what happened to you as a child?” b. “How do you feel about what is going on right now?” c. “Remember a time when you were calm.” d. “Tap your hands until the feeling goes away.”

ANS: B Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Recalling and remembering being calm or previous experiences is not included in mindfulness training. Eye movement desensitization and reprocessing (EMDR) includes expression of feelings and memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. The nurse is assessing the social support of a patient who is recently divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic? a. Encourage the patient to begin dating again, perhaps with members of her church. b. Discuss how divorce support groups could increase coping and social support. c. Note that being so particular about potential friends reduces social contact. d. Discuss using the Internet as a way to find supportive others with similar values.

ANS: B Use of support groups is a method whereby the individual uses inter-related coping strategies in the presence of a stressor. The nurse should focus on providing the patient with coping strategies aimed at decreasing stress. Resuming dating soon after a divorce could place additional stress on the patient rather than helping them cope with existing stressors.

Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose the patient to predators misrepresenting themselves to take advantage of vulnerable persons.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. A patient reports that he is overwhelmed with anxiety. Which question would be most important to use in assessing the patient during your first meeting? a. “What kinds of things do you do to reduce or cope with your stress?” b. “Tell me about your family history—do any relatives have problems with stress?” c. “Tell me about exercise—how far do you typically run when you go jogging?” d. “Stress can interfere with sleep. How much did you sleep last night?”

N

ANS: A The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. These data would indicate whether his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses such as drinking) and would help you understand how he copes and how well his coping strategies and resources are serving him. Therefore, of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended or broad-opening inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. A patient is newly diagnosed with anxiety and placed on a selective serotonin reuptake inhibitors (SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become effective? a. The medication will become effective immediately. b. The medication may take up to 12 weeks to become effective. c. The medication may take up to 6 weeks to become effective. d. The medication may take up to 4 weeks to become effective.

ANS: B Efficacy may take at least 8–12 weeks. The other options are not realistic.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. The nurse knows that which of the following medical conditions are most commonly associated with anxiety? (Select all that apply.) a. Cancer b. Pancreatitis c. Hypothyroidism d. Dysrhythmias e. Encephalitis f. Hyperthyroidism ANS: A, C, D, E, F Cancer, COPD, dysrhythmias, encephalitis, hypothyroidism, and hyperthyroidism are all associated with anxiety. Pancreatitis is not listed as a condition most commonly associated with anxiety.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. The nurse is reviewing the medication profile of a patient admitted with an anxiety disorder.

Which medications should a lNe r t the nurse to a potential interaction? (Select all that apply.) a. St. John’s Wort b. Kava kava c. Aspirin 81 mg d. Valerian root e. Multi-vitamin ANS: A, B, D Although supplements are available to purchase that “treat” anxiety, they are not under control of the Food and Drug Administration (FDA), so the nurse should obtain additional information relative to the use of any supplements that the patient is taking. Dosage of aspirin relates to a cardiac dose and a multi-vitamin would not pose a problem.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Patients with a cognitive impairment benefit from a predictable routine and consistent caregivers. Trips off of the unit may confuse the patient and disrupt their normal routine.

Offering too many selections causes confusion and can lead to agitation. Being in large groups for activities can overstimulate the patient and lead to agitation and fear.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? a. “Don’t worry; the patient should be fine once they are in a familiar environment.” b. “I can make a referral for a home health aide to assist with the patient.” c. “Once the dehydration is corrected, the patient’s confusion should improve.” d. “I can show you how to care for the patient once you return home.”

ANS: C The confusion caused by an underlying medical condition is a temporary condition that can be corrected once the underlying condition is treated, in this case once the patient is rehydrated. It is not necessary to teach home care or make a referral to home health because it is not expected that the patient will be confused at discharge. Telling the daughter that there is nothing to worry about diminishes her concern and may decrease her trust in the nurse.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. An older adult who is cognitively impaired is admitted to the hospital with pneumonia.

Which sign or symptom would the nurse expect to be exhibited by the patient?

N a. Severe headache b. Flank pain c. Increased confusion d. Decreased blood glucose ANS: C Increased confusion is a symptom that occurs in cognitively impaired patients who experience an infection. Severe headache occurs with migraines, meningitis, and other conditions. Flank pain occurs with pyelonephritis. Blood glucose typically increases with an infection.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse’s best response? a. “Hormone therapy will reverse the condition.” b. “Vitamin C and zinc will reverse the condition.” c. “There is no treatment that reverses dementia.” d. “Dementia can be reversed with diet, exercise, and medications.”

ANS: C

Currently there is no proven treatment that has been shown to reverse dementia, although some treatments can slow the progression of the illness. Hormone therapy, vitamin therapy, diet, and exercise are all important for overall health but do not reverse the progression of dementia.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? a. Leave a night light on in the room at all times. b. Leave the television on at night with the volume up. c. Restrain the patient to maintain safety during the confusion. d. Administer a sleeping medication to help the patient sleep.

ANS: A Having a night light on for the patient can help orient them to their surroundings. Having the flickering light and sound from a television will not help a confused patient remain calm or oriented. Restraining a patient will increase their agitation and actually increase their risk of injury if they try to get out of bed. Sleeping medications often increase confusion in cognitively impaired patients.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 8. An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sl e N ep. What data does the nurse consider as a probable cause of the patient’s confusion? a. Pain medication received earlier in the night b. The death of the patient’s spouse 2 years ago c. The patient’s history of diabetes d. The age of the patient ANS: A Medications such as narcotics, hypertensives, sleeping meds, and others can cause disorientation and symptoms of delirium. The death of a spouse is more likely to cause depression than disorientation. A history of diabetes alone does not cause disorientation.

Normal aging alone does not cause disorientation, although it is a risk factor.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE 1. The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which topics would be included in the presentation? (Select all that apply.) a. Do not use substances such as cannabis and alcohol. b. Wear helmets when riding bicycles and motorcycles. c. Complete a Mini Mental Status Exam (MMSE) yearly. d. Correct acid-base imbalances related to underlying disease processes.

e. Wear a seat belt whenever riding in a motorized vehicle. f. Complete a Confusion Assessment Method (CAM) scale yearly.

ANS: A, B, E Primary prevention attempts to prevent injury. Not using chemical substances, wearing a helmet, and wearing a seat belt are all measures to prevent injury to the brain, which protects cognitive function. An MMSE and CAM are secondary prevention, or screening tools performed once symptoms are present. Correcting acid-base imbalances from underlying disease processes is a tertiary prevention level, aimed at minimizing complications for disease already present.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 34: Psychosis Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. What is the nurse’s best response? a. Ignore his remarks and remain silent when providing care. b. Express doubt that there are spiders on the wall. c. Ask the patient if he also sees spiders in the day room. d. Tell the patient there are no spiders and he should stop worrying about it.

ANS: B The patient is experiencing visual hallucinations. Appropriate care for this patient would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.

OBJ: NCLEX Patient Needs Category: Psychosocial Integrity 2. A patient with schizophrenia is admitted to the inpatient unit. Which behavior should the nurse expect to see that is most likely to be associated with this disorder? a. Wringing of hands b. Monotone speech pattern c. Engaged in conversations d. Presence of hallucinationN s ANS: D Individuals who have a clinical diagnosis of schizophrenia present with positive (delusions, hallucinations, disorganized speech and behavior, catatonia, and agitation) as well as negative symptoms (alogia, affective blunting, asocial behavior, anhedonia, and avolition) which distances the patient from society.

OBJ:

NCLEX Patient Needs Category: Psychosocial Integrity

3. The nurse is planning discharge teaching for a patient taking clozapine. Which information is critical to include in the teaching plan? a. Caution about sunlight exposure b. Reminder to call the clinic if fever, sore throat, or malaise develops c. Instructions regarding dietary restrictions d. A chart to record patient weight ANS: B Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.

OBJ: NCLEX Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Which side effect is the highest priority for the nurse to assess for when diphenhydramine is administered to a patient also taking antipsychotic medication? a. Increased psychosis b. Cognitive impairment c. Respiratory depression d. Impaired memory ANS: C Diphenhydramine is an anticholinergic medication that may induce drowsiness or even respiratory depression taken along with anti-psychotic medication. Respiratory depression and airway are always highest priorities of care. While increased psychosis may occur, respiratory depression is highest priority. Cognitive impairment and impaired memory are not well-known effects of diphenhydramine.

OBJ: NCLEX Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend’s apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to Nt hi s patient? (Select all that apply.) a. Allow opportunities for him to express his anger. b. Provide patient and family teaching regarding PTSD. c. Tell the patient that hurting himself will solve nothing. d. Report him to the authorities. e. Exhibit a nonjudgmental attitude. f. Reassure him that everything will be all right.

ANS: A, B, E Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse–patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.

OBJ:

NCLEX Patient Needs Category: Physiological Integrity: Basic Care and Comfort

2. In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) a. Father diagnosed with paranoid schizophrenia b. Rural residence c. Recent immigration from Ecuador d. Occasional cannabis use

e. January birth date f. Physical abuse by the father ANS: A, C, E, F Genetic predisposition has been identified as a risk factor for development of schizophrenia.

Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.

OBJ:

NCLEX Patient Needs Category: Health Promotion and Maintenance

3. Patients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in patients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) a. Hallucinations b. Disorganized speech and behavior c. Anhedonia d. Delusions e. Agitation ANS: A, D, E Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the patient experiences hallucinations, delusions, or agitation.

Negative symptoms are those that cause a loss of normal function, such as when the patient exhibits disorganized speech and behavior and anhedonia.

N OBJ: NCLEX Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the highest priority for this patient? a. Describe how the alcohol is causing the withdrawal effects. b. Leave the patient by him/herself so as not to cause agitation. c. Promote a safe, calm, and comfortable environment. d. Refer the patient to an alcohol-abuse counselor.

ANS: C The main priority is the patient’s safety due to risk of harm from seizures, DTs, and anxiety.

The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. The nurse assesses the outcomes of a motivational interview on a patient with a dual diagnosis of alcoholism with delirium tremens (DTs) and determines that the communication was nontherapeutic. What is the nurse’s next priority? a. Encourage the patient to think of ways to change environmental triggers to abuse substances. b. Ask the patient what methods they think would work and encourage participating N in self-help groups. c. Notify provider to obtain order for oxazepam and vitamin B infusion. d. Notify provider to obtain order for CT scan and psychological consult.

ANS: C The patient will need to be treated for the psychosis prior to conducting the motivational interview, because the patient can become violent and nonreceptive to the interventions.

Oxazepam and vitamin B are the two therapies that work for DTs. OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 6. A 45-year-old man is brought to the emergency department presenting with a respiratory rate of 6 breaths/min, and cardiac dysrhythmias. What is the most appropriate question the nurse should ask the patient’s friend? a. “Does he take amphetamines or uppers?” b. “Has he ever used LSD?” c. “Have you two been out of the country in the last 2 days?” d. “Is he using any opioids such as heroin?”

ANS: D

The clinical manifestations of an opioid overdose include seizures, shock, respiratory depression, dysrhythmias, and altered level of consciousness. An opioid overdose is a medical emergency. Amphetamine overdose is ruled out because it causes hypertension and central nervous system disturbances such as paranoia, panic, and delusions. LSD overdose would also manifest with hypertension and tachypnea along with hallucinations and possible loss of contact with reality. Travel outside the country is unrelated.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. During history-taking, a patient tells the nurse that he is addicted to alprazolam and that he takes six 1 mg tablets a day. He quit cold turkey yesterday and now presents with extreme agitation, increased heart rate, and panic. Which disorder should the nurse suspect? a. Stress reaction b. Delirium tremens c. Overdose d. Relapse ANS: A Stress reaction is a withdrawal symptom that can occur when detoxing too quickly. DTs are usually associated with alcohol withdrawal. Overdose of alprazolam would present with extreme drowsiness, confusion, muscle weakness, and loss of balance or coordination. The effects of alprazolam are dizziness, drowsiness, dry mouth, and lightheadedness.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

N

1. Strategies that a nurse could use in a motivational interview to increase the chances of change include which of the following? (Select all that apply.) a. Educating the patient on the physical damage the substance is causing b. Encouraging the patient to think of ways to change environmental triggers to abuse substances c. Asking the patient how they think substance abuse affects their family life d. Explaining to the patient that substance abuse affects everyone in the family and give examples e. Asking the patient what methods they think would work and encouraging participating in self-help groups ANS: B, C, E Empowering the patient by helping them see what effect the abuse has on their life is a key component of motivation. Educating the patient is too much like lecturing and may cause resistance. Explaining how the family responds to the problem may elicit guilt and resistance.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. The nurse recognizes a potential health threat to an alcoholic patient who is using the drug disulfiram when the nurse reads in the health record that the patient is also taking which of the following? (Select all that apply.)

a. b. c. d. e.

Blood thinners Diphenhydramine Alcohol Penicillin Mouthwash

ANS: A, C, E Disulfiram increases the effect of anticoagulants such as warfarin (Coumadin). Ingesting alcohol may cause headache, nausea, vomiting, tachycardia, chest pain, or dizziness.

Mouthwash can have alcohol as one of the main ingredients and should be checked prior to using.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

N

d. “Have you discussed this with anyone else?”

ANS: B Depression and an increased risk of suicide are common outcomes from individuals experiencing interpersonal violence. It is critical that the nurse specifically assess for the risk of harm to the patient or to others during assessment. Asking if family or friends are available for support is good, but it is more important to assess for the safety concern of suicide or harm to others. It is not helpful to ask if a person who has stated that they don’t see a way out has thought of leaving—their comment indicates that they can’t see any solution. This situation is a high risk for suicide, or even homicide against the perpetrator.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. The nurse is reviewing case files for children at risk for injury resulting in brain injury.

Which child is at most risk for experiencing this type of violence? a. A Caucasian, 6-month-old infant living with a single mother b. An African-American, 24-month-old child living with her grandmother c. A Mexican, 3-year-old child living in an inner city apartment d. A Japanese, 8-year-old child living in a home with three generations of family ANS: A The highest incidence of traumatic brain injury occurs in Caucasian children aged birth to 1 year, and the abuse occurs most often from women.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. Critical Thinking: A crisis in N tervention nurse is training emergency department staff on treatment needs of persons in abusive relationships. What is a common difficulty staff encounter when caring for this population? a. There is not a good legal pathway to help persons in abusive relationships. b. The abused person may return to the abusive home setting. c. Hospital policies do not identify the legal care needed for abused persons. d. Because length of care is short in the emergency department, there is little staff can do for patients who have been abused.

ANS: B Abused persons return to abusive settings because they feel they have no other options or they fear reprisal from the abusive partner. There are policies in all healthcare facilities that describe the legal needs and the legal process that needs to be followed when caring for abused patients. Even in short-stay care settings there are interventions that can be helpful to a patient who has experienced abuse.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. The nurse is counseling women at a crisis shelter about risk factors for increased intimate partner violence. What event is most likely to trigger an increase in abusive behaviors? a. Moving to a new community b. Starting a new job c. Becoming pregnant d. The death of a grandfather

ANS: C Abuse is not likely to decrease, and can often increase when a woman becomes pregnant.

Moving, starting a new job, and a death in the family are all stressors, but they are not identified as factors that specifically increase violence more than pregnancy.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE 1. The nurse is admitting a child with a history of abuse. The nurse understands that the child may exhibit what behaviors that are consequences of being in an abusive environment?

(Select all that apply.) a. Reliving abuse incidents b. Sleep disturbance c. Overeating d. Acting out behaviors e. Intermittent fever ANS: A, B, D Posttraumatic stress disorder symptoms, depression symptoms, and aggression are all outcomes that children who are exposed to abuse experience. Overeating may be associated with some stressors, but it is not specifically indicative of abuse. Fever is not associated with abuse.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 37: Professional Identity Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Which key element is included in the scope of professional practice identity? a. Adhering to a fixed level of practice b. Finding out ways to get done faster with assigned tasks as the key focus of care c. Maintaining professional boundaries d. Remaining at the level of practice upon graduating from nursing school ANS: C The scope of professional identity includes five attributes, doing, and being, acting ethically, flourishing and changing identities. By maintaining professional boundaries, the nurse would be acting ethically. Adhering to a fixed level of practice would not be prudent for it would not allow the nurse to achieve attributes. Finding out ways to get done faster with assigned tasks would be in opposition to the attribute of “being” as the key focus is to do the right thing even when no one is looking. A nurse who remains at the level of practice upon graduation from nursing school would be in opposition to the attribute of flourishing.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A new registered nurse asks the registered nurse (RN) preceptor what could be done to become more professional. What is the preceptor’s best response? a. “Attend nursing educationNal meetings.” b. “Listen to other nurses.” c. “Read the agency newsletter.” d. “Pass the licensing exam.”

ANS: A Knowledge and commitment are essential components of professionalism. Attending nursing educational meetings can promote collaborative learning with peers and maintenance of competence in an ever-changing healthcare environment. Listening can promote professionalism, and communication is certainly a component of professionalism; however, there is also a social sense to listening, and without the educational/learning component, this is not the best answer. An agency newsletter could include information about professional opportunities, but it is not the best answer. The new nurse would have already passed the licensing exam, the legal requirement to be considered a nurse.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The qualities of leadership, clinical expertise and judgment, mentorship, and lifelong learning would best describe which type of nurse? a. Administrator b. Certified nurse specialist c. Practitioner d. Professional

ANS: D The qualities listed are those of a professional nurse. The other options are all nurses who may have these qualities, but the focus of their title includes qualities not essential for the professional nurse. The administrator would have management qualities; the clinical nurse specialist would have specialty area knowledge; and the practitioner would meet legal requirements as a healthcare provider.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The American Nurses Association (ANA) outlines expectations of nurse’s self-care habits in which type of documentation? a. Nurse Practice Acts b. Board of Nursing c. Code of Ethics d. Hospital Facility Protocols ANS: C The ANA focuses on the importance of nurses to develop their own personal self-care habits as part of their ethical code. This information is presented in the ANA Code of Ethics. Nurse Practice Acts define the scope of practice relative to the specific type of health professional.

The Board of Nursing provides minimum competency requirements for specific types of health professionals and identifies licensing, academic and practice requirements. Hospital facilities provide policies and protocols related to members of the interdisciplinary healthcare team.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Which nursing action best exemplifies clinical judgment? a. A nurse after performing an assessment seeks out additional information related to a finding. b. A nurse documents finding in the medical record in a timely manner. c. A nurse contacts the physician to provide the results of an imaging study for a patient. d. A nurse comforts a patient who is on hospice care.

ANS: A Clinical judgment represents a comprehensive well thought out series of action whereby the nurse incorporates assessment data in the context of norms and values. The nurse seeking out additional information to clarify a finding is demonstrating clinical judgment. A nurse who is documenting assessment data in the patients’ medical record in a timely manner is being efficient. A nurse contacting the physician to provide results of an imaging test is demonstrating effective communication. A nurse comforting a patient who is on hospice care is demonstrating compassion.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

6. Nursing demonstrates dedication to improving public health through which avenue? a. Changing healthcare standards b. Legal regulations c. Scope of practice d. Technology ANS: C Through the scope of practice, specialized knowledge, and code of ethics, the discipline of nursing has demonstrated its dedication to improving public health. The changing healthcare environment is one of the challenges to nursing, not an indicator of dedication. Legal regulations are generally promulgated by legislators rather than nurses to protect the public.

A highly technological environment is considered a challenge to nursing rather than an indicator of dedication.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. Components of a professional identity in nursing include which attributes? (Select all that apply.) a. Doing b. Being c. Acting ethically d. Flourishing e. Culture N ANS: A, B, C, D The scope of professional identity in nursing includes: doing, being, acting ethically, flourishing and changing identities. Cultural sensitivity is important to professional nursing; however, culture is an inherent quality of nurses and patients, not a component of the professional identity.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Responding entails adjusting the plan of care to the particular patient issue through one or more nursing interventions. In this case, the nurse is working with the patient’s wishes, knowing that the patient will most likely cheat. The patient will be allowed to “cheat.” The plan will be evaluated to be sure the snack does not elevate the glucose excessively and be readjusted if warranted. While it is true that most chocolate has a high glycemic index, providing a list of foods that do not include the one thing the patient enjoys will most likely lead to nonadherence to the diet. Advising the patient that they can have whatever they want to eat may lead to further dietary indiscretions and cause side effects such as obesity or high glucose readings. Knowledge Deficit is an inaccurate diagnosis for this patient as evidenced by the patient stating they understand the need to exercise and the need to diet.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A new graduate nurse is working with an experienced nurse to chart assessment findings.

The new nurse notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced nurse asks the new nurse what may be going on here. What is the best explanation for this statement? a. Data on the chart can sometimes be documented in a biased manner. b. Data on the chart changes as the patient’s condition changes. c. Data on the chart is usually accurate and can be verified from the patient. d. Reading the chart is not a wise use of time as this can be time consuming and tedious.

ANS: A It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record. N D a t a do indeed change (and need to be charted) as the patient’s condition changes, but this would not be the best answer to this question. Assessment data may at times be difficult to obtain, but that would not occur often enough to warrant a warning about the difficulty in charting it. Also, obtaining data is clearly a different activity from charting it. Charting can be time consuming and tedious, but this is not the most complete answer to this question.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A home care nurse receives a physician order for a medication that the patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient’s condition, questions its appropriateness, and examines alternative treatments. What is the nurse’s best action? a. Call the physician, explain rationale, and suggest a different medication. b. Consult an experienced nurse on whether there are other similar treatments. c. Hold the drug until the physician returns to the unit and can be questioned. d. Question other staff as to the physician’s acceptance of nursing input.

ANS: A

Determining how best to proceed on behalf of a patient’s best health outcomes care may require clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities have been examined. A home care nurse who is using good clinical judgment techniques should have confidence in their decision and may not have another nurse available as this is an autonomous setting. Holding the drug might jeopardize the patient’s health, so this is not the best solution. The nurse working at this level of critical thinking makes choices based on careful examination of situations and alternatives; whether or not the physician is open to nursing input is not relevant.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A patient has been admitted for a skin graft following third degree burns to the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes. When should the nurse initiate the educational plan? a. After the operation and the patient is awake b. On admission, along with the initial assessment c. The day before the patient is to be discharged d. When narcotics are no longer needed routinely ANS: B Initial discharge planning begins upon admission. After the operation has been completed is too late to begin the discharge planning process. The day before discharge is too late for the nurse to gather all pertinent information and begin teaching and coordinating resources.

After a complicated operation, the patient may well be discharged on narcotic analgesics.

Waiting for the patient to notNneed them anymore might mean the patient gets discharged without teaching being done.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse has designed an individualized nursing care plan for a patient, but the patient is not meeting goals. Further assessment reveals that the patient is not following through on many items. Which action by the nurse would be best for determining the cause of the problem? a. Assess whether the actions were too hard for the patient. b. Determine whether the patient agrees with the care plan. c. Question the patient’s reasons for not following through. d. Reevaluate data to ensure the diagnoses are sound.

ANS: B Having patient and/or family provide input to the care plan is vital in order to gain support for the plan of action. The actions may have been too difficult for the patient, but this is a very narrow item to focus on. The nurse might want to find out the rationale for the patient not following through, but instead of directly questioning the patient, which can sound accusatory, it would be best to offer some possible motives. Reevaluation should be an ongoing process, but the more likely cause of the patient’s failure to follow through is that the patient did not participate in making the plan of care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management

of Care 7. A new nurse appears to be second-guessing herself and is constantly calling on the other nurses to double-check their plan of care or rehearse what they will say to the doctor before she call on the patient’s behalf. This seems to be annoying some of the nurse’s coworkers.

What is the nurse manager’s best response? a. Explain to coworkers that this is a characteristic of critical thinking and is important for the new nurse to improve reasoning skills. b. Agree with the staff and have someone follow and work more closely with a preceptor. c. Have a talk with the nurse and suggest asking fewer questions. d. Tell the staff that all new nurses go through this phase, and ignore their behavior.

ANS: A Reflection-on-action is critical for development of knowledge and improvement in reasoning. It is where learning from practice is incorporated into experience. Inquisitiveness is a characteristic of critical thinking and reflects a desire to learn even when the knowledge may not appear readily useful. The manager should promote this. Suggesting the nurse work more closely with a preceptor implies that the manager thinks the nurse needs to learn more and increase confidence. In reality, this nurse is demonstrating a characteristic of critical thinking. Suggesting that the nurse ask fewer questions would hamper the development of the nurse as a critical thinker. All new nurses do go through a phase of asking more questions at one time, but dismissing the nurse’s behavior with this explanation is simplistic and will discourage critical thinking.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management N of Care 8. A nurse has committed a serious medication error and has reported the error to the hospital’s adverse medication error hotline as well as to the unit manager. The manager is a firm believer in developing critical thinking skills. From this standpoint, what action by the manager would best nurture this ability in the nurse who made the error? a. Have the nurse present an in-service related to the cause of the error. b. Instruct the nurse to write a paper on how to avoid this type of error. c. Let the nurse work with more experienced nurses when giving medications. d. Send the nurse to refresher courses on medication administration.

ANS: A

Nurturing critical thinking skills is done in part by turning errors into learning opportunities.

If the nurse presents an in-service on the cause and prevention of the type of error committed, not only will the nurse learn something but many others nurses on the unit will learn from it to. This is the best example of developing critical thinking skills. This option would allow the nurse to learn from the mistake, which is a method of developing critical thinking skills, but the paper would benefit only the nurse, so this option is not the best choice. Letting the nurse work with more experienced nurses might be a good option in a very limited setting, for example, if the nurse is relatively new and the manager discovers a deficiency in the nurse’s orientation or training on giving medications in that system.

Otherwise, this option would not really be beneficial. Sending the nurse to refresher courses might be a solution, but it is directed at the nurse’s learning, not critical thinking. The nurse might feel resentful at having to attend such classes, but even if they were helpful, only this one nurse is learning. Going to generic classes also does not address the specific reason this error occurred, and thus might be irrelevant. Critical thinking and learning can be enhanced by a presentation to the staff on the causes of the error.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nurse is caring for a patient in a long-term care facility who has not been sleeping well.

She notes that the patient is new to the facility, has been refusing therapy, and is also not eating well. The nurse interprets this to mean that the patient has been having trouble adjusting. The nurse decides to meet with the patient’s care team. The team decides to assess the patient’s willingneN s s to participate in group recreational activities. The patient agrees to participate. After 1 week, the nurse reevaluates the plan of care and notes that the patient has been sleeping much better. Which of the following terms best describe processes used in the nurse’s plan? (Select all that apply.) a. Clinical judgment b. Evidence-based practice c. The nursing process d. Collaborative care planning e. Positive reward process ANS: A, C, D Clinical judgment is a reflective process by which the nurse notices, interprets, responds, and reflects in action. The nursing process is a process by which the nurse assesses, diagnoses, implements, and evaluates the nursing care plan. Consulting and gaining input from the healthcare team is collaborative care planning. Evidence-based practice refers to using interventions found in research studies. The positive reward process is not a term used in care planning.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 39: Leadership Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nursing unit director exhibits the definition of leadership in which of the following responses? a. By referring the concern to the Director of the department b. By correcting the concern with the patient directly and not communicating his/her actions to the staff c. By meeting with the staff to discuss the concern and identify solutions d. By telling the staff that they need to correct the situation by tomorrow and leaves the meeting ANS: C Leadership is defined as an interactive process that provides needed guidance and direction which is present in the correct answer. The other choices do not involve an interactive process with staff to resolve the concern.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse who is certified as a Critical Care Registered Nurse (CCRN) represents the unit on the organizational performance improvement team. This is an example of which type of leadership?

N a. Formal b. Unit c. Organizational d. Informal ANS: D Informal leaders are recognized as leaders because of their capabilities and actions. Formal leaders are recognized because of the position they hold such as director or manager. Unit leadership refers to the leader of the particular unit. Organizational leadership refers to any leader within the organization.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The hospital must reduce the number of readmissions from 11% to 8% in the next year.

Which of the following best represents the transformational leadership style in accomplishing this goal? a. The Director communicates the goal of reducing readmissions to the hospital operations team and tells them to submit their action plan by the end of the week. b. The organization charters three work teams to identify solutions for the top three causes for readmissions. These teams are given full authority to implement their solution. c. The Director of Quality develops a vision statement and action plan to achieve the goal. The director works directly with the involved departments to implement the

action plan. d. The Chief Executive Officer (CEO) communicates the goal to the organizational directors and managers and states that they are entrusted to solve the problem.

ANS: C Transformational leaders communicate a vision and motivate employees to accomplish the goal. The Director who communicates the goal of reducing readmissions to the hospital operations team and tells them to submit their action plan by the end of the week leaves the solution to achieve the goal to the followers to develop without motivating them. The solution that is left to the work teams to resolve is not an example of transformational leadership. The CEO entrusts the managers and directors to solve the problem without giving them a vision or engaging in the solution with them.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The new Director of Case Management assessed the need to improve the organization’s patient satisfaction with the discharge process. Which statement below illustrates the vision that would lead the team to this goal? a. “The department will deliver reliable, collaborative, and compassionate discharge planning services to all patients.” b. “The department will hold weekly meetings every Tuesday at 11:00 AM.” c. “There will be implementation of a new uniform policy so staff can be readily identified.” d. “Staff are encouraged to complain about difficult patients, families, and physicians.”

N

ANS: A A vision is a statement about the long-term desired state for the department. The other choices describe specific actions, not a long-term vision statement.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. The clinical nurse leader needs to identify the staff who must go home due to low census.

Which answer below describes a democratic style of decision making? a. The clinical nurse leader identifies the staff person with the most vacation and asks them to go home. b. The clinical nurse leader tells the last person to show up for their shift to go home. c. The clinical nurse leader decides not to send anyone home because it is too difficult to decide who should lose hours. d. The clinical nurse leader asks the group if any of them would like the opportunity to go home and selects staff who volunteer.

ANS: D Democratic leaders use a participatory style of decision making. In the other choices, the clinical nurse leader makes the decision independent of the staff.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

6. A nurse is reviewing decision-making theories. Which statement is accurate according to situational and contingency theory? a. The theory challenges the concept that one leadership style is always best. b. The theory supports employee feelings, morale, and feedback during the change process. c. Motivation through inspiration and recognition is the focus for transforming employee behavior. d. A leader is someone who possesses great intelligence and decision-making authority.

ANS: A Situational and contingency theory challenges the assumption that there is “one best way” to lead. A theory that supports employee feelings, morale, and feedback during the change process describes behavioral leadership. Motivation through inspiration and recognition is the focus for transforming employee behavior describes transformational leadership. A leader is someone who possesses great intelligence and decision-making authority describes Great Man or Trait theory.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. To be an effective nursing leader today requires effective collaboration. Which model below best represents this process? a. The Nursing Manager of the observation unit was certain the psychology department would assist the unit with a motivational plan, so she did not request N their assistance. b. The Nursing Manager of the observation unit worked with the psychology department and physical therapy to develop a motivational plan for patients on the unit. c. The Nursing Director of Behavioral Health Services followed the administrative directive to reduce services and refused to provide services for patients on other units. d. Frustrated by the trend of patients unwilling to work with therapy, the Unit Manager recommended that these patients be placed on another unit.

ANS: B The nursing manager works collaboratively with other departments to solve the patient care issue. In the other choices, the unit manager does not involve collaboration to resolve the patient concern.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. What are the main features of complexity science that are relevant to nursing leadership?

(Select all that apply.) a. Focused on creating organizational change and looking at the whole versus

b. c. d. e.

individual parts Defined by efforts of leadership to mandate organizational change Autocratic in nature with a top-down structure for change Dependent on employees knowing what change is necessary and acting independently Non-linear and dynamic in nature, versus a static process

ANS: A, E Complexity science posits that interactions of the parts within a system are more important than the individual parts. Complexity science, however, recognizes that organizational processes are often non-linear and unpredictable. Through the dynamic interplay of negative and positive feedback an organization is able to make changes to keep abreast of the environmental context. The autocratic top-down decision making and mandates do not create a sustainable change. Being dependent on employees knowing what change is necessary and acting independently lacks interaction of leadership to stimulate change and adaptation among employees.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse is faced with an ethical issue. When assessing the ethical issue, which action should the nurse perform first? a. Ask, “What is the issue?” b. Identify all possible alternatives. c. Select the best option from a list of alternatives. d. Justify the choice of action or inaction.

ANS: A The first step in the situational assessment procedure is to find out the technical and scientific facts and assess the human dimension of the situation—the feelings, emotions, attitudes, and opinions. Trying to understand the full picture of a situation is time consuming and requires examination from many different perspectives, but it is worth the time and effort that is required to understand an issue fully before moving forward in the assessment procedure. Identifying alternatives is the second step in the situation assessment procedure.

A set of alternatives cannot be established until an assessment has been completed.

Selecting the best option is actually the third step in the situation assessment procedure.

Options cannot be selected until an assessment has been done to define the issue. Justifying the action or inaction is the final step in the situational assessment procedure. No justification can be made until the assessment and action phases have been completed.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nursing student is conductiNng a survey of fellow nursing students. Which ethical concept is the student following when calculating the risk-to-benefit ratio and concluding that no harmful effects were associated with a survey? a. Beneficence b. Human dignity c. Justice d. Human rights ANS: A Beneficence is a term that is defined as promoting goodness, kindness, and charity. In ethical terms, beneficence means to provide benefit to others by promoting their good.

Human dignity is the inherent worth and uniqueness of a person. Justice involves upholding moral and legal principles. Human rights are the basic rights of each individual.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A nurse on the unit makes an error in the calculation of the dose of medication for a critically ill patient. The patient suffered no ill consequences from the administration. The nurse decides not to report the error or file an incident report. The nurse is violating which principle of ethics? a. Fidelity b. Individuality c. Justice

d. Values clarification ANS: A Fidelity is the principle that requires us to act in ways that are loyal. In the role of a nurse, such action includes keeping your promises, doing what is expected of you, performing your duties, and being trustworthy. Individuality is something that distinguishes one person or thing from others. Injustice is when a person is denied a right or entitlement. Values clarification is a tool that allows the nurse to examine personal values in terms of ethical situations.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. An unconscious patient is treated in the emergency department for head trauma. The patient is unconscious and on life support for 2 weeks prior to making a full recovery. The initial actions of the medical team are based on which ethical principle? a. Utilitarianism b. Deontology c. Autonomy d. Veracity ANS: B Deontology is an approach that is rooted in the assumption that humans are rational and act out of principles that are consistent and objective and that compel them to do what is right.

Deontological theory claims that a decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty. Utilitarianism is an approach that is rooted in the assumption thatNan action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. An attempt is made to determine which actions will lead to the greatest ratio of benefit to harm for all persons involved in the dilemma. Autonomy is the principle of respect for the individual person. People are free to form their own judgments and perform whatever actions they choose. Veracity is defined as telling the truth in personal communication as a moral and ethical requirement.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A drug-addicted nurse switches a patient’s morphine injection with normal saline so that the nurse can use the morphine. The nurse is violating which principles of ethics? (Select all that apply.) a. Autonomy b. Utilitarianism c. Beneficence d. Dilemmas e. Veracity ANS: A, B, C, E

Beneficence is providing benefit to others by promoting their welfare. In general terms, to be beneficent is to promote goodness, kindness, and charity. By taking the patient’s pain medication and substituting saline, the nurse did harm, not good, for the patient. Autonomy is the principle of respect for the individual person; the nurse does not respect someone upon whom the nurse is inflicting harm. Utilitarianism is the principle that assumes that an action is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Because the patient’s pain medication was taken away, the consequences were all bad. Dilemmas are not included as a principle of ethics.

Veracity involves truth-telling.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Informal teaching is individualized one-on-one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes.

Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse is preparing to implement a teaching plan. Which factor might be considered to be a barrier to patient education? a. Family resources b. High school education c. Hunger and pain d. Need perceived by patient ANS: C A patient who is hungry or in pain has limited ability to concentrate or learn. Family resources would be considered in developing a plan of care and could be an asset or a barrier to patient education. The patient’s educational level would be considered in planning teaching strategies but would not be a barrier to education. A need perceived by a patient would provide motivation for learning and would not be a barrier.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. A nurse has prepared a dischaNrge teaching plan for an adult patient who is not being compliant. Which strategy should the nurse include to help increase compliance with following discharge instructions? a. Individualized handout b. Instructional videos c. Internet resources d. Self-help books ANS: B An instructional video would provide a visual/auditory approach for discharge instructions.

Repeatedly not following written instructions is a clue that the patient may not be able to read or understand the information. While assessing the literacy level of an adult patient can be challenging, the information that they have not been able to follow previous written instructions would suggest that the nurse use an alternate strategy that does not require a high degree of literacy. An individualized handout would be written, very similar to previous instructions, and would not address a concern about literacy. Internet resources generally require an individual to be able to read, and although videos are available through the Internet, this is not the best response. Self-help books would be appropriate for an individual who reads. There is a question about whether this patient is literate, so these would not be the best choice.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. When planning to evaluate a patient’s satisfaction with a teaching activity, what is the most appropriate strategy? a. Include a survey instrument. b. Observe for level of skill mastery. c. Present information more than one time. d. Provide for a return demonstration.

ANS: A A survey or questionnaires can be used to measure affective behavior change as well as patient satisfaction with the teaching experience. Observing for level of skill mastery would evaluate achievement of a psychomotor goal rather than satisfaction with the experience.

Repeating information more than one time or in more than one way may be appropriate strategies to include in the teaching plan but would provide no evaluation data. Providing for a return demonstration would help in evaluating achievement of a psychomotor goal, not satisfaction with the activity.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. A nurse manager is reviewing interrelated concepts to the professional nursing role. Which factor should the nurse manager consider when addressing concerns about the quality of patient education? a. Adherence b. Developmental level c. Motivation d. Technology ANS: D N The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 42: Health Promotion Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Which tertiary prevention measure should be included in the health promotion plan of care for a patient newly diagnosed with diabetes? a. Avoiding carcinogens b. Foot screening techniques c. Glaucoma screening d. Seat belt use ANS: B Foot screening is considered a tertiary prevention measure, one that minimizes the problems with foot ulcers, an effect of diabetic disease and disability. Avoiding carcinogens is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Glaucoma screening is considered secondary screening—measures designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Seat belt use is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. When teaching a patient withNa family history of hypertension about health promotion, the nurse describes blood pressure screening as which type of prevention? a. Illness b. Primary c. Secondary d. Tertiary ANS: C Blood pressure screening is considered secondary prevention. It is a measure designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Illness prevention is considered primary prevention. Primary prevention measures are those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Tertiary prevention measures are those that minimize the effects of disease and disability.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The primary healthcare nurse would recommend screening based on known risk factors, because of which action? a. Eliminate the possibility of developing a condition. b. Identify appropriate treatment guidelines. c. Initiate treatment of a condition or disease. d. Make a substantial difference in morbidity and mortality.

ANS: D Screenings are typically indicated and recommended if the effort makes a substantial difference in morbidity and/or mortality of conditions, and they are safe, cost-effective, and accurate. Ideally a screening measure will accurately differentiate individuals who have a condition from those who do not have a condition 100% of the time; however, there may be a false-negative result, or the patient may develop a condition after the screening was conducted. A screening does not specify treatment guidelines; the screen provides results, and the healthcare provider identifies the treatment. The goal of screening is to identify individuals in an early state of a disease so that prompt treatment can be initiated. The screening results are used for this purpose.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. At the well-child clinic, how does the nurse correctly teach a mother about health promotion activities and describe immunizations? a. Unique for children b. Primary prevention c. Secondary prevention d. Tertiary prevention ANS: B Immunizations/vaccinations are considered primary prevention measures, those strategies aimed at optimizing health and disease prevention in general. Immunizations/vaccinations are primary prevention measures for individuals across the lifespan, not just children.

Secondary prevention measures are those designed to identify individuals in an early state of a disease process so that pro mNpt treatment can be started. Tertiary prevention measures are those that minimize the effects of disease and disability.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. The nurse in a newly opened community health clinic is developing a program for the individuals considered at greatest risk for poor health outcomes. How should the nurse consider this group? a. Global community b. Sedentary society c. Unmotivated population d. Vulnerable population ANS: D Vulnerable populations refer to groups of individuals who are at greatest risk for poor health outcomes. The entire world is the global community. Sedentary refers to the lifestyles of people worldwide who have epidemic rates of obesity and many other related chronic diseases. Unmotivated population refers to the individuals who have not demonstrated interest in changing.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. When there is evidence that supports a screening for an individual patient but not for the general population, the nurse would expect the United States Preventive Services Task Force Grading (USPSTF) to be what? a. No recommendation for or against b. Recommends c. Recommends against d. Strongly recommends ANS: A The USPSTF Grading is an example of how evidence is used to make guidelines and determine priority. When there is evidence that supports a screening for an individual patient but not for the general population, there is no recommendation for or against screening the general population. Recommends is the grading when there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Recommends against is the grading when there is moderate or high certainty that the intervention has no net benefit or that the harms outweigh the benefits. Strongly recommends is the grading when there is high certainty that the net benefit is substantial.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. A nurse manager is reviewing interrelated concepts to professional nursing. Which concepts should the nurse manager consider when addressing concerns about the quality of health promotion? (Select all that apply.) a. Culture N b. Development c. Evidence d. Nutrition e. Health policy ANS: C, E The interrelated concepts to professional nursing include evidence, healthcare economics, health policy, and patient education. Culture is a patient attribute concept. Development is a patient attribute concept. Nutrition is a health and illness concept.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 43: Communication Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient states, “I had a bad nightmare. When I woke up, I felt emotionally drained, as though I hadn’t rested well.” Which response by the nurse would be an example of interpersonal therapeutic communication? a. “It sounds as though you were uncomfortable with the content of your dream.” b. “I understand what you’re saying. Bad dreams leave me feeling tired, too.” c. “So, all in all, you feel as though you had a rather poor night’s sleep?” d. “Can you give me an example of what you mean by a ‘bad nightmare’?”

ANS: D The technique of clarification is therapeutic and helps the nurse examine meaning. The distracters focus on patient feelings but fail to clarify the meaning of the patient’s comment.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. The nurse is admitting a patient to the medical/surgical unit. Which communication technique would be considered appropriate for this interaction? a. “I’ve also had traumatic life experiences. Maybe it would help if I told you about them.” b. “Why do you think you had so much difficulty adjusting to this change in your life?” c. “You will feel better afterNgetting accustomed to how this unit operates.” d. “I’d like to sit with you for a while to help you get comfortable talking to me.”

ANS: D Because the patient is newly admitted to the unit, allowing the patient to become comfortable with the setting is a technique that can assist in establishing the nurse-patient relationship. It helps build trust and conveys that the nurse cares about the patient. The nurse should not reveal their life experiences as this is not therapeutic. Asking why the patient is having difficulty may provide insight; however, this would be best saved for an established relationship with the patient. Assuring the patient that they will feel better may not be true depending on the reason for the admission.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is seeking clarification of a statement that was made by a patient. What is the best way for the nurse to seek clarification? a. “What are the common elements here?” b. “Tell me again about your experiences.” c. “Am I correct in understanding that …” d. “Tell me everything from the beginning.”

ANS: C

Clarification ensures that both the nurse and the patient share mutual understanding of the communication. The distracters encourage comparison rather than clarification and present implied questions that suggest the nurse was not listening.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. A nurse is conducting a therapeutic session with a patient in the inpatient psychiatric facility. Which remark by the nurse would be an appropriate way to begin an interview session? a. “How shall we start today?” b. “Shall we talk about losing your privileges yesterday?” c. “Let’s get started discussing your marital relationship.” d. “What happened when your family visited yesterday?”

ANS: A The interview is patient centered; thus, the patient chooses issues. The nurse assists the patient by using communication skills and actively listening to provide opportunities for the patient to reach goals. In the distracters, the nurse selects the topic.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. The nurse and the patient are conversing face to face. What communication technique is being demonstrated? a. Linguistic b. Paralinguistic c. Explicit N d. Metacommunication ANS: A Conversing face to face, reading newspapers and books, and even texting are all common forms of linguistic communication. Paralinguistics include less recognizable but important means of transmitting messages such as the use of gestures, eye contact, and facial expressions. Explicit communication is not a therapeutic communication technique.

Metacommunication factors that affect how messages are received and interpreted would include internal personal states (such as disturbances in mood), environmental stimuli related to the setting of the communication, and contextual variables (such as the relationship between the people in the communication episode).

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE 1. The nurse is working with a patient diagnosed with posttraumatic stress disorder related to childhood sexual abuse. The patient is crying and states, “I should be over this by now; this happened years ago.” Which response(s) by the nurse will facilitate communication? (Select all that apply.) a. “Why do you think you are so upset?” b. “I can see that this situation really bothers you.” c. “The abuse you endured is very painful for you.”

d. “Crying is a way of expressing the hurt you’re experiencing.” e. “Let’s talk about something else, since this subject is upsetting you.”

ANS: B, C, D Reflecting and giving information are therapeutic techniques. “Why” questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 44: Collaboration Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A newly licensed nurse is assigned to an experienced nurse for training on a medical unit of a hospital. What type of nurse-to-nurse collaboration does this assignment demonstrate? a. Interprofessional b. Shared governance c. Interorganizational d. Mentoring ANS: D Mentoring is a collaborative partnership between a novice nurse and an expert nurse to help transition a nurse through career development, personal growth, and socialization into the profession. Interprofessional collaboration is working with several disciplines. Shared governance is a type of management for nursing. Interorganizational collaboration often includes teams from inside and outside an organization to meet a common goal.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse is presenting an in-service on the importance of collaborative communication.

The nurse includes which critical event identified by the Joint Commission as an outcome of poor communication among healthcare team members? a. The occurrence of a patieNnt event resulting in death or serious injury b. Decreased ability to document expenses of care provided c. Longer time to begin surgical cases d. Increased time to discharge patients to outpatient care ANS: A The Joint Commission has identified that poor communication is the primary factor in the occurrence of sentinel events, or events resulting in unintended death or serious injury to patients. Lack of documentation, longer time to begin surgery, and increased delays in discharge all contribute to the management of health care, but do not result in critical patient outcomes.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A nurse is reviewing the concept of professional collaboration. Which patient scenario should the nurse identify as the best example of professional collaboration? a. The nurse, physician, and physical therapist have all visited separately with the patient. b. The nurse, physical therapist, and physician have all developed separate care plans for the patient. c. The nurse mentions to the physical therapist that the patient may benefit from a muscle strengthening evaluation. d. The nurse and physician discuss the patient’s muscle weakness and initiate a

referral for physical therapy.

ANS: D Professional collaboration includes team management and referral to needed providers to meet patient needs. Each discipline retains responsibility for their own scope of practice but recognizes the expertise of other providers. Working separately does not develop a comprehensive plan of care. Casual mentioning of patient needs does not follow professional communication channels and frequently delays needed interventions.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A registered nurse (RN) is reviewing the concept of collaboration. Which statement correctly describes the RN nursing’ role in collaboration? a. State boards of nursing mandate that collaboration can only occur in hospitals. b. Collaboration should occur only with physicians. c. Collaboration occurs only between nurses with the same level of education. d. Collaboration may occur in health-related research.

ANS: D RNs collaborate with many different persons, including patients, managers, educators, and researchers. Collaboration does not occur only with physicians or nurses of equivalent educational background, but with anyone who is working toward meeting patient goals.

Collaboration occurs in any healthcare setting as well as community and home settings.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

N 5. A nurse manager is looking to promote a culture of safety on the medical unit. Which action should the nurse manager implement? a. Focus on the number of medication errors occurring on the unit. b. Focus on adapting system changes. c. Providing incentives to nurses who don’t make any medication errors. d. Placing nurses on restricted duty who have made medication errors.

ANS: B The Institute of Medicine (IOM) and QSEN initiative have switched their perspective from medication errors to systematic changes that focus on safety aspects. The nurse manager should not use rewards or incentives to motivate change of behavior as that would not promote a culture of safety if individuals feared retaliation or were treated differently for safe behavior practices.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. The nurse and physician are explaining that home care that will be needed by a patient after discharge. The patient’s spouse states angrily that it will not be possible to provide the care recommended. What is the best response by the nurse? a. “Let me review what is needed again.” b. “It is important that you do what the physician has prescribed.” c. “What concerns do you have about the prescribed care?”

d. “I can come back after you talk with your spouse about the care.”

ANS: C The patient needs to be the focus of developing care plans, and communication is an important part of collaboration with the patient to discover barriers for the patient to follow recommendations. It is important to either provide solutions to the barriers or present other options. Reviewing the care again does not demonstrate willingness to have the patient be part of the team. Insisting that the patient do what is prescribed is autocratic and does not recognize the role the patient has in their care. Leaving the patient and spouse with the situation unresolved fosters distrust and more anger.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. The nurse is caring for a patient with a progressive, degenerative muscle illness. The patient states that she would like to remain in her home with her daughter as long as possible. What action should the nurse take? a. Teach the patient muscle strengthening and stretching exercises. b. Tell the patient to make plans to move to an assisted-living facility. c. Discuss resources to help the patient and make appropriate referrals. d. Ask the patient to come in for daily physical therapy.

ANS: C To honor the patient’s request to stay at home the nurse should make appropriate referrals for needed evaluation and assistance. Most nurses will not have the expertise to teach appropriate exercises for degenerative illness. Asking the patient to move to an assisted-living facility does not account for the patient’s request. The patient has not been assessed for the need of dailyNtherapy, and it is not likely that a patient with a degenerative illness will be able to make daily appointments for treatment as the illness progresses.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

8. A patient has been admitted to an acute care hospital unit. The nurse explains the hospital philosophy that the patient be an active part of planning their care. The patient verbalizes understanding of this request when they make which statement? a. “I will have to do whatever the physician says I need to do.” b. “Once a plan is developed, it cannot be changed.” c. “My insurance will not pay if I don’t do what you want me to do.” d. “We can work together to adjust my plan as we need to.”

ANS: D Treatment plans need to be developed, evaluated, and adapted as needed based on the patient status and willingness to complete the prescribed care. Stating that the patient has to do whatever the care provider prescribes does not include the principle of collaboration.

Care plans can be altered based on patient status. Insurance providers do not determine a patient’s ability to complete prescribed care, although they do reimburse for standard care given.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

9. The management of a community hospital is trying to encourage a more collaborative environment among staff members. Which concept is most important for management to develop first? a. Post educational posters about how well collaboration is being performed b. Highlight that no single profession can meet the needs of all patients c. Provide meetings for each department on how their role affects patients d. Begin implementing evaluations of collaborative skills on annual performance reviews ANS: B Recognizing that collaboration needs all professions to provide patient-centered care is an important first step to implementing a different philosophy in the hospital. Posting an evaluation of performance before education will not encourage participation. Collaboration requires an understanding of more than your own discipline. It is unfair to evaluate staff on a requirement that they have not been introduced to.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. Which activities are appropriate for the nurse to collaborate with a patient? (Select all that apply.) a. Prescribing a new medication dose b. Health promotion activities c. End-of-life comfort decisions N d. Interpreting laboratory results e. Lifestyle changes to improve health ANS: B, C, E Nurses should include patients and their families when exploring health promotion activities, end-of-life decisions, lifestyle changes, and treatment options. Prescribed medication doses are initiated by educated professionals, although the patient gives feedback on the effectiveness of medications. Patients are not trained to interpret lab results, but patients rely on health professionals to explain results to them.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

3. A nurse administers an incorrect medication to a patient. In reviewing this medication error, the nurse finds out that incorrect medication was placed in the Pyxis system. What type of error has the nurse committed? a. Latent error b. Blunt end c. Did not follow nursing process d. Latent error resulting in active error ANS: D The situation described is a latent error which resulted in an active error as incorrect medication was placed in the Pyxis system. Latent errors are also referred to as blunt end whereas active errors are applied as occurring at the sharp end. There is no provided information to suggest that the nurse did not follow nursing process.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Prior to drug administration the nurse reviews the seven rights, which include right patient, right medication, right time, right dose, right education, right documentation, and what other right? a. Room b. Route c. Physician d. Manufacturer

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ANS: B The right route (e.g., oral or intramuscular) is an essential component to verify prior to the administration of any drug. The patient does not need to be in a specific location. There may be a number of physicians caring for a patient who prescribe medications for any given patient. A similar drug may be made by a number of different companies, and checking the manufacturer is not considered one of the seven rights. However, the nurse will want to be aware of a difference, because different companies prepare the same medication in different ways with different inactive ingredients, which can affect patient response.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. Which nursing action indicates that a nurse is more likely to incur a medication error during medication administration? a. Checks the original medication order on the patient’s chart b. Asks the patient to state his/her name and date of birth c. Does not scan the barcode of the patient prior to administering the medication d. Does not provide the patient with a glass of water ANS: C

Use of barcode scanning of both the medication and the patient’s hospital band is critical to maintaining safe practice during medication administration. The nurse by not scanning the barcode is not maintaining the required elements and as a result is more likely to incur a medication error. Checking the original order and asking the patient to provide identification are required elements. Not providing a glass of water to the patient is not related to a medication error but does not represent best practice unless the patient is NPO except meds which would require sips of water.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. To promote safety, the nurse manager sensitive to point of care (sharp end) and systems level (blunt end) exemplars works closely with staff to address which point of care exemplar? a. Care coordination b. Documentation c. Electronic records d. Fall prevention ANS: D The most common safety issues at the sharp end include prevention of decubitus ulcers, medication administration, fall prevention, invasive procedures, diagnostic workup, recognition of/action on adverse events, and communication. These are the most common issues the staff nurse providing direct patient care encounters. Each of the other options is classified as systems level exemplars.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. Aspects of safety culture that contribute to a culture of safety in a healthcare organization include which component? a. Communication b. Fear of punishment c. Malpractice implications d. Team nursing ANS: A Aspects that contribute to a culture of safety include leadership, teamwork, an evidence base, communication, learning, a just culture, and patient-centered care. Fear of professional or personal punishment and concern about malpractice implications are considered barriers to a culture of safety. No model of nursing care has been related to a culture of safety.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A staff nurse reports a medication error due to failure to administer a medication at the scheduled time. What is the charge nurse’s best response? a. “We’ll conduct a root cause analysis.” b. “That means you’ll have to do continuing education.”

c. “Why did you let that happen?” d. “You’ll need to tell the patient and family.”

ANS: A In a just culture the nurse is accountable for their actions and practice, but people are not punished for flawed systems. Through a strategy such as root cause analysis the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences. Requiring continued education may be an appropriate recommendation but not until data is collected about the event. Telling the patient is part of transparency and the sharing and disclosure among stakeholders, but it is generally the role of risk management staff, not the staff nurse.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 9. To promote a culture of safety, the nurse manager preparing the staff schedule considers the anticipated census in planning the number and experience of staff on any given shift. Which is the human factor primarily addressed with this consideration? a. Available supplies b. Interdisciplinary communication c. Interruptions in work d. Workload fluctuations ANS: D Including an adequate number of staff members with experience caring for anticipated patients is a strategy to manage the workload and potential fluctuations. A safety culture requires organizational leaderNship (e.g., the nurse manager) that gives attention to human factors such as managing workload fluctuations. This strategy also applies principles of crew resource management in that it addresses workload distribution. Lack of supplies can create a challenge for safe care but could not be addressed with the schedule. Concerns with communication and coordination across disciplines, including power gradients, and excessive professional courtesy can create hazards but would not be the best answer.

Strategies to minimize interruptions in work are essential but would not be the best answer in this situation.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 46: Technology and Informatics Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The staff nurse who uses informatics in promoting quality patient care is most likely to access data in which domain? a. Certified clinical information systems (CIS) b. Clinical healthcare informatics c. Public health/population informatics d. Translational bioinformatics ANS: B Clinical healthcare informatics and the subset, nursing informatics, provides for the development of direct approaches to patients and their families which can be used by the staff nurse to promote quality patient care. Certified CIS refers to the tools for achieving quality outcomes, including electronic health records, clinical data repositories, decision support programs, and handheld devices—not the data. Public health/population informatics is the domain which relates information, computer science, and technology to public health science to improve the health of populations; this domain would provide data for the nurse working with communities. Translational bioinformatics refers to the research science domain where biomedical and genomic data are combined; it is a new term that describes the domain of where bioinformatics meets clinical medicine, generally for healthcare research rather than direct patient care.

OBJ:

NCLEX Client NeedsNCategory: Health Promotion and Maintenance

2. When discussing the purposes of healthcare informatics with a nurse during orientation, the nurse educator would be concerned if the nurse orientee stated that which is one purpose of informatics? a. Develop a cognitive science. b. Improve disease tracking. c. Improve the health provider’s work flow. d. Increase administrative efficiencies.

ANS: A Cognitive science is one of the theories that play a role in the implementation of informatics.

Its development is not a purpose, and the nurse educator would use this incorrect response of the orientee to plan additional teaching about the purposes of healthcare informatics.

Purposes of information health technology include to improve health provider work flow, improve healthcare quality, prevent medical errors, reduce healthcare costs, increase administrative efficiencies, decrease paperwork, and improve disease tracking.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. To design and implement a decubitus ulcer risk management protocol in the electronic health record, the informatics nurse would first perform which action? a. Build the screens in the electronic health record.

b. Determine evidence supporting decubitus ulcer risk management. c. Develop the training program for staff. d. Select the appropriate standardized language.

ANS: B Collecting the evidence related to the issue is the first step in addressing a problem (remember the nursing process, the foundation of nursing practice). Based on the evidence, an assessment tool or tools and data needed from a patient perspective would be identified.

The screens in the electronic record would be based on the workflow surrounding the patient assessment. A training program could not be developed until the protocol is adopted. The appropriate standardized language is selected based on what needs to be documented and what has been approved for use by the agency (e.g., ANA recognized terminologies).

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The application of information processing that deals with the storage, retrieval sharing, and use of healthcare data, information, and knowledge for communication and decision making is the definition of which area? a. Computer science b. Health informatics c. Health information technology d. Nursing informatics ANS: C This is the definition of health information technology. Computer science is a branch of engineering that studies compNutation and computer technology, hardware, software, and the theoretical foundations of information and computation techniques. Health informatics is a discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. The nurse manager of a medical/surgical unit wants to increase the use of healthcare technology on the unit and is working with an ANA-certified informatics nurse to reduce which barriers to health information exchange? a. Basic informatics knowledge and skills b. Offering the best set of tools c. Privacy and security policies d. Unit-specific terminology ANS: D

Unit-specific terminology would be a barrier to sharing health information because there could be confusion about terms. Standardized terminology within the electronic health record is critical for communicating care to the interprofessional team and exchanging health information. Competency in informatics including basic informatics knowledge and skills could facilitate the use of informatics; lack of competency could be a barrier. Offering the best set of tools could promote the ease of data entry and access. Privacy and security policies reduce legal and ethical concerns about sharing data, thus reducing barriers to health information exchange.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse is reviewing concepts related to documentation in the electronic health record.

Which statement best represents the concept of “meaningful use”? a. Allows for privacy of information b. Uses individualized log on for access c. Completes charting in a timely manner d. Meets established criteria related to technological use ANS: D The concept of “meaningful use” refers to the establishment of criteria related to technological use of the electronic health record as determined by federal guidelines.

HIPAA policy mandates privacy of personal information and patient medical records. Use of an individualized log on to access relates to security concerns. Completing charting in a timely manner is an expectation of prudent practice.

OBJ: NCLEX Client NeedsNCategory: Safe and Effective Care Environment: Management of Care 7. Which are exemplars of the health informatics concept? a. Clinical research informatics b. Hardware and software c. Privacy and security d. Standard terminology ANS: A Exemplars of the health informatics concept include clinical healthcare informatics, clinical research informatics, public/population health informatics, and translational bioinformatics.

Hardware and software, privacy and security, and standardized information systems and terminology are considered attributes related to the concept, not exemplars.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

b. Randomized controlled study c. Systematic reviews/meta-analysis d. Survey study ANS: B A randomized controlled study is a type of quantitative research that seeks to control and examine the variables to determine effectiveness. In this case, the variables would be those that were administered tramadol (Ultracet) and those that were administered hydrochloride and acetaminophen (Percocet) for managing back pain. Correlational research methods help determine association between or among variables. A longitudinal study examines variables over a designated course of time. A systematic review/meta-analysis is a type of literature review and not a research method. A survey study is a type of qualitative research method.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The nurse in the psychiatric unit is involved in a research study for a depression medication.

In the study, patients are randomly assigned to one depression medication and the other group is receiving no medication to treat the depression. What method of research are the patients involved with? a. Descriptive b. Correlational c. Quasi-experimental d. Experimental ANS: D Experimental tests an interveN ntion and includes both a control group and random assignment. This research study tests an intervention and includes both a control group and random assignment. Descriptive defines the magnitude of a concept and its characteristics.

Correlational determines association between or among variables. Quasi-experimental tests an intervention and lacks either a control group or random assignment.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. How does the Iowa model transcend mere nursing care? (Select all that apply.) a. It includes formalized internal feedback loops. b. Its triggers can have their origins practically anywhere. c. It generates change in practice solely through research. d. It implies a layer of policy development. e. It addresses multiple disciplines’ impacts on quality.

ANS: A, B, D, E

The triggers addressed within the Iowa model process can be problem focused and evolve from risk management data, process improvement data, benchmarking data, financial data, and clinical problems. The triggers can also be knowledge focused, such as new research findings, change in a national agency’s or an organization’s standards and guidelines, expanded philosophy of care, or questions from the institutional standards committee.

Because the Iowa model is often implemented at a fairly high level of nursing or hospital administration, it scrutinizes the input of nursing and other disciplines in its process. Its output is applied as widely as possible throughout the organization, and it can affect policy within a multihospital system and even across systems. The success of EBP is determined by all involved, including healthcare agencies, administrators, nurses, physicians, and other healthcare professionals.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. Which statements are true about the Iowa model of EBP? (Select all that apply.) a. It addresses utilization of research findings at an individual level. b. It addresses the relevance of the question to the organization. c. Individual nurses enact an Iowa decision tree when they examine risk management data. d. It identifies triggers capable of posing hazard or benefit. e. It reiterates that innovators embrace change far earlier than laggards.

ANS: B, D The Iowa model of EBP provides direction for the development of EBP in a clinical agency and as such focuses on the relevance of the question to the organization. In a healthcare agency, there are triggers t h a N t initiate the need for change, and the focus should always be to make changes based on best evidence. The Iowa model of EBP was revised in 2015 to provide additional feedback loops, detailed instructions, and inclusion of patient preferences.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse is conducting a review of the literature for pain management techniques. Which of the following should the nurse consider when conducting research that yields solid EBP? (Select all that apply.) a. Search the literature to uncover evidence to answer the question. b. Evaluate the outcome. c. Use the nursing process to evaluate evidence. d. Evaluate the evidence found. e. Develop an answerable question. f. Develop a question that has not been answered. g. Apply the evidence to the practice situation.

ANS: A, B, D, E, G To facilitate the use of evidence, steps have been developed to systematically approach a question of patient care. The steps are outlined as follows: • Develop an answerable question.

• Search the literature to uncover evidence to answer the question.

• • • •

Evaluate the evidence found.

Apply the evidence to the practice situation.

Evaluate the outcome.

The nursing process is a method of problem solving and can be used to develop a plan of care. Formulating a question that has not been answered in the research would be considered primary research. Therefore, there is no evidence in which to draw from.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

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4. What are two major foci of The Joint Commission (TJC) in the delivery of health care? a. Cost containment, safety b. Safety, quality c. Quality, assessment d. Assessment, evaluation ANS: B The focus of TJC is quality and safety for patient care. TJC does not address cost containment, assessment of care, or evaluation of care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A student nurse and clinical instructor are discussing quality in health care. The instructor knows the student understands when the student makes which statement? a. “Quality is apparent in all health care.” b. “Quality is an outcome of health care.” c. “Quality is seen and unseen in health care.” d. “Quality is achieved by collaboration in health care.”

ANS: C Quality in health care is tangible and intangible. Quality in health care is not apparent in all health care, as many areas of health care are lacking. Quality of care does not always affect the outcome of care; the patient may recover no matter what care is given. Quality is not always achieved by collaboration.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. The focus of quality health care should be on which of the following items? (Select all that apply.) a. Excellent services b. Comprehensive communication c. Private hospital rooms d. Health team collaboration e. Culturally competent care ANS: A, B, D, E Excellent services, communication, collaboration, and culturally competent care bring quality to the health care delivered to the patient. Private hospital rooms may be a preference by some patients, but they do not add to the quality of care.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. What are the major attributes of health-care quality? (Select all that apply.) a. Conforms to standards b. Sound decision making

c. High acuity patients d. Low health-care costs e. Identifies adverse events ANS: A, B, E Major attributes of health-care quality include conformation to standards set by regulatory agencies, sound decision making regarding care, and identifying potential adverse events.

High acuity of patients does not contribute to quality health care, because the care demand is increased, and low health-care costs mean fewer services may be available.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

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4. The nurse is discussing care coordination with a patient. The patient asks the nurse to explain care coordination. What is the nurse’s best response? a. “Care coordination is a cost effective method created by the community.” b. “Care coordination forces the health-care facilities in the community to work together.” c. “Care coordination exists for the children and uninsured in the community.” d. “Care coordination allows health-care services to work together in the community.”

ANS: D Care coordination allows all health-care/community services to work together so that patient and family needs can be met. Care coordination does not focus on cost methods. Cost coordination does not exist just for children or the uninsured. No one service is forced to work with another service.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. Nurses work to serve the population, and they know that which priority population needs to be served by care coordination? a. Most vulnerable and the frail b. Uninsured and the very young c. Underinsured and the elderly population d. Whole population of the community ANS: A The priority population is the most vulnerable and the frail, because they have the most health-care needs. Other popuNlations do need health care, but they do not always have immediate need of the health-care system.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nursing instructor is talking about care coordination with nursing students. The instructor stresses which of the following to the students concerning care coordination? a. “A patient must ask for what they need in order to coordinate care.” b. “The nurse does most of the work in care coordination.” c. “Medical diagnoses are an integral part of care coordination.” d. “Collaboration is a significant part of care coordination.”

ANS: D Collaboration is a big part of care coordination. Without the collaboration, there would be no care coordination. Patients asking for their needs to be met does not collaborate care.

Nurses do not do all the work in care collaboration. Medical diagnoses are one small part that drives the need for care collaboration.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. Care coordination models should be adopted in health-care facilities. If models are not put into practice, the shortcomings of the health-care system may display which of the following items? (Select all that apply.) a. Decrease in patients b. Fragmented services c. Low birth weight newborns d. Cost inefficiencies e. Poor health outcomes f. Increased pharmacy costs ANS: B, D, E Fragmented services, cost inefficiencies, and poor health outcomes may be some of the shortcomings seen in health care without the proper model in place to guide the health-care delivery system.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

The father will be cared for at the adult daycare, and it is a nice alternative for the daughter.

She will be able to work and know that her father is safe during the day. The daughter thinking the father will be okay in a few days is not realistic, nor can she deadbolt the door and lock him in the house.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. Many middle-aged adults are called the “sandwich” generation because they are caring for their children and their aging parents. What is the priority reason for aging parents needing care? a. Mental clarity b. Immobility c. Blindness d. Multiple chronic illnesses ANS: D Multiple chronic illnesses come with the aging process. Middle-aged adults are becoming the caregivers for the generation before them and the one after them. Mental clarity is a positive aspect of aging and does not need care. Immobility and blindness do not always mean that the person needs direct care.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. A mother is talking with the community-based nurse concerning her adult son. The son is mentally challenged and not able to live on his own. The mother is concerned about her son’s welfare when she is no longer able to care for him. What is the best response by the N nurse? a. “Let’s look into the community resources that are available to assist you.” b. “You have raised your son well, and he will be okay on his own.” c. “Contact your distant relatives to see if anyone would take your son.” d. “There are places for mentally challenged adults; let’s place him there.”

ANS: A The mother, with the assistance of the nurse, can research resources in the community that will service and care for her son when she is no longer able to do so. How the son is raised does not mean that he will be okay on his own. Distant relatives may not want or be able to care for the son, so this may not be a viable option. Placing the son is too general of an option, and he may not do well in this setting.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE 1. Many grandparents today are caring for grandchildren in place of a parent. Identify the reasons why this phenomenon is happening. (Select all that apply.) a. Children prefer living with their grandparents. b. Parents are incarcerated. c. Parents are deceased. d. Grandparents are better caregivers.

e. Parents are mentally ill. f. Parents are substance abusers.

ANS: B, C, E, F Grandparents are usually caring for children because the parents are deceased, in prison, substance abusers, or mentally ill and cannot care for the children. The fact that children prefer to live with the grandparents or the grandparents may be better caregivers is not a main reason for this phenomenon to happen.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity 2. Caregivers are often categorized by their relationship to the person being cared for. Which of the following are the roles? (Select all that apply.) a. Grandparent b. Spouse c. Parent d. Adult children e. Neighbor/friend f. Young children ANS: A, B, C, D, E All of these options can provide care whether it is on a temporary or permanent basis.

Young children do not provide care.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

4. The student demonstrates a lack of understanding of palliative care when making which statement? a. “Palliative care is designed to promote comfort.” b. “Palliative care is designed to reduce disease exacerbations.” c. “Palliative care is designed to decrease acute care hospital admissions.” d. “Palliative care is designed to promote a cure for chronic disease.”

ANS: D Palliation is the reduction of symptoms without elimination of the cause. Palliative care refers to the provision of care for patients who are diagnosed with a disease or condition without a cure.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort 5. Which is one of the biggest challenges facing current nursing practice? a. The number of aging Americans living with chronic disease b. The number of patients entering into hospice programs c. The number of cancer patients receiving supportive care d. Reduced length of stay in hospice care ANS: A Millions of Americans are living with one or more chronic debilitating diseases, and 7 out of 10 can expect to live with their diseases several years before dying. When coupled with the advancing age of the eight million baby boomers who now qualify for Medicare, this will soon create a huge demand on health-care resources and community-based services.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. When considering the trajectory of a specific disease, what is the most important concept? a. Hospital admissions b. Physical functioning c. Quality of life d. Symptom management ANS: B The disease trajectory occurs from the onset of a life-limited diagnosis until death. Physical functioning determines the decline in the patient’s physical status. Decline in status is used to determine when to intervene with palliative and end-of-life care.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The interprofessional core team includes members from which disciplines? a. Nursing, medicine, volunteers, and nutrition b. Medicine, nursing, social work, and clergy c. Medicine, nursing, physical therapists, and volunteers d. Nursing, home health aides, volunteers, and clergy ANS: B

An interprofessional team approach involving healthcare professionals from different disciplines is central to optimal palliative care practice and quality outcomes. The interdisciplinary core team includes members from medicine, nursing, social work, and clergy. Ancillary disciplines are also included. Volunteering is not considered a discipline in health care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Concept 52: Health Disparities Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for a Chinese patient diagnosed with cancer who is suffering from pain, yet refuses analgesia administration. What type of health disparities is this patient exhibiting? a. Avoidable and acceptable b. Avoidable and unacceptable c. Unavoidable and acceptable d. Unavoidable and unacceptable ANS: B Health disparities that are avoidable and unacceptable unfortunately occur in healthcare settings and these are the targets of interventions. For example, a disparity in cancer pain management exists between Asians and Whites. This difference is attributable to Asian cultural values and attitudes related to cancer pain and pain medication distinguished from the cultural values of Whites. The disparity is avoidable if Asian cancer patients are adequately educated and instructed on cancer pain management strategies including pain medication and complementary and alternative medicine. Also, this disparity is unacceptable because this gives an unnecessary burden of pain to Asian cancer patients that could be easily managed by using existing strategies.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management N of Care 2. An experienced nurse tells the student nurse, “I have found that most Hispanic immigrants live in unsanitary conditions but are hard workers.” How should the student nurse best classify this statement? a. Stereotyping b. Prejudice c. Discrimination d. Misinformed ANS: A Stereotyping often leads to biased clinical decision making. Stereotyping refers to the process by which people use social categories (e.g., gender or race/ethnicity) in acquiring, processing, and recalling information about others. Both implicit and explicit negative attitudes and stereotypes of healthcare providers significantly shape interactions with patients, influence how information is recalled, and guide expectations and inferences in systematic ways. Stereotyping often occurs subconsciously, unlike prejudice or discrimination. Prejudice, which refers to unjustified negative attitudes based on a person’s group membership, is another source of biased clinical decision making. Discrimination refers to the actual mistreatment of individuals based on race, gender, ethnicity, etc. The nurse is not misinformed as the nurse has practiced for some time and made a statement based on observation and experience.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment: Management

of Care 3. Which type of health disparities are most frequently encountered by nurses in clinical and community settings? a. Avoidable and acceptable b. Avoidable and unacceptable c. Unavoidable and acceptable d. Unavoidable and unacceptable ANS: B Although there are many types of health disparities, the avoidable and unacceptable health disparities are the ones that healthcare providers, including nurses, frequently encounter in clinical and community settings. Furthermore, these are the health disparities that healthcare providers need to target to intervene.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The nurse is caring for diverse population groups at a health clinic. Which of the following patients demonstrates a potential health disparity group? a. A 26-year-old woman who is receiving follow-up after a car accident b. A 30-year-old immigrant who does not speak English c. A 28-year-old man who needs a tetanus booster d. A 12-month-old with an appointment for immunizations ANS: B Poor health literacy skills areNan example of a health disparity that limits an individual’s ability to access or communicate about healthcare needs. Patients who are receiving needed care are not experiencing a gap between health need and actual care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Which is the best strategy the nurse manager should include when working to reduce healthcare disparities on a medical-surgical unit? a. Less diverse workforce b. Increase interpreter availability c. Authoritarian leadership d. Annual staff training ANS: B Key elements are cultural competence that can reduce health disparities including: a diverse workforce; interpreter availability; finding common ground versus authoritarian leadership; frequent staff training and updating staff as needed throughout the year.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A new nurse requires further teaching when failing to identify which practice as a health disparity?

a. b. c. d.

Annual mammogram Early prenatal care Blood pressure screening Frequent fast food meals

ANS: D Preventive care, screening, and health promotion activities are not considered health disparities. Examples include mammograms, prenatal care, and blood pressure checks.

Frequent fast food meals, containing high fat content, are considered a health disparity due to possible lack of money or access to healthy meals.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. Before beginning work on a culturally diverse hospital unit, the nurse should perform which action first? a. Improve self-awareness of one’s own biases. b. Attend an anti-discrimination rally or march. c. Build rapport and trust with the patients. d. Take a foreign language class.

ANS: A Before working with culturally diverse groups, the nurse should first identify own biases and assumptions in order to objectively and competently care for patients. Attending a rally or march may not raise awareness of various biases. The nurse should establish rapport and trust when working with patients, after self-awareness is appreciated. Taking a foreign language may be helpful; how Neve r the first step is self-awareness.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

8. The nurse who has been hired to work on an oncology unit identifies which group of women as being at highest risk of developing breast cancer? a. African b. Caucasian c. Asian d. Hispanic ANS: C Breast cancer is the most common cancer in Asian women in the United States, but Asian women have relatively lower rates of breast cancer screening than African American and white women in the United States. Furthermore, disparities in breast cancer screening reportedly result from low income, lack of a local mammography center, lack of transportation to a mammography center, lack of a usual healthcare provider, lack of a recommendation from a healthcare provider to get mammography screening, lack of awareness of breast cancer risks and screening methods, and cultural and language differences.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE 1. A healthcare provider whose native country is India is explaining the treatment plan to a patient. The patient tells the nurse she is having trouble understanding the provider but is embarrassed about asking to repeat the information over and over. The nurse should assess for which results due to this disparity in provider-patient communication? (Select all that apply.) a. Patient dissatisfaction b. Optimal health outcome c. Poor adherence d. Increased patient confidence e. Improved communication ANS: A, C When sociocultural differences between healthcare providers and patients are not appreciated or communicated effectively in clinical encounters, patient dissatisfaction, poor adherence, poorer health outcomes, and racial/ethnic disparities in healthcare easily happen.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse in the immunization clinic should place emphasis on educating and reaching which groups about the disease preventing effects of immunizations? (Select all that apply.) a. Caucasian b. All individuals living below the federal poverty level regardless of race or ethnicity N c. Low income d. Parents of children e. High income ANS: B, C, D It is important to reach out to all individuals living below the federal poverty level (parents and children) as they are most likely not to have completed the specified immunization schedule. Research obtained from the Center for Disease Control (CDC) in 2014 suggests that those living below the federal poverty level were less likely to have the full series of vaccination coverage.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

A nurse working as a public health nurse, who is providing care to a patient who has been exposed to a disease such as tuberculosis, would be providing disease prevention. Health protection would include providing educational materials to patients. Health promotion would include providing healthy educational programs. Community nursing is considered a specialty area of practice not an aspect of care.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. A parent asks the nurse to explain the term “herd immunity.” How should the nurse respond? a. “As long as your child receives his/her immunizations, they will be protected by this concept.” b. “It is important for 90% of the population to maintain their vaccination status for herd immunity to be effective.” c. “The term applies to individuals who have decided not to immunize but instead use isolation practices to maintain health.” d. “The term relates to individual groups of patients who are immunized.”

ANS: C The concept of herd immunity refers to 90% of the population being immunized in order for it to be effective on a population level. Although it is important for individual children to be immunized, the overall population must maintain a high immunization status to be effective.

Immunization is the key to the concept and the term does not relate to individual groups.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 5. A nurse is reviewing factors tNh a t lead to prevention of non-communicable diseases. Which intervention would be most effective for the nurse to implement for a group of patients? a. Check the patient’s immunization records. b. Maintain scheduled appointments with their healthcare provider. c. Offer information related to smoking cessation. d. Check patient’s medication record.

ANS: C Health promotion is an essential aspect of population health. Offering information related to smoking cessation would be most effective. Although it is important to check the patient’s immunization record, this relates to communicable diseases. Checking the patient’s medication record and maintaining scheduled appointments with their healthcare provider are important as well but in terms of health promotion, providing smoking cessation information would be more important.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A nurse is reviewing health promotion strategies with regard to population health. Which non-communicable disease processes linked to high morbidity and mortality can be addressed through health promotion? (Select all that apply.) a. Cardiac disease

b. c. d. e.

Diabetes End stage renal disease Stroke Chronic lower respiratory disease

ANS: A, B, C, D, E Of the ten leading causes of death, five of them are linked to non-communicable diseases: heart disease, diabetes, end stage renal disease, stork and chronic lower respiratory disease.

Each of which can be addressed via health promotion measures.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

ANS: C External environmental factors that affect organizations are conditions or events that occur outside the control of the agency, such as new health laws, governmental regulations, or economic trends. Internal environmental factors occur within the organizational structure and include such factors as technology issues, changes in personnel roles, or the implementation of new policies.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse manager recognizes that systems theory identifies that there is a social component within an organization that affects the overall functioning of the system. What indicator would demonstrate to the nurse manager that the social needs of an organization are being met? a. Most employees from the organization attend an annual holiday celebration. b. Separate eating areas for each discipline are set up in the cafeteria. c. Nurse managers are planning to move to a centralized area away from the care units. d. The summer softball teams are canceled due to lack of interest.

ANS: A Systems theory focuses on the needs and desires of people who work in the organization.

Good attendance at a work-sponsored function indicates that staff enjoy interacting and are meeting social and relationship roles. Separating disciplines does not foster a sense of team.

Moving administration away from staff limits interaction and informal conversations that build trust. Lack of participation in sponsored events such as a softball team indicates that staff relationships are not stroNng, and a social component is not being achieved within the work environment.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A hospital organization is working to improve a feeling of being valued and respected among all staff members. Which action by administration would reinforce the feeling of being valued? a. Create professional pathways that require advanced education for any advancement of staff. b. Seek staff input when planning a remodeling project of patient rooms. c. Form committees that consist of upper management to plan organizational goals. d. Consistently schedule required staff meetings at the same time each month.

ANS: B Including staff at all levels of an organization in planning and projects demonstrates respect for the intelligence and creativity of the individual. Requiring advanced education for any advancement limits those with barriers to attending additional schooling; advancement should be available in a variety of ways to show the value of the individual. Committees that only consist of upper management cause a feeling of disconnect between staff and administration. Scheduling meetings at the same time does not consider those who work shifts and either have to come in on their day off or must disrupt sleep to attend.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A quality improvement committee is reviewing discharge surveys. Results show that patients and their families have difficulty finding departments and areas of the hospital.

What action by the committee would best address this concern for the organization? a. Continue to review future surveys to monitor the situation. b. Give additional training to the receptionists and switchboard personnel to give better directions. c. Form a multidisciplinary committee to identify options to help travel through the hospital. d. Send a work order to the maintenance department requesting that brighter lights be installed.

ANS: C Successful organizations respect the input of all disciplines when searching for solutions for problems. Continuing to gather data delays solving a problem. There is no indication that verbal directions will solve the problem; additional measures may be required. Merely providing additional light may not solve the problem—multi-language signs or even remodeling may be identified by the committee as being needed.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse manager finds an unsigned note reporting that patient care standards are not consistently being followed. Within the organizational structure, what is the best action for N the manager? a. Schedule a staff meeting to ask staff who left the note. b. Send an email reminder that all staff need to review the policy and procedure book. c. Wait for a staff member to come forward who is willing to be identified. d. Form a small group to explore why staff are not comfortable reporting errors.

ANS: D There are significant problems in an organization where staff are not willing to openly discuss problems, especially problems that affect patient care. A focus group can help identify what is preventing a sense of comfort to reveal problems. Scheduling a meeting is unlikely to have the person admit to complaining about care provided by coworkers in front of coworkers. A request to review policies and procedures is so broad the staff will not be able to identify a specific problem that needs to be corrected. Unless organizational changes are made, it is unlikely that staff will decide to come forward when they would not do so in the first place.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A hospital is experiencing a drop in patient admissions, resulting in the implementation of a hiring freeze. What is a potential critical consequence of this internal organizational decision? a. A decrease in the availability of future nurses to hire b. A savings of salaries and benefits

c. Increased scholarships to nursing students from the local high school d. Increased cross-training of current staff ANS: A In an economic climate where hospitals are not hiring, nursing schools may limit enrollment which will limit the availability of future nurses available to be hired when the current nurses retire or reduce their hours. Salary savings is minimal as the number of patients, staffing, and revenue are closely aligned. Scholarships will decrease as hiring commitments to scholarship holders will no longer be in effect. Cross-training may occur, but it is not a critical consequence of a hiring freeze.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A hospital organization is applying for Magnet© status to show excellence in nursing practice. What components would indicate that the hospital is meeting Magnet© principles?

(Select all that apply.) a. The education budget for nursing has been cut to provide for new laboratory equipment. b. On average, 40% of new nurses are leaving within 1 year of hire. c. Nurses are active participants on all major hospital committees. d. Quality improvement projects are planned and evaluated by nurses. e. Patient care outcome data are reported in the annual executive board meeting.

N ANS: C, D To gain Magnet© status, an organization must show that nurses are active participants in the organization administrative structure, fully involved in quality improvement projects, and are recognized as a valuable resource.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 58: Health Care Economics Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. What do the economics of health care include? a. Medicare and Medicaid dollars b. Patients’ rights c. Equal distribution of health care d. Nurse salaries ANS: C The economics of health care include the equal distribution of healthcare services so everyone may be served when services are needed. Medicare and Medicaid, patients’ rights, and nurse salaries do not factor into the economics of health care; they are only parts of the healthcare system.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A student asks the instructor about healthcare economics. The instructor knows the student understands when the student makes which statement? a. “The elderly population uses most of the healthcare services.” b. “Everyone should have health insurance to obtain services.” c. “Healthcare dollars should be partitioned by the government.” d. “Resources will be needeN d to serve healthcare issues.”

ANS: D Every healthcare issue needs resources to bring it to fruition. Without the resources, the healthcare issue would not be served. The elderly are a large part of the population, but that does not change the economics of health care. Everyone does not have health insurance so that statement would not enter into healthcare economics. Last, all health care dollars are not partitioned by the government; third party payers exist.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The U.S. healthcare system is different from that of other countries in which way? a. The United States charges money from the private sector only. b. U.S. health care is funded from private organizations. c. The U.S. healthcare system is not entirely government funded. d. The U.S. healthcare treats the older person first.

ANS: C

Other countries fund the healthcare system so that every citizen may have health care. In addition they provide the option that citizens may purchase private health care too. The United States has a combination of private companies and government agencies funding health care, so money is not coming from just the private sector. The older person in the population receives care according to the insurance coverage they have, but the care is not before anyone else.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. Which of the following statements is true about health care in the United States? a. The United States spends more money on health care than any other nation. b. The United States provides health care to every citizen. c. The United States relies on government funding to treat most citizens. d. The United States spends less money on pediatric care than other nations.

ANS: A The United States spends more money on health care than any other country. The United States does not provide health care to every citizen, nor does it rely entirely on government funding. The United States does not spend less money on pediatric care but usually more than other countries.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Two nurses are discussing managed healthcare organizations. The two nurses know which to be true about managed h eaNl t h care? a. Care is mostly provided by nurses. b. Prices for care are negotiated by the patient. c. Providers may encounter additional cost if care provided exceeds reimbursement. d. Patients can select any healthcare provider for treatment without additional costs.

ANS: C Managed healthcare organizations include both PPO (Preferred Provider Organizations) and HMO (Health Maintenance Organizations). Fees are determined by the insurance company with a provided listing of healthcare providers who are in-network. Delivery of care is physician based. Additional costs to the patient may be incurred if the patient decides to see an out-of-network healthcare provider. Providers are paid a preset reimbursement for each patient and may suffer losses if their cost exceeds this stipulated amount.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A student nurse is discussing Medicare coverage with the clinical instructor. The instructor knows the student understands Medicare when the student makes which statement(s)?

(Select all that apply.) a. Medicare covers all patients while they are in the hospital.

b. c. d. e.

Medicare is funded by the federal government.

Medicare is for persons 65 years old and older.

Medicare is partially funded by private third-party payers.

Medicare is for patients who are disabled and/or have end-stage renal disease.

ANS: B, C, E Medicare is funded by the federal government. It covers people who are 65 years old and older, disabled people, and patients who have end-stage renal disease. It does not cover all patients in the hospital, because some patients do not qualify for Medicare. It is not funded by third-party payers.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. An Accountable Care Organization (ACO) seeks to deliver which of the following aspects of health care? (Select all that apply.) a. Lessen Medicare payments b. Integrate care c. Enhance evidence-based practices d. Manage acute conditions e. Support hospice charges ANS: B, C ACOs work to integrate care, manage chronic conditions, and enhance the use of evidence-based practices. They do not have any involvement with Medicare payments, the management of acute conditions, or hospice care.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

4. Which of the following components are included in health policy at the state level? a. Americans with Disabilities Act of 1990 b. Scope of nursing practice c. Health Insurance Portability and Accountability Act (HIPAA) of 1996 d. Patient Safety and Quality Improvement Act of 2005 ANS: B The scope of nursing practice is correct, because it is controlled at the state level by state boards of nursing. The Americans with Disabilities Act of 1990, the HIPAA of 1996, and the Patient Safety and Quality Improvement Act of 2005 are all regulated at the national level.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Which of the following is the intent of HIPAA? a. Release patient information for purposes of insurance reimbursement. b. Prevent healthcare providers from billing for procedures done for the insured person. c. Protect patients from reviewing their own medical records. d. Limit the ability of healthcare providers to sell patient information to outside sources.

ANS: D The intent of HIPAA is to protect patient information and prevent it from being sold to outside agencies. The right ofNheath care providers to bill for services is necessary for patient payment and is not prohibited. Patients have the right to view their own patient information.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. Nurses can be health advocates in which of the following ways? (Select all that apply.) a. Supporting their professional nursing organization when discussing upcoming legislation b. Discussing the upcoming classes with a neighbor c. Rallying for coverage for childhood immunizations d. Arranging for a patient to meet with case management for home health care e. Discussing a patient they are concerned about with a fellow student in the public cafeteria ANS: A, C, D

Supporting a professional nursing organization, rallying for coverage for childhood immunizations, and arranging for a patient to meet with case management are examples of how nurses can be a positive influence on healthcare policy. Discussing an upcoming class with a neighbor is not effective because it could be determined to be negative. Talking about a patient in a public area is an example of inappropriate communication between healthcare workers and is a violation of patient confidentiality.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nursing student is preparing a care plan for an assigned patient. When accessing the electronic medical record, what is acceptable information to view? (Select all that apply.) a. Laboratory data of the assigned patient b. Admission diagnosis for a patient who is a former neighbor c. The patient’s age, date of birth, and gender d. The history and physical of the assigned patient e. A classmate’s brother’s chest x-ray report ANS: A, C, D The laboratory data, age, date of birth, gender, history, and physical of an assigned patient are necessary for identification and care of the patient so it is acceptable to view this information in the electronic medical record. The patient information in the medical record, whether electronic or print, is only to be viewed by those who have a legitimate role in the patient’s care. Viewing information on patients other than the assigned patient is not appropriate, because the student does not have a need to view the information for patient care. These are violations of patient privacy.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 60: Health Care Law Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The new nurse correctly defines a law when stating which information? a. “Law is a fundamental concept for healthcare professionals.” b. “Law’s rule is developed by the employee’s organization.” c. “Law’s rule is enacted by a government agency that defines what must be done in a given circumstance.” d. “Law is a mandate from the Joint Commission or other accrediting agency.”

ANS: C This is the correct definition of a law.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. Which of the following is true about healthcare legislation? a. The U.S. Constitution addresses healthcare law specifically to give the federal government the ability to license professionals and institutions. b. The power of the U.S. Constitution does not have a direct relationship to health care and reserves most of the power to the states. c. State laws are considered the highest source of healthcare law and trump the federal laws. d. The federal government aNsserts its power over healthcare legislation through the U.S. Constitution.

ANS: B The power of the U.S. Constitution does not have a direct relationship to health care and reserves most of the power to the states. The other statements are false. The U.S. Constitution does not address health care specifically. Either state or federal laws can be considered the highest source of law depending on which law has the stricter regulation or rule.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. Which is an example of the regulatory power to make law? a. Joint Commission establishing a medication reconciliation standard b. Centers for Disease Control and Prevention (CDC) developing recommendations for childhood immunizations c. Institute of Medicine (IOM) defining the approximate number of medication errors that result in significant patient harm or death d. Centers for Medicare and Medicaid Services (CMS) enacting rules for restraint and seclusion for participating hospitals ANS: D

The Centers for Medicare and Medicaid Services (CMS) enacting rules for restraint and seclusion for participating hospitals refers to the enactment of law, while the other answers discuss the development of standards and recommendations that do not have the authority of law. There are some healthcare rules that may define expected behavior, but if these rules were not created by a government entity with legal authority, then they are not healthcare laws.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. What is one of the major attributes of healthcare law? a. It defines the expected behavior of persons in the business of health care. b. The law or rule is easy to interpret and comply with. c. It is established by any healthcare authority. d. The creator must be an expert in health care.

ANS: A A healthcare law or rule defines expected behavior of persons in the business of health care or in healthcare relationships. Healthcare law is not easy to interpret or comply with and can only be established by organizations with legal authority for law making. Creators of healthcare law are often not experts in health care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. The Board of Nursing (BON) is reviewing a nurse’s practice based on a reported violation of the Nurse Practice Act. W hNa t action can the BON take if the complaint is found to be unsupported? a. Censure the nurse. b. Assess a penalty in the form of monetary cost. c. Reinstate the nurse’s license. d. Dismiss the complaint.

ANS: D The Board of Nursing (BON) in each state defines and interprets the Nurse Practice Act. The BON is responsible for investigating and providing actions based on complaints and/or violations of the Nurse Practice Act. If the BON finds that the complaint is not supported by evidence, then the complaint will be dismissed with no disciplinary action taken. Actions allowable by the BON with a supported complaint and/or violation range from censure, talking additional courses, paying a fine/penalty, probation, suspension, and revocation to denial of licensure.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. Which of the following is an example of a nurse violating the Health Insurance Portability and Accountability Act (HIPAA) of 1996? a. The nurse asks the unit clerk to look up lab values for her relative recently admitted to the hospital. b. A group of fellow employees are discussing a patient’s clinical status in a public

place. The nurse manager requests that they step into private room to complete the discussion. c. After entering the progress notes on a patient’s electronic medical record, the nurse logs off the computer to allow her coworker to use the terminal. d. As a family approaches the nursing desk, the nurse removes the patient census sheet from view on the counter.

ANS: A When the nurse asks the unit clerk to look up lab values for her relative recently admitted to the hospital, the nurse is accessing protected health information not required for the nurse to perform his or her job. This is a violation of privacy even if it is a relative. The other choices are all actions that are consistent with protecting a patient’s privacy right as defined by HIPAA. OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. In which of the following answers is the hospital in compliance with the Consolidated Omnibus Budget Reconciliation Act and Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA)? a. The emergency department staff asks a patient to stay in the waiting room until the patients with insurance are treated. b. The emergency registration personnel explain to a patient that they must have proper identification to receive treatment. c. A patient with chest pain is triaged directly to a room for evaluation and registration information is obtained after the patient is stabilized. d. The emergency departmeN nt physician discharges and instructs a patient who is actively suicidal to go to the neighborhood facility that has psychiatric services.

ANS: C EMTALA requires that any hospital that operates an emergency department and receives Medicare funds provide an appropriate screening exam to anyone who presented and stabilize any emergency medical condition prior to transfer to another facility. The other choices are in conflict with EMTALA because a medical screening exam must be provided without consideration of the patient’s insurance, whether the patient has identification, or the facility’s services.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

8. Which of the following is false regarding state licensure laws? a. These laws establish the requirements for licensure to practice. b. Licensure is not necessary if the individual has completed training. c. The state regulatory agencies such as the state board of nursing are responsible for creating and enforcing these rules. d. The scope of practice defines what the professional can and cannot do within the scope of their licensure.

ANS: B

Licensure is required to practice after the completion of all required training for the profession. The state laws establish the requirements to practice and the state regulatory agencies are responsible for creating and enforcing the rules. The scope of practice defines what activities the professional is legally authorized to perform.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

9. The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b. identifies a need for physical therapy. c. is a developmental screening tool. d. provides a framework for health teaching.

ANS: C The Denver II is the most commonly used measure of developmental status used by healthcare professionals; it is a screening tool. Screening tools do not provide a diagnosis.

Diagnosis requires a thorough neurodevelopment history and physical examination.

Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

10. To plan early intervention a n Nd care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b. autism. c. attention-deficit/hyperactivity disorder (ADHD). d. failure to thrive.

ANS: D Failure to thrive is also a physical development exemplar. Cerebral palsy is an exemplar of motor/developmental delay. Autism is an exemplar of social/emotional developmental delay. ADHD is an exemplar of a cognitive disorder.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

11. To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition.

ANS: C

Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes); hence determination of development would be the focus of preventive interventions. Environment is considered to significantly affect development. Nutrition is considered to significantly affect development.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

12. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychological evaluation. The nurse’s best initial response is to a. refer the child to a psychologist immediately. b. explain that playing make believe is normal at this age. c. complete a developmental screening using a validated tool. d. separate the child from the mother to get more information.

ANS: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time.

OBJ:

NCLEX Client NeedsNCategory: Health Promotion and Maintenance

13. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. b. rebel against rules. c. regress because of stress. d. want to know everything.

ANS: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors.

An adolescent may want to “know everything” with their logical thinking and deductive reasoning, but that would not explain why they would act like a child.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

Concept 02: Functional Ability Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is assessing a patient’s functional ability. Which patient best demonstrates the definition of functional ability? a. Considers self as a healthy individual; uses cane for stability b. College educated; travels frequently; can balance a checkbook c. Works out daily, reads well, cooks, and cleans house on the weekends d. Healthy individual, volunteers at church, works part time, takes care of family and house ANS: D Functional ability refers to the individual’s ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, healthy individual, church volunteer, part time worker, and the patient who takes care of the family and house fully meets the criteria for functional ability.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. The nurse is assessing a patient’s functional performance. What assessment parameters will be most important in this assessment? a. Continence assessment, gait assessment, feeding assessment, dressing assessment, N transfer assessment b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Health and well-being, amount of community volunteer time, working outside the home, and ability to care for family and house ANS: A Functional impairment, disability, or handicap refers to varying degrees of an individual’s inability to perform the tasks required to complete normal life activities without assistance.

Height, weight, BMI, and vital signs are part of a physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient’s functional ability. What question would be the most appropriate? a. “Are you able to shop for yourself?” b. “Do you use a cane, walker, or wheelchair to ambulate?” c. “Do you know what today’s date is?” d. “Were you sad or depressed more than once in the last 3 days?”

ANS: B

“Do you use a cane, walker, or wheelchair to ambulate?” will assist the nurse in determining the patient’s ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient? a. Eating and drinking, personal cleansing and dressing, working and playing b. Toileting, transferring, dressing, and bathing activities c. Sleeping, expressing sexuality, socializing with peers d. Maintaining a safe environment, breathing, maintaining temperature ANS: D The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service after left knee replacement. Which tool is the best for the nurse to utilize? N a. Minimum Data Set (MDS) b. Functional Status Scale (FSS) c. 24-Hour Functional Ability Questionnaire (24hFAQ) d. The Edmonton Functional Assessment Tool ANS: C The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is assessing a patient’s functional abilities and asks the patient, “How would you rate your ability to prepare a balanced meal?” “How would you rate your ability to balance a checkbook?” “How would you rate your ability to keep track of your appointments?” Which tool would be indicated for the best results of this patient’s perception of their abilities? a. Functional Activities Questionnaire (FAQ) b. Mini Mental Status Exam (MMSE) c. 24hFAQ d. Performance-based functional measurement ANS: A

The FAQ is an example of a self-report tool which provides information about the patient’s perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is used to assess functional ability in postoperative patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient’s risk for falls so that falls prevention can be implemented if necessary.

Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence ANS: B, D, E, F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Taking meNdications to treat hypertension that may lead to hypotension and dizziness is a fall risk. Dizziness does contribute to falls.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Concept 03: Family Dynamics Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions and lack of family support for a patient would be to a. enforce hospital visiting policies. b. monitor the dysfunctional interactions. c. notify the primary care provider. d. role model appropriate support.

ANS: D Nurses can, at times, role model more appropriate interactions or provide suggestions for improving communication and interactions among family members. If the nurse determines that the number of visitors has a negative impact on the patient, hospital policy may be to limit visitors, but that would not be the initial action. Monitoring the dysfunctional interactions would not be an adequate response. The primary care provider should certainly be notified, but that would not be the initial response.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. The nurse caring for a patient would identify a need for additional interventions related to family dynamics when a. extended family offers to help. b. family members express cNoncern. c. the ill member demands attention. d. memories are shared.

ANS: C It is not uncommon for the ill family member to become demanding and indicate that they deserve special treatment and care, and the supportive family may need assistance in understanding the dynamics of the illness in order to continue to be supportive. Offers from extended family to help can be indicative of positive dynamics. Concern expressed by family members can be indicative of positive dynamics. Sharing of family memories can be indicative of positive dynamics.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. Two women have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of a baby. The nurse identifies them as which type of family? a. Cohabiting b. Nuclear c. Same-sex d. Single parent ANS: C

This family would be considered a same-sex family. Cohabiting refers to a couple who live together with no legal bond. Nuclear refers to the traditional male and female core family with one or more children. Single parent refers to a family with one adult and one or more children.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. The nurse identifies the family with a child graduating from college as having which effect on the family life cycle? a. Minimal impact b. Considered to be a negative impact on the family unit c. Leads to role confusion d. Expectation of role change ANS: D The family life cycle developmental theory focuses on the growth and development of changes in role relationships during transitional periods. A child graduating from college is an example of a transition which requires a role change. As this is a transition, one would expect to see a change so minimal impact would not be expected. Graduation does not imply that it will be a negative change on the family life cycle or lead to role confusion.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of which aspect of the family?

N a. Development b. Function c. Political views d. Structure ANS: C An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nurse is planning to assess the structure of a family. Which question should the nurse ask? a. “Who lives with you in this home?” b. “Who does the grocery shopping?” c. “Who provides support in your family?” d. “How old are the members of your family?”

ANS: A

The structure of the family includes who is in the family and what their relationship is.

“Who does the shopping?” would provide information about family functioning. “Who provides support?” would provide information about family functioning. “How old are the members?” would provide information about family development.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. Which factors which would alert the nurse to negative/dysfunctional family dynamics? a. Aging of family members b. Chronic illness of a family member c. Disability of a family member d. Intimate partner violence ANS: D Intimate partner violence is an exemplar of negative/dysfunctional family dynamics. Aging of family members is an exemplar of changes to family dynamics. Chronic illness of a family member is an exemplar of changes to family dynamics. Disability of a family member is an exemplar of changes to family dynamics.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 04: Culture Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for an older Chinese adult male who is grimacing and appears restless after abdominal surgery. What is the nurse’s best action? a. Ask the patient if he is anxious about his hospital stay. b. Ask a translator to conduct a FACES pain scale assessment. c. Ask the patient about pain and assess vital signs. d. Ask the patient about any history of depression or anxiety.

ANS: C In the Chinese culture, elderly Chinese people believe that they must be stoic about pain and there is a stigma about talking about any mental health problems. The nurse should ask the patient about pain and also assess vital signs for physiological signs of pain, since the patient may not admit to any pain. Assuming the patient is depressed or anxious is not the best action when considering individual cultural differences and the risk of pain after major surgery. The registered nurse should never delegate assessment to any unlicensed member of the healthcare team such as a translator. The translator may assist with communication, but the nurse is responsible for the pain assessment.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. Understanding cultural differN ences in health care is important because it will help the nurse to understand the manner in which people decide on obtaining treatments and medical care.

In independent cultures an individual will a. put himself first. b. consult family members for advice. c. ask for a second opinion. d. travel great distances to receive the best care.

ANS: A In independent cultures, an individual will put himself first in the case of a life-threatening illness, whereas even in dire circumstances, members of collectivist cultures may still consult other family members for the best course of action. In independent cultures, an individual will not consult with other family members, ask for a second opinion, or travel great distances to receive the best care.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the patient nodding yes to everything that is being said. With a better understanding of cultural interdependence in self-concept, a nurse should immediately a. write everything down for the patient to refer to later. b. prompt further to elicit additional questions or concerns. c. call the recognized elder for this patient. d. call the oldest male relative for help with decision making.

ANS: B When a nurse provides nutritional education to a patient who is from a culture that values greater power distance, it might appear that the patient is willing to accept all that the nurse suggests, when further prompting would elicit additional questions or concerns. The patient from a collectivist culture will usually consult family members for a best course of action. It is not acceptable for nurses to take it upon themselves to call the recognized elder or oldest male relative for help with decision making. While writing everything down may be OK for some cultures, with Asian patients it may be best to prompt further to elicit additional questions or concerns.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. Women who are given the job of caretaker for aging relatives are subject to caregiver strain due to a. feminine attributes. b. unequal gender. c. fixed gender roles. d. female inequality.

ANS: C In cultures with more fixed gender roles, women are usually given the role of caretaker for aging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers to harmonious relationships, modesty, and taking care of others. Unequal gender refers to roles of males and females being unevenly distributed. Female inequality refers to female gender and roles being less than or unequal to male roles.

N OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. A 60-year-old Italian immigrant presents for an annual physical. He is counseled about diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and pneumococcal vaccination. His reply is “If it ain’t broke, don’t try to fix it.” When developing a plan of care, the nurse should consider which cultural orientation for this patient? a. Short term b. Long term c. Leisurely term d. Noncommittal ANS: A Short-term cultural orientation focuses on the present or past and emphasizes quick results.

Long-term cultural orientation focuses the future and long-term rewards.

Long-term-oriented cultures favor thrift, perseverance, and adopting to changing circumstances. Leisurely term and noncommittal are undefined in cultural orientation.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. The emphasis on understanding cultural influence on health care is important because of a. disability entitlements. b. HIPAA requirements.

c. increasing global diversity. d. litigious society.

ANS: C Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. What interrelated constructs facilitate a nurse to become culturally competent? a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge b. Cultural desire, self-awareness, cultural knowledge, and cultural identity c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity d. Cultural desire, self-awareness, cultural knowledge, and cultural skill ANS: D The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and histoNrical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

ANS: A There are a few similar and related terms to spirituality worth mentioning to provide distinction and clarification. Faith, as defined by Dyess, refers to an “evolving pattern of believing, that grounds and guides authentic living and gives meaning in the present moment of inter-relating.” Religiosity, another similar term, is an external expression (public or private), in the form of practicing a belief or faith, whereas spirituality is an internalized spiritual identity (or experiential). Specifically, religiosity is defined as “the adherence to religious dogma or creed, the expression of moral beliefs, and/or the participation in organized or individual worship, or sacred practices.”

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity 4. When developing a plan of care, the nurse should consider which attribute of the concept of spirituality? a. Spirituality is not a well-known universal concept. b. Chronic versus acute illnesses affect spirituality. c. Convincing patients to pray is a priority intervention. d. Referrals may be needed to spiritual counselors.

ANS: D The attributes of the concept of spirituality in the context of nursing care are described below.

• Spirituality is universal. All individuals, even those who profess no religious belief, are driven to derive meaning and purpose from life.

• Illness impacts spirituNality in a variety of ways. Some patients and families will draw closer to God or however they conceive that higher Power to be in an effort to seek support, healing, and comfort. Others may blame and feel anger toward that Higher Power for any illness and misfortune that may have befallen a loved one or their entire family. Still others will be neutral in their spiritual reactions.

• There has to be willingness on the part of patient and/or family to share and/or act on spiritual beliefs and practices.

• The nurse needs to be aware that specific spiritual beliefs and practices are impacted by family and culture.

• The nurse needs to be willing to assess the concept of spirituality in patients and families and based on this ongoing assessment to integrate the spiritual beliefs of patients and families into care.

• The nurse needs to be willing to refer the patient or family to a Spiritual Expert i.e., a Minister, Priest, Rabbi, an Imam.

• Community-based religious organizations can provide supportive care to families and patients and nurses need to be aware of these resources.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity MULTIPLE RESPONSE

1. When completing the FICA tool for spiritual assessment, which questions should the nurse ask the patient? (Select all that apply.) a. What things do you believe in that give meaning to life? b. Are you connected with a faith center in your community? c. How has your illness affected your personal beliefs? d. When was the last time you have been to church? e. What can I do for you?

ANS: A, B, C, E The FICA tool for spiritual assessment stands for Faith or beliefs, Importance and influence, Community, and Address. “When was the last time you have been to church?” is not a question included in the FICA assessment. The patient may attend community activities, besides church, that foster his/her spiritual well-being.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. Which are true statements about the definition of spirituality in nursing? (Select all that apply.) a. Patient’s quality of life, health, and sense of wholeness are affected by spirituality. b. An exact definition was developed and adopted in the late 1980s. c. Encompasses principle, an experience, attitudes, and belief regarding God d. Head knowledge affects spirituality more than heart knowledge. e. Mind, body, spirit, love, and caring are interconnected.

ANS: A, C, E The concept of Spirituality is an elusive concept to define. Authors who write about spirituality in nursing advocaNte the position that a patient’s quality of life, health, and sense of wholeness are affected by spirituality, yet still the profession of nursing struggles to define it. Why? There are a number of explanations for this. One explanation is that spirituality represents “heart” not “head” knowledge and “heart” knowledge is difficult to encapsulate into words. A second explanation is that spirituality is unique to each person so a precise definition is somewhat elusive. The definitions of spirituality encompass the following: a principle, an experience, attitudes and belief regarding God, a sense of God, the inner person. Most descriptions of spirituality include not only transcendence but also the connection of mind, body, and spirit, plus love, caring, and compassion and a relationship with the Divine.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Health Promotion and Maintenance 3. Which life events should the nurse recognize as being spiritually life changing? (Select all that apply.) a. Births b. Weddings c. Medical diagnoses d. Career day to day job duties e. Loss of independence ANS: A, B, C, E

The meaning and significance of the event might only be experienced by one individual; others who might be participants in the event might be left virtually untouched and unchanged. These life changing spiritual events include just about any occurrence that has intense and personal relevance to those involved in the event. Examples of spiritually life changing events include births, deaths, weddings, divorces, illnesses, diagnoses, and loss of abilities, loss of independence, death and so many more. These events, having the power to change individuals and families, also have the power to draw people toward the transcendent—for many people that transcendent is known as God but this is not universal.

Day-to-day activities are not the best examples of spiritually life changing events.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Psychosocial Integrity

N

b. Establish a rapport with the patient by complimenting them on what they did correctly, and ask what strategies they have tried thus far. c. Refer the patient to a certified diabetic educator, because the educator is an expert on management of diabetes complications. d. Have the patient explain what medications they are on and what diet they should be following.

ANS: B Principles of a TPB indicate that the patient will need to establish a good rapport with the nurse in order to talk about nonadherence. If the patient finds it difficult to discuss their diabetes self-management and adherence with the nurse, the patient may not open up to the nurse. Although a referral to an educator is a good idea, it would be better to use this resource as a follow-up for this visit. Having the patient verbalize medications and diet is not part of the TPB method.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. The nurse is assessing a newly diagnosed diabetic, and the patient’s readiness to learn about glucose monitoring. Before planning teaching activities, which approach would be most effective? a. Assist the patient with long-term goals and plan teaching according to these goals. b. Provide the patient with all the latest research from the Internet on glucose monitoring. c. Refer the patient to the diabetic specialist who can assist the patient with the glucometer. d. Assist the patient in developing realistic short-term goals.

N

ANS: D Concordance reflects development of an alliance with patients based on realistic expectations. Providing the patient with the research will not help with the practical skill of using the glucometer. Long-term goals are useful; however, the goals need to be immediate with a newly diagnosed patient learning a new skill. Referring the patient would be useful if the patient has not been able to grasp the concept after several attempts.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse is developing a care plan for a patient who has low motivation and nonadherence with blood glucose monitoring. Which statement by the patient would indicate to the nurse that the patient is not motivated and will most likely not comply? a. “I do not like to test my sugar, but I do it because my wife nags me.” b. “I forget to check my sugar once in a while.” c. “I don’t see or feel any different when I do keep my blood sugars under control.” d. “I have no idea what the signs of low blood sugar are.”

ANS: C If patients do not perceive any benefit from changing their behavior, sustaining the change becomes very difficult. Having someone remind the patient is more likely to reinforce compliance. Forgetting to check glucose occasionally may indicate the patient needs memory cues or joggers. The patient who does not know the signs of low glucose will need further teaching.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is preparing a discharge teaching plan for a patient who has peripheral vascular disease and has poor circulation to the feet. Which learning goal should the nurse include in the teaching plan? a. The nurse will demonstrate the proper technique for trimming toenails. b. The patient will understand the rationale for proper foot care after instruction. c. The nurse will instruct the patient on appropriate foot care before discharge. d. The patient will post reminder stickers on the calendar to check feet every day and record scheduled appointments with podiatrist.

ANS: D To improve the patient adherence to treatment, it will be important to help them develop reminder strategies that fit into their lifestyle. Options A and C describe actions that the nurse will take, rather than behaviors that indicate that patient learning has occurred. Option B is too vague and nonspecific to measure whether learning has occurred.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. A patient with hypertension is prescribed a low-sodium diet. The patient’s teaching plan includes this goal: “The patient will select a 2-gram sodium diet from the hospital menu for the next 3 days.” Which intervention would be most effective at increasing the patient’s compliance with the diet? a. Check the sodium content of the patient’s menu choices over the next 3 days. b. Ask the patient to identify which foods on the hospital menus are high in sodium. c. Have the patient list favo N r ite foods that are high in sodium and foods that could be substituted for these favorites. d. Compare the patient’s sodium intake over the next 3 days with the sodium intake before the teaching was implemented.

ANS: C Including a patient’s favorite foods will most likely increase compliance, because the patient is not being deprived. Checking the sodium will be useful for teaching strategies but will not be the most effective means of increasing adherence.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 8. The nurse is evaluating the need to refer a patient with osteoarthritis for a home care visit to be sure the patient can function in accomplishing daily activities independently. What is the nurse’s first priority? a. Determine if the patient has had home visits before and if the experience was positive. b. Check the patient’s ability to bathe without any assistance the next day. c. Have the patient demonstrate the learned skills at the end of the teaching session. d. Arrange a physical therapy visit before the patient is discharged from the hospital.

ANS: A

To begin the assessment of adherence, it is first important to clarify with the patient (a) their beliefs and perceptions about their health risk status, (b) their existing knowledge about cardiovascular disease risk reduction, (c) any prior experience with healthcare professionals, and (d) their degree of confidence with controlling the disease. The other actions allow evaluation of the patient’s short-term response to teaching.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

9. A 73-year-old male patient is seen in the home setting for a routine physical. The nurse notes which behavior as the most reassuring sign that the patient has been following the treatment plan for the diagnoses of hypertension, diabetes, and hyperlipidemia? a. The patient has a list of glucose readings for the past 10 days. b. The patient has a list of medications along with newly refilled meds. c. The patient has a list of all foods and beverages for a 3-day period. d. The patient verbalizes the side effects of all his medications.

ANS: B Confirming how often a patient renews or refills his/her prescriptions is a measurement of the patient’s persistence with continuation of the treatment. Having a list of glucose readings or verbalizing side effects does not necessarily mean that the patient is compliant unless the readings were all normal, which is not indicated. Listing foods may not indicate the patient is following the treatment plan.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 07: Self-Management Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is developing a plan of care for a newly diagnosed hypertensive patient who is being discharged on medications and given the Dietary Approaches to Stop Hypertension (DASH) diet to follow. What statement by the patient signals to the nurse that the patient is motivated to learn? a. “I am sure the medications will help to bring down my blood pressure.” b. “I can’t wait to try the new recipes, and I’m hopeful I will lose weight.” c. “Do I really need to follow the diet and take medications?” d. “I have my parents to blame for this. They both have high blood pressure.”

ANS: B A patient who is motivated will see what the benefits of following the teaching will do for them and will most likely be able to manage their own care. The patient who believes medications are the only solution may not be motivated to follow the prescribed diet.

Blaming the parents for their condition does not show accountability or motivation for change.

OBJ: NCLEX Client Needs Category: Physiological Integrity | NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is assessing a patient’s readiness to be discharged and ability to manage care at home. What is the most approNpriate question for the nurse to ask to determine the patient’s learning needs before planning teaching activities? a. “What are your hobbies and occupation?” b. “What do you need to know before you go home from the hospital?” c. “Do you have any cultural or religious beliefs that you would like incorporated into your plan of care?” d. “What were your grades and learning style when you were in school?”

ANS: B Motivation and readiness to learn depend on what the patient values. The other questions are also important but do not address what information interests the patient most at present and will assist the patient in managing his own care.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. Which acute medical event should the nurse identify as requiring self-management when planning care for a patient? a. Prenatal care b. Depression c. Diabetes d. Femur fracture ANS: D

A femur fracture is considered an acute medical event. Pregnancy is an expected and normal life event/condition. Depression and diabetes are considered disease states.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. An 8-year-old child is newly diagnosed with asthma. Which nursing intervention best promotes self-efficacy for the parents to help the child follow the prescribed treatments? a. Ask parents to list all possible triggers for asthma. b. Request a spacer for the metered dose inhaler. c. Suggest the parents enforce a strict exercise regimen. d. Recommend replacing carpeting in the home with wood flooring.

ANS: B The most realistic and helpful interventions will promote self-management. A spacer is helpful for children learning to use inhaled medication. Listing all the triggers for asthma may be overwhelming. The parents should focus on the individual triggers for the child.

Enforcing a strict exercise regimen is restrictive and will not promote self-management.

Environmental changes must be feasible and cost-effective. Replacing carpeting is optimal but may not be affordable.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. When developing a plan of care to promote self-management, which patient is least likely to be affected by depression? a. A 55-year-old employed female b. A 35-year-old Hispanic male c. A 40 year old with 5th grN ade education d. A 42 year old with private insurance ANS: D Individuals most affected by depression are midlife adults ages 45–64, women, minorities, individuals without a high school education, and individuals without health insurance.

Treatment for depression includes the use of medication and psychological therapy.

Additionally, patients must learn to manage moods including suicidal thoughts, recognize triggers and relapse, and set goals for behavioral management of their disease.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is assisting an older adult patient, diagnosed with type 2 diabetes, with self-injection of insulin. What is the most appropriate intervention for this patient at discharge? a. Arrange daily home visits for injections. b. Request an insulin pen prescription. c. Recommend upper arm injection sites. d. Supply patient with 100 unit insulin syringes.

ANS: B

An insulin pen will be the most effective method for injection for an older adult secondary to reduced eyesight and dexterity compared to using syringes. A 100 unit syringe has very small calibration marks and numbers, making it more difficult for older adults to see the appropriate doses. Daily home visits are not usually paid for by insurance. Most patients must learn to administer medications themselves. The upper arm subcutaneous site is too difficult for self-administration and may not be feasible for an older adult.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. The nurse is developing a teaching plan for a patient diagnosed with congestive heart failure. Which are the most appropriate teaching points to include that will assist in self-management of the disease? (Select all that apply.) a. Side effects of medications b. Activity restrictions c. Daily weights d. Increased sodium intake e. Blood pressure monitoring ANS: A, B, C, E Congestive heart failure (CHF) is one of the most common complications of coronary artery disease in which the heart fails to pump efficiently enough to meet the metabolic demands of the body. Fluid overload is a common complication. As with most chronic conditions, patients with CHF benefit from education about their disease and self-managing diet, physical activity, weight, andNmedication adherence. Fluid retention occurs with increased sodium intake; therefore sodium is usually restricted in a congestive heart failure diet.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

d. Blood pressure 98/58 ANS: C Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. An overnight weight gain indicates a fluid gain.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a. Vomiting all day and not replacing any fluid b. Tumor that secretes excessive antidiuretic hormone (ADH) c. Tumor that secretes excessive aldosterone d. Tumor that destroyed the posterior pituitary gland ANS: B ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia.

The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.

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NCLEX Client NeedsNCategory: Physiological Integrity: Reduction of Risk Potential

5. The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a. Development of ankle or sacral edema b. Increased skin tenting and dry mouth c. Postural hypotension and tachycardia d. Decreased level of consciousness ANS: D Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a. Severe hemorrhage b. Diabetes insipidus c. Oliguric renal disease d. Adrenal insufficiency

ANS: C When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. The patient’s laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the priority nursing intervention? a. Raise bed side rails due to potential decreased level of consciousness and confusion. b. Examine sacral area and patient’s heels for skin breakdown due to potential edema. c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

ANS: D Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

N

1. The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all that apply.) a. Bilateral ankle edema b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau sign e. Flat neck veins when upright f. Decreased patellar reflexes ANS: B, C, D Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient?

(Select all that apply.) a. Test for skin tenting. b. Measure rate and character of pulse. c. Measure postural blood pressure and heart rate. d. Check Trousseau sign. e. Observe for flatness of neck veins when upright. f. Observe for flatness of neck veins when supine.

ANS: A, B, F ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

Thyroid hormone increases metabolic rate, causing a patient with severe hyperthyroidism to have high risk of metabolic acidosis from increased production of metabolic acids.

Metabolic acidosis decreases level of consciousness. Changes in urine output, urine color, and lung sounds are not signs of metabolic acidosis. Although metabolic acidosis often causes tachycardia, many other factors influence heart rate and blood pressure, including thyroid hormone.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. The nurse is making a home visit to a child who has a chronic disease. Which finding has the most implication for acid-base aspects of this patient’s care? a. Urine output is very small today. b. Whites of the eyes appear more yellow. c. Skin around the mouth is very chapped. d. Skin is sweaty under three blankets.

ANS: A Oliguria decreases the excretion of metabolic acids and is a risk factor for metabolic acidosis. Jaundice requires follow-up but is not an acid-base problem. Perioral chapped skin needs intervention but is not an acid-base issue. With three blankets, diaphoresis is not unusual.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first? a. “Is there a place that I canNdispose of my unused morphine pills?” b. “I want to lose at least 20 pounds without getting sick this time.” c. “I think I have asthma because I cough when dogs are near.” d. “I ran out of money and am cutting my insulin dose in half.”

ANS: D Decreasing an insulin dose by half creates high risk of diabetic ketoacidosis, and this patient has the highest priority. The other patients have less priority due to lower risk situations with longer time course before development of an acid-base imbalance. The coughing when dogs are near is not a sign of a severe asthma episode that causes respiratory acidosis, although this patient does need attention after the insulin situation is handled. Disposing of morphine properly helps prevent respiratory acidosis from opioid overdose. Guidance regarding weight loss helps prevent starvation ketoacidosis.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Management: Management of Care MULTIPLE RESPONSE 1. The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.) a. Skin pale and cold b. Tingling of fingertips

c. Heart rate of 102 d. Numbness around mouth e. Cramping in feet ANS: B, D, E Hyperventilation is a risk factor for respiratory alkalosis. Respiratory alkalosis can cause perioral and digital paresthesias and pedal spasms. Pallor, cold skin, and tachycardia are characteristic of activation of the sympathetic nervous system, not respiratory alkalosis.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 2. Which statements said by patients indicate that the nurse’s teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.) a. “Baking soda is an effective and inexpensive antacid.” b. “I should take my insulin on time every day.” c. “My aspirin is on a high shelf away from children.” d. “I have reliable transportation to dialysis sessions.” e. “Fasting is a great way to lose weight rapidly.”

ANS: B, C, D Taking insulin as prescribed helps prevent diabetic ketoacidosis. Safeguarding aspirin from children prevents metabolic acidosis from increased acid intake. Regular dialysis reduces the risk of metabolic acidosis from decreased renal excretion of metabolic acid. Baking soda is sodium bicarbonate and should not be used as an antacid due to the risk of metabolic alkalosis. Fasting without carbohydrate intake is a risk factor for starvation ketoacidosis.

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NCLEX Client NeedsNCategory: Health Promotion and Maintenance

With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. What is the priority nursing action for a patient suspected to be hypothermic? a. Assess vital signs. b. Hydrate with intravenous (IV) fluids. c. Provide a warm blanket. d. Remove wet clothes.

ANS: D The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. Which strategies should the nurse include in a community program for senior citizens related to dealing with cold winter temperatures? a. Avoiding hot beverages b. Shopping at an indoor mall c. Using a fan at low speed d. Walking slowly in the p a N rk ANS: B Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is recommended to conserve body temperature.

Physical activity can increase body temperature, and if the senior is going to walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a. Impaired cognition b. Occupational exposure c. Physical agility d. Temperature extremes ANS: C

Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation? a. Oral thermometer b. Rectal thermometer c. Temporal thermometer scan d. Tympanic membrane sensor ANS: B The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

8. Which similar exemplar should the nurse consider when planning care for a patient with hypothermia?

N a. Heat exhaustion b. Heat stroke c. Infection d. Prematurity ANS: D Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

In Stage 1 (N1 or Non-REM Stage 1), referred to as light sleep, the individual can be awakened easily. In this stage, brain waves slow and, on EEG, the slower wave pattern known as alpha waves appears. The individual at this point is likely to drift in and out of sleep and can be awakened easily. Sensations known as hypnagogic hallucinations can occur during this stage. A common sensation of this type is the feeling of falling.

Uncontrolled muscle jerks sometimes occur at this stage along with sudden movements that can startle the individual and restore wakefulness.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

4. The nurse must awaken a patient from Stage 4 non-rapid eye movement sleep in order to prepare the patient for a procedure. The patient is disoriented. What is the nurse’s best action? a. Notify the healthcare provider. b. Re-assess the patient’s orientation. c. Administer an anti-anxiety medication. d. Cancel the patient’s procedure.

ANS: B Stage 3 (N3) and Stage 4 (N4) are the periods of deep sleep. N3 is characterized by very slow brain waves called delta waves interspersed with smaller, faster waves. In Stage 4 (N4), the EEG shows almost exclusively delta waves. In this type of sleep it is difficult to awaken the individual and muscle activity is very limited or may be completely absent. A person awakened from Stage 3 or 4 of sleep could be disoriented for a brief period of time before regaining awareness.

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NCLEX Client NeedsNCategory: Physiological Integrity: Basic Care and Comfort

5. A patient complains of not being able to fall asleep at night and asks the nurse if there is a safe, non-prescription medication he can try. After consulting the healthcare provider, the nurse should recommend which naturally occurring hormone? a. Melatonin b. Cortisol c. Luteinizing hormone d. Estrogen ANS: A A rise in the hormone melatonin at the onset of sleep helps to promote and maintain sleep, and a drop in levels leads to eventual awakening. The immune system is enhanced as well during sleep as proteins associated with fighting illness are produced. The circadian rhythm, or the typical 24 hour (more or less) cycle through which the body passes, including both awake and sleep cycles, is responsible for regulating all of the physiologic processes in the body. An adequate amount and quality of sleep, therefore, is essential to all of the regulatory mechanisms that take place in the body.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

6. A mother tells the nurse she is concerned because her 8-month-old infant sleeps all day and night and is only awake about 2–3 hours per day. What is the nurse’s best response? a. “This sleep pattern is very normal for an infant at this age.”

b. “Adding an additional feeding will keep the child awake more.” c. “I recommend that you notify the child’s pediatrician.” d. “Be sure you are laying the child on his back to sleep at night.”

ANS: C By approximately 6 months of age, the infant should sleep through the night with at least one nap during the day. 2–3 hours of wakefulness per day is not an expected finding at age 8 months and should be reported to the pediatrician to determine the underlying cause. An additional feeding may be warranted; however the pediatrician should be notified first.

Lying on infant on the back to sleep is recommended to prevent sudden infant death syndrome; however the priority concern is the length of time the child is sleeping.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. The nurse is caring for a child with tonsillar enlargement. What is the nurse’s priority concern? a. Low oxygen saturation b. Daytime fatigue c. Increased temperature d. Antibiotic administration ANS: A Tonsillar enlargement in children often leads to obstructive sleep apnea which can cause decreased oxygen saturation levels. Low oxygen is a priority concern which carries the highest safety risk to the child. Obstructive sleep apnea occurs in an estimated 1–3% of children, though the causative factors may differ with tonsillar enlargement being a significant component in chilNdren. Infection that leads to an increased temperature and requires antibiotic therapy is a concern, but the priority health concern is low oxygen levels.

Obstructive sleep apnea can interfere with sleep patterns and lead to daytime fatigue, but the highest priority of care is low oxygen.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is caring for a patient who received a recent bone marrow transplant. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a. Mucositis b. Confusion c. Depression d. Mild temperature elevation ANS: D The earliest sign of infection in an immunosuppressed patient can be a mild fever.

Mucositis, confusion, and depression are possible clinical manifestations but are representative of less life-threatening complications.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? a. Being a woman b. Family history of hypertension c. Cigarette smoking as a teenager d. Advancing age ANS: D Aging is a non-modifiable risk factor for the development of cancer with an associated increase seen with aging. In terms of gender and age, lifetime risk is higher for males than females. Family history of c oN- morbidities such as hypertension is not directly correlated with cancer development. Cigarette smoking as a teenager for the patient is a risk factor but may have mitigated impact at this point in time based on the patient’s stated age and length of time as a non-smoker.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. In caring for a patient admitted with lung cancer, which of the following should the nurse expect to find on assessment? a. No use of accessory muscles during respirations b. Orthostatic hypotension upon change of positioning c. Clear sputum d. Weight loss compared to last admission ANS: D Common signs/symptoms of lung cancer include coughing, hemoptysis, and weight loss, shortness of breath and chest pain. The nurse should expect to see weight loss and altered breathing patterns. Clear sputum and orthostatic blood pressure changes would not be seen.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A female patient complains of a “scab that just won’t heal” under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What is the nurse’s best action?

a. Continue to conduct a symptom analysis to better understand the patient’s symptoms and concerns. b. End the appointment and tell the patient to use skin protection during sun exposure. c. Suggest further testing with a cancer specialist and provide the appropriate literature. d. Tell her to put a bandage on the scab and set a follow-up appointment in 1 week.

ANS: A A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague. The nurse should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.

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NCLEX Client Needs Category: Health Promotion and Maintenance

8. A patient with prostate cancer is taking hormonal therapy to control tumor growth. He reports that his left calf is swollen and painful. Which of the following would be the nurse’s best action? a. Instruct the patient to keep the leg elevated. b. Measure the calf circumference and compare the measurement with the right calf circumference measurement. c. Apply ice to the calf after a 10-minute massage of the area. d. Document assessment findings as an expected response with estrogen therapy.

ANS: B N A nurse should be aware of potential complications from hormonal therapy such as the development of thrombus formation. Massaging a calf that is swollen and painful is never correct, because this action might break a clot, causing formation of an embolus, which could then travel to the lungs.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

9. A patient being evaluated for breast cancer is not certain whether she and her family should participate in a genetic screening plan since no one can guarantee the results. What is the nurse’s best response? a. “If you have a family history of breast cancer, the chances for you to have this type of cancer increases.” b. “The decision is up to you in the final analysis.” c. “If there is no family history, then there is no need to go through the process.” d. “If your insurance will pay for the screening, then there is no associated risk.”

ANS: A

Individuals with a family history of breast cancer (especially 1st degree relatives) are at increased risk for disease occurrence. The nurse should inform the patient of the outcome measures of the screening plan. The nurse should not dissuade the patient from the process based on stating there is no family history, as there is no evidence that an adequate family history has been obtained. Similarly, to correlate the need for genetic testing with insurance and no implied risk cannot be stated equivocally. Although the decision is up to the patient in the final analysis, that response does not address relevant information about the purpose of genetic screening.

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NCLEX Client Needs Category: Health Promotion and Maintenance

10. A nurse is reviewing assessment findings for a female patient admitted to the oncology unit.

Which finding should alert the nurse to contact the physician? a. Blood pressure 130/88 b. Noticeable difference in circumference of lower legs c. Presence of goiter previously identified on prior admission d. Negative guaiac test ANS: B Examination findings relative to oncology patients and neoplastic growth manifest as visible lesions, physical asymmetry, palpable masses, abnormal sounds or the presence of blood on screening tests. A blood pressure of 130/88 is within normal range as is a negative guaiac test. Observation of a previous goiter which is consistent with a prior admission is not a concern. The detection of physical asymmetry as seen by a difference in circumference should be reported to the physician.

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NCLEX Client NeedsNCategory: Physiological Integrity: Physiological Adaptation

Concept 13: Intracranial Regulation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient with increased intracranial pressure (ICP). Which action would be considered to be a collaborative intervention? a. Decreasing perfusion b. Administering an osmotic diuretic c. Assessing orientation d. Assessing for edema ANS: B Collaborative interventions are aimed at preventing secondary injury by improving cerebral perfusion. This would include decreasing edema by administering an osmotic diuretic which in turn would lead to decreased ICP and improved oxygenation. Assessing orientation and for the presence of edema would not be considered as a collaborative intervention.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation? a. Change in level of consciousness b. Inability to focus visually c. Loss of primitive reflexes N d. Unequal pupil size ANS: A A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refer to those reflexes found in a normal infant that disappear with maturation.

These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS. OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. When caring for a patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings? a. Hypertension and bradycardia b. Hypertension and tachycardia c. Hypotension and bradycardia d. Hypotension and tachycardia ANS: A

Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushing triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. Which components of the Glasgow Coma Scale (GCS) should the nurse use to assess a patient after a head injury? a. Blood pressure b. Cranial nerve function c. Head circumference d. Verbal responsiveness ANS: D Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale.

Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N 5. The nurse is teaching a patient about head injuries. Which information should the nurse include as a primary prevention strategy to reduce the occurrence of head injuries? a. Blood pressure control b. Smoking cessation c. Maintaining a healthy weight d. Violence prevention ANS: D Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.

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NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse preparing to care for a patient after a suspected stroke would question which order? a. Antihypertensive b. Antipyretic c. Osmotic diuretic d. Sedative

ANS: A Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure.

Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand.

Long-acting sedatives would be avoided to provide times for periodic neurologic assessments.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. After shunt procedure, the nurse would monitor the patient’s neurologic status by using which test? a. Electroencephalogram b. Glasgow Coma Scale c. National Institutes of Health Stroke Scale d. Monro-Kellie doctrine ANS: B The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This scale is an example of one type of specific tool for nurses to use when assessing a patient following stroke. The Monroe-Kellie doctrine is not an assessment or monitoring strategy; it describes the interrelationship of volume and compliance of the three cranial components, brain tissue, cerebral spinal f lNui d, and blood.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

3. The nurse is caring for a patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What is the nurse’s best action? a. Encourage increased fluid and water intake b. Teach about risk for malignancies c. Monitor for changes in level of consciousness d. Assess labwork for potassium level changes ANS: C As the name suggests, SIADH is a condition in which antidiuretic hormone (ADH) is secreted despite normal or low plasma osmolarity, resulting in water retention and dilutional hyponatremia. In response to increased plasma volume, aldosterone secretion increases and further contributes to sodium loss. Hyponatremia frequently manifests with changes in level of consciousness from confusion to coma. A large number of clinical conditions can cause SIADH including malignancies, pulmonary disorders, injury to the brain, and certain pharmacologic agents. Malignancies often lead to SIADH versus SIADH causing malignant conditions. Water intoxication can lead to hyponatremia, therefore water intake is restricted.

The most affected electrolyte from SIADH is sodium versus potassium.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. Following a parathyroidectomy, which electrolyte should the nurse most closely monitor? a. Potassium b. Sodium c. Magnesium d. Calcium

N

ANS: D Because the parathyroids are located on the thyroid gland, similar concerns for postoperative monitoring apply. Additionally, calcium levels are monitored to avoid hypocalcemic crisis.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. Radioactive iodine is indicated for the treatment of hyperthyroidism. Which item should the nurse include in the plan of care? a. Isolation is required for 6–8 weeks. b. Continued thyroid monitoring is required. c. Thyroid replacement therapy is prescribed. d. An overnight hospital stay is required.

ANS: B Radioactive iodine (RAI) is indicated for the treatment of hyperthyroidism. It is given as an oral preparation, usually as a single dose on an outpatient basis. The radioactive iodine makes its way to the thyroid gland where it destroys some of the cells that produce thyroid hormone. The RAI is completely eliminated from the body after about 4 weeks. The extent of thyroid cell destruction is variable, thus the patient has ongoing monitoring of thyroid function. If thyroid production remains too high a second dose may be needed. The goal of this procedure is to destroy thyroid hormone producing cells; additional thyroid hormone is not prescribed.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The nurse is caring for a patient who has undergone a thyroidectomy. Which patient complaint is highest priority requiring further evaluation? a. Pain at surgical site b. Thirst c. Hoarseness d. Nausea ANS: C Thyroidectomy involves a surgical incision in the anterior neck. Hoarseness may be a sign of airway edema. A patent airway is always a priority of care for any post-operative patient.

General anesthesia is used for this surgery requiring insertion of an artificial airway, therefore throat irritation and thirst is expected. Nausea may be a side effect from anesthesia. Pain is expected at the surgical site.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. Which statement made by a student nurse indicates the need for additional teaching about pituitary insufficiency? a. “Synthetic human growth hormone may be prescribed for children who are small for gestational age.” b. “Testosterone supplements may be prescribed for women with gonadotropin deficiency.” c. “Estrogen is known to regulate the action of growth hormone in men and women.” d. “Chronic kidney disease tNreatment may include synthetic growth hormone replacement.”

ANS: B Synthetic human growth hormone (HGH) is used for growth hormone deficiencies caused by pituitary insufficiency, as well as other conditions such as Turner syndrome, chronic kidney disease, and children small for gestation age. Testosterone is used as supplement for men with gonadotropin deficiency. Estrogen and progesterone supplements, also referred to as hormone replacement therapy (HRT), are indicated for women with gonadotropin deficiency and for the relief of post-menopausal symptoms. Estrogen is also known to regulate secretion and action of GH in men and women.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end-stage renal disease. Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be filtered into the urine.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. What is the nurse’s best response about developing diabetes to the patient whose father has type 1 diabetes mellitus? a. “You have a greater susceptibility for development of the disease because of your family history.” b. “Your risk is the same as the general population, because there is no genetic risk for development of type 1 diabetes.” c. “Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore the risk for becoming diabetic is 50%.” d. “Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual development of the disease. However, your brothers will become diabetic.”

ANS: A Even though type 1 diabetes does not follow a specific genetic pattern of inheritance, those with one parent with type 1 diabetes are at an increased risk for development of the disease.

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NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse recognizes which pNatient as having the greatest risk for undiagnosed diabetes mellitus? a. Young white man b. Middle-aged African-American man c. Young African-American woman d. Middle-aged Native American woman ANS: D The highest incidence of diabetes in the United States occurs in Native Americans. With age, the incidence of diabetes increases in all races and ethnic groups.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? a. Decreased hunger sensation b. Report of no urine output c. Increased respiratory rate d. Decreased thirst ANS: C

Ketoacidosis decreases the pH of the blood, stimulating the respiratory control area of the brain to buffer the effects of the increasing acidosis. The rate and depth of respirations are increased (Kussmaul respirations) to excrete more acids by exhalation. Usually polydipsia (increased thirst), polyphagia (increased hunger), and polyuria (increased urine output) are seen with hyperglycemia and ketoacidosis.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) a. Tremors b. Nervousness c. Extreme thirst d. Flushed skin e. Profuse perspiration f. Constricted pupils ANS: A, B, E When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.

OBJ:

NCLEX Client NeedsNCategory: Physiological Integrity: Physiological Adaptation

Concept 16: Nutrition Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern? a. The patient’s son uses a marked pillbox to set up the patient’s medications weekly. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient tells the nurse that a close friend recently died.

ANS: B A 10-pound weight loss in 1 month could indicate cancer or may be an indication of further progression of memory loss. Depression is also another common cause of weight loss. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an older patient would have friends who have died.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? a. “Your weight is within normal limits. Continue maintaining with current lifestyle choices.” b. “You are a little overweight. Cut down on calories and increase your activity, and N you should be fine.” c. “You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery.” d. “You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight.”

ANS: D This patient is at an increased risk for sarcopenia and should be instructed to increase activity that includes strength training to prevent muscle loss. Diet is not indicated. A BMI of 31 is considered obese; however, this patient does not qualify for surgical intervention until BMI reaches over 35.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

3. The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient? a. Regular diet b. Low sodium diet c. Pureed diet d. Low sugar diet ANS: B

A low sodium diet will prevent water retention which could increase blood pressure.

Patients with hypertension would not be on a regular diet due to sodium content. A pureed diet is indicated for stroke patients who may have impaired swallowing. A low sugar diet is indicated for patients with diabetes.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

4. During a nutritional assessment, the nurse calculates that a female patient’s BMI is 27. The nurse would advise the patient to follow which of these recommendations? a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. b. This measurement indicates that the patient is underweight and will need to take measures to gain weight. c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery. d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.

ANS: A A BMI of 25–29.9 is in the overweight range. A BMI of <18.5 is in the underweight range.

A BMI of 30–34.9 is obesity class I, a BMI of 35–39.9 is obesity class II, and a BMI of >40 is obesity class III (morbid obesity). A BMI of 19–24 is in the normal range.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a Nquick screening tool to assess dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall ANS: D A 24-hour recall is useful as a quick screening tool to assess dietary intake. A food diary provides detailed information, but it is not convenient and requires a follow-up visit. A calorie count requires several days to collect data and requires a trained dietician to analyze the results. A comprehensive diet history may provide more accurate reflection of nutrient intake, but it is time-consuming to acquire and requires a trained/skilled dietary interviewer.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

6. During a physical examination, the nurse notes that the patient’s skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein ANS: C

Dry and scaly skin is a manifestation of essential fatty acid deficiency. Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae. Vitamin B deficiency is too large a category to consider. Specific categories of vitamin B deficiency have been identified, such as pyridoxine and thiamine. Protein deficiency causes decreased pigmentation and lackluster hair.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. During a physical examination, the nurse notes that the patient’s skin is dry and flaking.

What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves and numbness and tingling in extremities d. Fissures and inflammation of the mouth ANS: A Hair loss (alopecia) and hair that is easily removed from the scalp (easy pluckability), like dry, flaking skin, is caused by essential fatty acid deficiency. Inflammation of the tongue (glossitis) and fissured tongue are manifestations of a niacin deficiency. Inflammation of peripheral nerves (neuropathy) and numbness and tingling in extremities (paresthesia) are manifestations of a thiamin deficiency. Fissures of the mouth (cheilosis) and inflammation of the mouth (stomatitis) are manifestations of a pyridoxine deficiency.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

N MULTIPLE RESPONSE 1. An African American is at an increased risk for which of the following? (Select all that apply.) a. Vitamin D deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome ANS: A, D, E, F Type 1 diabetes and celiac disease are more common in Northern European heritage.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

4. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3–4 minutes. The patient asks the nurse why this is happening. What is the nurse’s best response? a. “Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel.” b. “Some people have a slower bowel than others, and this is nothing to be concerned about.” c. “The foods you eat contribute to peristalsis, so you should eat more fiber in your diet.” d. “Bowel peristalsis is slow because you are not walking. Get more exercise during the day.”

ANS: A Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. What is a primary prevention tool used for colon cancer screening? a. Abdominal x-rays b. Blood, urea, and nitrogen (BUN) testing c. Serum electrolytes d. Occult blood testing ANS: D Occult blood testing will reveNal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a. Increase fiber intake. b. Increase water consumption. c. Decrease physical exercise. d. Refrain from alcohol. e. Refrain from smoking.

ANS: A, B Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on the quality of bowel movements.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. When conducting a health history assessment, which information would be viewed as most important as related to the patient’s elimination status? (Select all that apply.) a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine c. Time of day patient defecates d. Discomfort or pain with elimination e. List of medications taken by patient f. Patient’s preferences for toileting ANS: A, B, D, E Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Personal preferences are not the most important data the nurse needs to collect.

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NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

N

4. The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? a. Mental alertness b. Perfusion c. Pain d. Reaction to medications ANS: B Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A patient’s serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? a. Tissue ischemia b. Brain malformations c. Intestinal blockage d. Cardiac dysrhythmia ANS: D Cardiac dysrhythmia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.

N OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nurse is explaining the concept of perfusion to a student nurse. The nurse knows the student understands the concept of perfusion when the student makes which statement? a. “Perfusion is a normal function of the body, and I don't have to be concerned about it.” b. “Perfusion is monitored by the physician.” c. “Perfusion is monitored by vital signs and capillary refill.” d. “Perfusion varies as a person ages, so I would expect changes in the body.”

ANS: C The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a. Elevated blood pressure b. Bounding pedal pulses

c. Night blindness d. Reflux disease ANS: A Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes.

This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

Concept 19: Gas Exchange Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange? a. Blood glucose of 350 mg/dL b. Anticoagulant therapy for 10 days c. Hemoglobin of 8.5 g/dL d. Heart rate of 100 beats/min and blood pressure of 100/60 ANS: C The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential | NCLEX Client Needs Category: Physiological Adaptation 2. The nurse is reviewing the patient’s arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b. Tachycardia and decreaseNd blood pressure c. Increased anxiety and irritability d. Hyperventilation and lethargy ANS: A The patient is experiencing respiratory acidosis (pH and PaCO2) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO 2.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem? a. Peripheral arterial disease of the lower extremities b. Chronic obstructive pulmonary disease (COPD) c. Chronic asthma d. Severe anemia secondary to chemotherapy ANS: A Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is assessing a patient’s differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient’s gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. Eosinophil count will assist to identify the presence of a respiratory infection. c. White cell count will differentiate types of respiratory bacteria. d. Level of neutrophils provides guidelines to monitor a chronic infection.

ANS: A Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patient’s gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? a. Chronic lung disease with increased carbon dioxide retention b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention c. Decreased cardiac output with increased serum lactic acid production d. Gastric drainage with increased removal of gastric acid ANS: A N Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen? a. Hemoglobin level of 8.0 b. Bronchoconstriction and mucus c. Peripheral arterial disease d. Decreased thoracic expansion ANS: A Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a. The infant is becoming more active. b. There is an increase in intake of breast milk or formula. c. The infant is unable to maintain an adequate iron intake. d. A depletion of fetal hemoglobin occurs.

ANS: D Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2–3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

8. Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a. Decreasing venous stasis and risk for pulmonary emboli b. Implementation of strict hand washing routines c. Maintaining current vaccination schedules d. Prevention of pneumonia in patients with chronic lung disease ANS: D Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation,Nimmunizations, and prevention of postoperative complications.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. Endocrine system c. Pulmonary system d. Immune system e. Cardiovascular system f. Hepatic system ANS: A, C, E The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange.

The immune system primarily protects the body against infection.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. Oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.

ANS: B, E, F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

N

Concept 20: Reproduction Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A female college student is planning to become sexually active. She is considering birth control options and desires a method in which ovulation will be prevented. To prevent ovulation while reaching 99% effectiveness in preventing pregnancy, which option should be given the strongest consideration? a. Intrauterine device b. Coitus interruptus c. Natural family planning d. Oral contraceptive pills ANS: D Oral contraceptive pills prevent ovulation and are 99% effective in preventing pregnancy when taken as directed. Intrauterine devices, coitus interruptus, and natural family planning will not prevent ovulation while reaching 99% effectiveness in preventing pregnancy, so they are not recommended for this college student.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. The nurse at the family planning clinic conducts a male history for infertility evaluation.

Which finding has the greatest implication for this patient’s care? a. Practice of nightly masturNbation b. Primary anovulation c. High testosterone levels d. Impotence due to alcohol ingestion ANS: D Factors affecting male infertility include impotence due to alcohol. Nightly masturbation and high testosterone levels do not have the greatest implication on male infertility in a patient with admitted alcohol issues. Primary anovulation refers to female infertility, so it is not a consideration for male infertility.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. The emergency department nursing assessment of a pregnant female at 35 weeks gestation reveals back pain, blood pressure 150/92, and leaking of clear fluid from the vagina. Which complication of pregnancy does the nurse suspect? a. Ectopic pregnancy b. Spontaneous abortion c. Premature rupture of membranes d. Supine hypotension ANS: C

Leaking of clear fluid from the vagina with back pain and elevated BP is associated with premature rupture of membranes, a complication of pregnancy. An ectopic pregnancy usually manifests as unilateral pain early in the pregnancy. Vaginal bleeding is a classic sign of miscarriage, or spontaneous abortion, not leaking of clear fluid. This patient’s blood pressure is elevated. Supine hypotension occurs when the woman is lying supine; then low blood pressure occurs due to the decrease in venous return from the gravid uterus placing pressure on the vena cava.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. The nurse is admitting a prenatal patient for diagnostic testing. While eliciting the psychosocial history, the nurse learns the patient smokes a pack of cigarettes daily, drinks a cup of cappuccino with breakfast, has smoked marijuana in the remote past, and is a social drinker. Which action should the nurse first take? a. Strongly advise immediate tobacco cessation b. Elimination of all caffeinated beverages c. Serum and urine testing for drug use and alcohol use d. Referral to a 12-step program ANS: A There are numerous risk factors for women and men affecting reproductive health and pregnancy outcomes. These can be categorized into biophysical, psychosocial, sociodemographic, and environmental factors. Some of the risk factors for human reproduction fit into multiple categories. Psychosocial factors cover smoking, excessive caffeine, alcohol and drug abuse, psychological status including impaired mental health, addictive lifestyles, spouse abuse, and noncompliance with cultural norms. Drinking a cup of a caffeinated beverage a d aNy is not associated with adverse fetal outcomes usually. Serum and urine testing for drug/alcohol use is not required for stated marijuana use in the remote past. Patient referral to a 12-step program is usually advisable for current alcohol and/or drug use.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A female infertility patient is found to be hypoestrogenic at the preconceptual clinic visit.

She asks the nurse why she has never been able to get pregnant. Which is the best nursing response? a. Circulating estrogen contributes to secondary sex characteristics. b. Estrogen deficiency prevents the ovum from reaching the uterus and may be a factor in infertility. c. Hyperestrogen may be preventing the zona pellucida from forming an ovum protective layer. d. The corona radiata is preventing fertilization of the ovum.

ANS: B

The cilia in the tubes are stimulated by high estrogen levels, which propel the ovum toward the uterus. Without estrogen, the ovum won’t reach the uterus. The results of a series of events occurring in the ovary cause an expulsion of the oocyte from the ovarian follicle known as ovulation. The ovarian cycle is driven by multiple important hormones: (1) gonadotropic hormone, (2) follicle-stimulating hormone (FSH), and (3) luteinizing hormone (LH). The cilia in the tubes are stimulated by high (4) estrogen levels, which propel the ovum toward the uterus. The zona pellucida (inner layer) and corona radiata (outer layer) form protective layers around the ovum. If an ovum is not fertilized within 24 hours of ovulation by a sperm, it is usually reabsorbed into a woman’s body. A patient who is hypoestrogenic would not have excess circulating estrogen. A patient with low estrogen would not be classified as hyperestrogenic. Without sufficient estrogen, there can be no fertilization of the ovum.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. An obstetric multipara with triplets is placed on bed rest at 24 weeks’ gestation. Her perinatologist is managing intrauterine growth restriction with serial ultrasounds. This prescribed treatment is an example of which type of care? a. Antenatal diagnostics b. Primary prevention c. Secondary prevention d. Tertiary prevention ANS: C An example of secondary prevention relating to reproductive health would be managing fetal intrauterine growth restriction by serial ultrasounds. This type of diagnostic maternal/fetal monitoring is pNerformed to determine the best time for delivery due to potential fetal nutritional, circulatory, or pulmonary compromise. A cesarean section (operative delivery) may be performed if maternal or fetal conditions indicate that delivery is necessary. Antenatal diagnostics refers to prior to pregnancy. An example of primary prevention is teaching a high school class about reproductive health. An example of tertiary prevention would be aimed at improving health following an illness and/or rehabilitation.

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NCLEX Client Needs Category: Safe and Effective Care Environment

7. A female patient comes to the clinic after missing one menstrual period. She lives in a house beneath electrical power lines which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest implication for this patient’s plan of care? a. Electrical power lines are a potential hazard to the woman and her fetus. b. Living near an oil field may mean the water supply is polluted. c. Alcohol exposure should be avoided during pregnancy due to teratogenicity. d. Eating sweets may cause gestational diabetes or miscarriage.

ANS: C

Stages of development include ovum, embryonic, and fetal. The beginning of the fourth week to the end of the eighth week comprise the embryonic period. Teratogenicity is a major concern because all external and internal structures are developing in the embryonic period. A pregnant woman should avoid exposure to all potential toxins during pregnancy, especially alcohol, tobacco, radiation, and infections during embryonic development. Living in a house beneath power lines is not the greatest implication in this patient’s plan of care as there are no definite risks to the developing fetus. Living near an oil field has no definite risks to the fetus. Eating sweets may contribute to maternal obesity, large for gestational age fetus, and maternal gestational diabetes but does not have the immediate implication of a daily beer drinker which can cause fetal alcohol syndrome.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

Concept 21: Sexuality Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse is reviewing concepts related to physiological responses that occur during sexual acts. Which statement should the nurse identify as not being accurate? a. During resolution, ADH and oxytocin are released. b. Most often in males, orgasm occurs with ejaculation. c. Genital congestion occurs as part of a reflexive response. d. Dopamine secretion acts as an inhibitory transmitter.

ANS: D The general phases of sexual arousal include motivation, arousal, genital congestion, orgasm and resolution. Dopamine secretion is considered to be an excitatory and released during the arousal stage. Orgasm and ejaculation occur more frequently in males. Genital congestion is under reflexive autonomic response.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is obtaining a sexual history from an adolescent patient. Which finding has the greatest implication for this patient’s care? a. Patient denies any sexual activity. b. Patient states that he/she uses “safe sex” practices. c. Patient states that he/she is in a monogamous relationship. d. Patient has been intimate Nwith more than one person in the last year.

ANS: D The Center for Disease Control (CDC) had identified the 5P’s with regard to obtaining information for a sexual history. They focus on partners, practices, protection from infection, past history of infection, and prevention of pregnancy. An individual who has had more than one partner within the time frame should be questioned regarding condom use.

Denial of sexual activity is part of the patient’s self-disclosure. The patient stating that he/she is in a monogamous relationship again represents self-disclosure. Use of “safe sex” practices may need to be further explored but it does not have the greatest implication at this point.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. A 45-year-old female patient, gravida 3 para 3, presents with complaints of decreased desire to engage in sexual activity with her husband as it is becoming more painful. What physical assessment data should the nurse focus on? a. Urine culture to identify potential STD. b. Obtain vital signs as a baseline to rule out infection. c. Prepare for a vaginal exam. d. Inspection of the abdomen for pelvic mass.

ANS: C

Based on the patient’s reported complaint and obstetrical history, it may be likely that the patient has a pelvic prolapse. Therefore, a vaginal exam would be indicated to help identify possible anatomical changes. There is no clinical data that supports a potential pelvic mass and inspection alone would not confirm this finding. Obtaining vital signs as well as a urine culture may be needed, but the focus should be on determination of physical findings related to the pelvic area.

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NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. An adult patient comes for a well-check up to the primary care provider’s office. In completing the office admission form, the patient does not indicate gender on the form and seems somewhat agitated when providing the form back to the nurse. How should the nurse respond? a. Ask the patient to complete all of the information at this time. b. Ask the patient if you can assist with completing the form. c. The nurse should just indicate which gender she/he thinks is appropriate. d. Tell the patient that if the form is not completed, then the doctor will not see you.

ANS: B Gender identity is defined by the individual patient. The nurse should not designate this description or identity nor should the nurse tell the patient that if the form is not completed, that the patient will not be seen by the healthcare provider. Asking the patient to complete the information without acknowledging that the patient is exhibiting signs of distress is not therapeutic. The nurse should offer to provide assistance to the patient.

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NCLEX Client Needs Category: Psychological Integrity

N 5. A nurse is working with a male patient being treated for erectile dysfunction. Which statement indicates that additional teaching is needed? a. “I like to go walking around my community each night after dinner.” b. “I have a few drinks during the week when I go out after work.” c. “I have maintained my weight for the past 5 years after losing 20 pounds.” d. “I monitor my blood pressure at home using a portable cuff.”

ANS: B Erectile dysfunction (ED) is a common problem affecting the male population and can be chronic or transient in nature. Alcohol use can affect ED, so the patient’s reported alcohol intake indicates that additional teaching is warranted. Exercise, maintaining a healthy weight and monitoring of blood pressure are examples of appropriate activities.

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NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nursery nurse performing the first physical assessment of the newborn observes that there is no clear identification of genitalia as being either female or male. How should the nurse identify this newborn? a. Gender neutral b. Bisexual c. Observation of intersex d. Asexual

ANS: C Intersex represents a group of conditions where the external genitalia of an infant does not appear as either male or female and/or is not consistent with genetic sex or organs. The nurse cannot attribute sexual preference such as asexual or bisexual. Gender neutral does not apply to this clinical situation.

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NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A nurse working with a family whose child has recently told them that he identifies with the LGBTQ community asks the nurse to explain how this happened considering the fact that the child was raised as a male and played with appropriate toys. What is the best nursing response to the family’s concerns? a. Tell them that there is no need for concern for their child has shared this information with them. b. Ask the parents if they ever noticed something different about their son as he was growing up. c. Explain that sexual orientation changes can occur over time. d. Suggest that this behavior may be temporary.

ANS: C Sexual orientation and gender identification is now thought of as a fluid concept, with the term sexual fluidity being used to convey this meaning for individuals who identify with other than heterosexual relationships. The nurse should respond to the parent’s concerns and not minimize their reaction but rather let them know that it is the chosen response of their child. Relating the sexual orientation or gender identification to how one was raised indicates an implied bias. Telling the family that the behavior may be temporary is not N correct.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

Concept 22: Immunity Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient’s discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques c. The importance of wearing a face mask in public d. Limiting contact with the general population ANS: B The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes Nt ha t the child’s growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition? a. Primary immunodeficiency b. Secondary immunodeficiency c. Cancer d. Autoimmunity ANS: A Primary immunodeficiency is a risk for patients with two or more of the listed problems.

Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12–24 hours post operation dependent on which condition? a. His immune system is functioning properly. b. He is properly vaccinated. c. He has an infection. d. The suppressor T-cells in his body are activated.

ANS: A Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the body’s response to intentional tissue impairment. The redness and swelling at the incision site in the first 12–24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement? a. “My body will treat the new kidney like my original kidney.” b. “I will have to make sure that I avoid being around people.” c. “The medications that I take will help prevent my body from attacking my new kidney.” d. “My body will only have a problem with my new kidney if the donor is not directly related to me.”

ANS: C Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will n o Nt treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they don’t have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient’s respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition? a. Suppressed immune response b. Hyperimmune response c. Allergic reaction d. Anaphylactic reaction ANS: D

The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication.

These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA).

The nurse should explain which goal of treatment to the patient? a. Eradicate the disease b. Enhance immune response c. Control inflammation d. Manage pain ANS: C Medications for RA are intended to control the inflammation that results from the body’s hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response.

The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

N MULTIPLE RESPONSE 1. The parents of a newborn question the nurse about the need for vaccinations: “Why does our baby need all those shots? He’s so small, and they have to cause him pain.” The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) a. Are only required for infants b. Are part of primary prevention for system disorders c. Prevent the child from getting childhood diseases d. Help protect individuals and communities e. Are risk free f. Are recommended by the Centers for Disease Control and Prevention (CDC) ANS: B, D, F Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient won’t get the disease, but it decreases the potential to contract the illness. No medication is risk free.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

Concept 23: Inflammation Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following? a. “The coating on these medications is irritating to my intestines.” b. “I need a more immediate response from my medications than can be obtained from enteric coated medications.” c. “Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue.” d. “I don’t need to use these medications because they cause diarrhea, and I have had enough trouble with diarrhea and rectal bleeding over the past weeks.”

ANS: C Enteric coatings on medications are designed to prevent breakdown and absorption of the medication until lower in the digestive tract, usually to prevent stomach irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with ulcerative colitis, the intestinal lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, enteric coated medications should be avoided. The coating is not irritating, but the medication can be. The response time of the medication is not a concern in this instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.

N

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. What is the nurse’s best response? a. “Use ice only when the ankle hurts.” b. “Ice should be applied for 15–20 minutes every 2–3 hours over the next 1–2 days.” c. “Wrap an ice pack around the injured ankle for the next 24–48 hours.” d. “Ice is not recommended for use on the sprain because it would inhibit the inflammatory response.”

ANS: B Ice is used on areas of injury during the first 24–48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2–3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. A patient is being treated with an antibiotic for an infected orthopedic injury. What explanation should the nurse give to the patient about this medication?

a. b. c. d.

“Antibiotics will decrease the pain at the site.”

“An antibiotic helps to kill the infection causing the inflammation.”

“An antibiotic inhibits cyclooxygenase, an enzyme in the body.”

“Antibiotics will reduce the patient’s fever.”

ANS: B Antimicrobials treat the underlying cause of the infection which leads to inflammation.

Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient’s wound. The nurse realizes what information about this fluid? a. Contains the materials used by the body in the initial inflammatory response b. Indicates that the patient has an infection at the site of the wound c. Is destroying healthy tissue d. Results from ineffective cleansing of the wound area ANS: A Exudate is fluid moved from the vascular spaces to the area around a wound. It contains the proteins, fluid, and white blood cells (WBCs) needed to contain possible pathogens at the site of injury. Exudate appears as part of all inflammatory responses and does not mean an infection is present. Exudate is part of normal inflammatory responses which contain self-monitoring mechanisms to help prevent damage to healthy tissue. Exudate appears at wound sites regardless of cleaNning done to the area of injury.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. The nurse reviews the patient’s complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates what type of inflammatory response? a. Chronic b. Resolved c. Early stage acute d. Late stage acute ANS: C Elevated neutrophils and monocytes within normal limits are findings indicative of early inflammatory response. Neutrophils increase in just a few hours, while it takes the body days to increase the monocyte levels. Chronic inflammation results in varying elevations in WBCs dependent on multiple issues. Elevated neutrophils are not indicative of resolved inflammation. Elevations in monocytes occur later in the inflammatory response.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. What teaching should the nurse provide for this patient?

a. b. c. d.

“Don’t eat with the other students.”

“Avoid sharing razors and other personal items.”

“Have a complete blood count (CBC) checked monthly.”

“Disinfect showers and bathroom floors weekly after use.”

ANS: B Avoidance of sharing personal items like razors and hairbrushes can decrease the spread of pathogens that cause inflammation and infection. Not eating with the others in his college apartment won’t relieve or prevent the spread of infection. A CBC monthly will not treat or prevent inflammation. Showers should be disinfected before and after each use.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. The nurse assesses the patient and notes all of the following. Which of the findings indicates systemic manifestations of inflammation? (Select all that apply.) a. Oral temperature 38.6 C/101.5 F b. Thick, green nasal discharge c. Patient complaint of pain at 6 on a 0–10 scale on palpation of frontal and maxillary sinuses d. WBC 20 cells/McL  109/L e. Patient reports, “I’m tired all the time. I haven’t felt like myself in days.”

ANS: A, D, E Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise andNfatigue. Purulent exudates and pain are both considered local manifestations of inflammation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Concept 24: Infection Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element? a. Host b. Mode of transmission c. Portal of entry d. Reservoir ANS: C Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry.

Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. While reviewing the completN e blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of which type of infection? a. Bacterial b. Fungal c. Parasitic d. Viral ANS: C Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels. Bacterial infections do not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T lymphocytes, neutrophils, and monocytes.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. Which set of assessment data is consistent for a patient with severe infection that could lead to system failure? a. Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours c. BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24

hours d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours ANS: B The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A nurse is teaching a group of business people about disease transmission. The nurse knows that additional teaching is needed when one of the participants states which of the following? a. “When traveling outside of the country, I need to be sure that I receive appropriate vaccinations.” b. “Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has no resistance.” c. “If I don’t feel sick, then N I don’t have to worry about transmitted diseases.” d. “I need to be sure to have good hygiene practices when traveling in crowded planes and trains.”

ANS: C People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. In order to provide an intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide? a. Whether a patient has an infection. b. Where an infection is located. c. The type of cells that are being utilized by the body to attack an infection. d. The specific type of pathogen that is causing an infection.

ANS: D

People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.) a. Administration of protease inhibitors b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission d. Preventing visitors from entering the room e. Administration of intravenous fluids f. Strict monitoring of intake and output ANS: B, C, E, F Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the use of personal protectiveNequipment and teaching on methods to inhibit transmission to help break the chain of infection. Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of Clostridium difficile, because it causes diarrhea with fluid loss.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort | NCLEX Client Needs Category: Physiological Adaptation 2. Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a. Uninsured or underinsured status b. Easy access to health screenings c. High cost of medications d. Inadequate nutrition e. Mostly female gender ANS: A, C, D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection. Gender has not been shown to be an increased risk factor for infection in the lower socioeconomic population.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort |

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 25: Mobility Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening.

What is the nurse’s best response? a. “Your iron level is low. This is known as anemia.” b. “Your immobility in the hospital is known as deconditioning.” c. “Your poor appetite is known as malnutrition.” d. “Your medications have caused drug induced weakness.”

ANS: B When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body, but this is not known as deconditioning which is the most likely cause in this patient’s situation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. An older patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. What is the nurse’s best response? a. “Walk at least 5 miles every day for exercise.” b. “Wear proper fitting shoes to prevent tripping.” c. “Talk with your physicianNabout a calcium supplement.” d. “Stand up slowly so you don’t feel faint.”

ANS: C Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones, but the patient should consult with the healthcare provider before any exercise regimen is implemented for the older adult. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. Mobility for the patient changes throughout the lifespan. What is the term that best describes this process? a. Aging and illness b. Illness and disease c. Health and wellness d. Growth and development ANS: D Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they don’t always affect mobility.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? a. “Patients must have a trapeze over the bed to move properly.” b. “Patients should move themselves in bed to prevent immobility.” c. “Patients should always have a two-person assist to move in bed.” d. “Patients must be moved correctly in bed to prevent shearing.”

ANS: D Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional if the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly. A patient may move himself or herself if he or she is able; but shearing may still occur.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement? a. “Patients with impaired bed mobility have an increased risk for pressure ulcers.” b. “Patients with impaired bed mobility like to have extra visitors.” c. “Patients with impaired bed mobility need to have a mechanical soft diet.” d. “Patients with impaired bed mobility are prone to constipation.”

N

ANS: A Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is instituted.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. What percentage of hip fractures is the result of falls? a. 50% b. 80% c. 90% d. 100% ANS: C About 90% of falls end with a hip fracture.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. The lack of weight bearing leads to what effects on the skeletal system? a. Demineralization, calcium loss b. Thickened bones c. Increased range of motion

d. Increased calcium deposition in the bones ANS: A Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium that strengthen it. Thickened bones will not occur with the lack of weight bearing. Range of motion may be decreased with a lack of weight bearing movements.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

Concept 26: Tissue Integrity Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer? a. “Limit the time you spend in the sun.” b. “Monitor for signs of infection.” c. “Monitor spots for color change.” d. “Use skin creams to prevent drying.”

ANS: C The ABCDE method (check for asymmetry, border irregularity, color variation, diameter and evolving) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient? a. Obtaining a complete blood count (CBC) b. Protection from excessiveNheat c. Protection from excessive ultraviolet (UV) exposure d. Instructing the patient to take their multivitamin prior to treatment ANS: C Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a. Apply the cream generously to affected areas. b. Apply a thin coat to affected areas, especially the face. c. Apply a thin coat to affected areas; avoid the face and groin. d. Apply an antihistamine along with applying a thin coat of steroid to affected areas.

ANS: C

The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity.

The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

5. To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevNent sunburn by replacing lost nutrients. d. Apply sunscreen 30 minutes prior to exposure.

ANS: D Wearing sunglasses and sunscreen are recommended by the National Cancer Institute.

Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for additional teaching? a. “I wear a hat and sit under the umbrella when not in the water.” b. “I don’t bother with sunscreen on overcast days.” c. “I use a sunscreen with the highest SPF number.” d. “I wear a UV shirt and limit exposure to the sun by covering up.”

ANS: B The sun’s rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

7. A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism? a. Candida albicans b. Group A -hemolytic streptococci c. Staphylococcus aureus d. E. Coli ANS: C Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

8. A nurse is conducting community education classes on skin cancer. One participant says to the nurse: “I read that most melanomas occur on the face and arms in fair-skinned women.

Is this true?” How should the nurse respond? a. “That is not correct. Melanoma is more commonly found on the torso or the lower legs of women.” b. “That is correct, because the face and arms are exposed more often to the sun.” c. “That is not correct. Melanoma occurs on the top of the head in men but is rare in women.” d. “That is incorrect. Melanoma is most commonly seen in dark-skinned individuals.”

ANS: A Melanoma is more commonlyN found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

9. The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse’s teaching? a. Bathing and drying the skin vigorously to stimulate circulation b. Keeping the head of the bed elevated 30 degrees c. Limiting intake of fluid and offer frequent snacks d. Turning the patient at least every 2 hours ANS: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

10. A patient asks the nurse what the purpose of the Wood’s light is. Which response by the nurse is accurate? a. “We will put an anesthetic on your skin to prevent pain.” b. “The lamp can help detect skin cancers.” c. “Some patients feel a pressure-like sensation.” d. “It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions.”

ANS: D The Wood’s light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 27: Sensory Perception Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A 75-year-old woman walks into the emergency department with complaints of “not feeling well.” Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings? a. Normal in the older adult b. A need for the patient to be evaluated for cognitive impairment c. A side effect of anti-hypertensive medication d. Pathologic impairment of sensory responses ANS: D This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli.

Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The nurse requests that a m o tNhe r give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? a. “This will help us to identify your baby’s risk for ear infections the first year of life.” b. “Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother.” c. “Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child.” d. “Imitation of sounds is the first step in language development, and it is important to identify alterations early.”

ANS: D Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby’s response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse’s best response? a. “Your wife should increase the spices in your food, as the pneumonia changes

your sense of smell.” b. “Notify your doctor immediately, because this is a concerning reaction to the medication.” c. “You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection.” d. “You should see an improvement in the next week or so. Call if this continues.”

ANS: D Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process.

Understanding of the instructions is evident when the daughter says which of the following? a. “I will make sure that dad always wears warm socks.” b. “Dad needs to wear his glasses so he can delay the onset of macular degeneration.” c. “I will ask the home health aide to carefully inspect dad’s feet every day when she helps him bathe.” d. “We will give him only warm foods, so that he doesn’t burn his mouth.”

ANS: C Diabetes increases risk of perNipheral neuropathy, and it is hard to inspect one’s own feet.

Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse’s best action to provide recreational activities during the rehabilitation phase? a. Place the television to the left or right of patient’s visual field. b. Encourage the patient to learn braille. c. Suggest use of talking books. d. Provide headphones for listening to music.

ANS: C Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

6. The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the nurse’s priority action? a. Notify the physician. b. Document the finding in the records. c. Recheck the reflex after several hours. d. Monitor the eye movements and pupil reactions closely.

ANS: A The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? a. “I will take my child to the audiologist because he doesn’t seem to hear me except when I look directly at him.” b. “Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle.” c. “Making my child wear ear plugs when she goes to a rock concert may save her hearing!” d. “I see now why when my child has a cold, he complains about everything tasting blah!”

ANS: B Each person should always h Na v e their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

8. During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient’s wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure? a. Tympanoplasty b. Irrigation of the ear c. Pure tone test d. Otoscopic exam by a specialist ANS: B The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

Concept 28: Pain Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of what type of pain? a. Neuropathic pain b. Nociceptive pain c. Chronic pain d. Mixed pain syndrome ANS: B Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer.

Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A 19-year-old male has sustaN ined a transection of C-7 in a motor vehicle crash rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. What type of pain is this patient describing? a. Neuropathic pain b. Visceral pain c. Eudynic pain d. Nociceptive pain ANS: A Neuropathic pain results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Simply put, neuropathic pain is pathologic. Examples of neuropathic pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and post stroke pain syndrome. Patients with neuropathic pain use very distinctive words to describe their pain, such as “burning,” “sharp,” and “shooting.” Visceral pain arises from the body cavities and responds to stretching, swelling and decreased oxygen levels. Eudynic pain refers to the normal transmission of pain via nociceptive receptors. Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping or throbbing.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. Controlling pain is important to promoting wellness. Unrelieved pain has been associated with complication?

a. b. c. d.

Prolonged stress response and a cascade of harmful effects system-wide Large tidal volumes and decreased lung capacity Decreased tumor growth and longevity Decreased carbohydrate, protein, and fat destruction

ANS: A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or stress response.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis (OA) pain. You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include which actions or activities? a. Pilates, breathing exercises, and aloe vera b. Guided imagery, relaxatioNn breathing, and meditation c. Herbs, vitamins, and tai chi d. Alternating ice and heat to relieve pain and inflammation ANS: C Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi. Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs and vitamins.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A 70-year-old retired patent is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should the nurse consider in the plan of care considering the patient’s expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Mind-body therapies such as music therapy, distraction techniques, meditation,

prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services ANS: B Mind-body therapies are designed to enhance the mind’s capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others.

Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the mind’s capacity to affect bodily function and symptoms.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. A 30-year-old male is admitted to the hospital with acute pancreatitis. He is in acute pain described as a 10/10, which is localized to the abdomen, periumbilical area, and some radiation to his back. The abdomen is grossly distended. He is restless and agitated, with elevated pulse and blood pressure. An appropriate pain management plan of care may include which medication(s)? a. IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen b. Norco 5/500 q 4 hours PO and Benadryl 25 mg PO q 6 hours c. Phenergan 25 mg IM q 6 hours d. Tylenol 325 mg q 6 hoursN ANS: A A variety of routes of administration are used to deliver analgesics. A principle of pain management is to use the oral route of administration whenever feasible. All of the first-line analgesics used to manage pain are available in short-acting and long-acting formulations.

For patients who have continuous pain, a long-acting analgesic, such as modified-release oral morphine, oxycodone, or hydromorphone, or transdermal fentanyl, is used to treat the persistent baseline pain. A fast-onset, short-acting analgesic (usually the same drug as the long-acting) is used to treat breakthrough pain if it occurs. When the oral route is not possible, such as in patients who cannot swallow or are NPO or nauseated, other routes of administration are used, including intravenous (IV), subcutaneous, transdermal, and rectal.

Norco, Benadryl, Phenergan, and Tylenol are not appropriate solo choices for acute pancreatitis with pain reported as 10/10.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. An 80-year-old male patient is in the intensive care unit has suffered a fractured femur. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioid doses q 4 hours. What is the nurse’s first action? a. Call the rapid response team to care for the patient immediately. b. Discontinue the opioids on the medication administration record.

c. Assess the patient’s blood pressure and pain level. d. Start a second intravenous line with a large bore catheter.

ANS: A After establishing unresponsiveness, the next action is to call a Rapid Response. The patient is not able to subjectively describe pain if unresponsive. Another IV line may be needed, but first the nurse should call for help. The opioids should be discontinued on the MAR; however the priority action is to call for help.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

N

Concept 29: Fatigue Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Based on the significant effects of chronic idiopathic fatigue, what is the nurse’s priority assessment? a. Cholesterol level and lipid profile b. Creatinine and BUN levels c. Memory loss testing d. Mental health evaluation ANS: D Fatigue does not cause death or organ failure, but mortality from suicide was higher than the general population in patients with chronic idiopathic fatigue. Therefore a mental health evaluation is a priority assessment. Cholesterol and lipid levels are indicative of heart disease. Creatinine and BUN levels are indicators of kidney function. Memory loss is not a significant effect of chronic fatigue.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The nurse is assessing for fatigue in a patient diagnosed with multiple sclerosis. Which self -reporting tool is best for the nurse to utilize? a. Multidimensional Assessment of Fatigue (MAF) b. Fatigue Severity Scale (FSS) N F I) c. Brief Fatigue Inventory ( B d. Multidimensional Fatigue Inventory (MFI) ANS: B The FSS was developed for patients with multiple sclerosis and lupus. The MAF was designed for arthritis patients and is also used in cancer patients and those with chronic pulmonary disease. The BFI is used for cancer patients. The MFI is used with various patient populations, including cancer, chronic fatigue syndrome, and COPD. OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A patient presents to the clinic complaining of nausea, vomiting, and fatigue. Lab results reveal elevated BUN and creatinine levels. Which acute condition is this patient at most risk for developing? a. Influenza b. Mononucleosis c. Acute renal failure d. Pneumonia ANS: C

The patient’s symptoms are most congruent with dehydration. Hypovolemia, due to dehydration, can lead to decreased perfusion to the kidneys resulting in acute renal failure.

Influenza symptoms include headache, fever, body aches, and fatigue. Mononucleosis can manifest as severe fatigue. Pneumonia presents with cough, respiratory distress, and decreases in oxygen saturation.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is caring for a patient diagnosed with amyotrophic lateral sclerosis. The nurse should assess for which priority problem? a. Fatigue b. Bradypnea c. Hypertension d. Fall risk ANS: B Amyotrophic lateral sclerosis is a chronic condition that causes fatigue; however specific respiratory muscle fatigue leading to bradypnea is the priority safety risk. Respiratory muscle fatigue can lead to bradypnea, decreased ventilation, and eventually cessation of breathing which is the condition of highest importance with this illness. Hypertension is not a high priority problem specifically related to ALS. While the patient is a fall risk due to overall skeletal muscle fatigue, respiratory depression is the priority safety risk.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A patient with chronic kidney disease is most likely to complain of which symptom?

N a. Fatigue b. Thirst c. Constipation d. Excess bleeding ANS: A Erythropoietin is produced by the kidneys. A patient with chronic kidney disease produces less erythropoietin, resulting in anemia and fatigue as a common symptom. Thirst, or polydipsia, is a common sign of hyperglycemia and diabetes which can lead to chronic kidney disease. Constipation is not a common symptom of chronic kidney disease.

Excessive bleeding can result from a decrease in platelets and clotting factors that are produced by the liver, not the kidneys.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A patient has been recently diagnosed with chronic fatigue syndrome and asks the nurse about the cause of this illness. What is the nurse’s best response? a. “The provider will be able to tell you when the lab results are back.” b. “An exact cause may not be determined, but a treatment plan will be discussed.” c. “Stress is the main cause; a referral to a counselor may be helpful.” d. “This is considered a psychiatric illness requiring behavioral medicine.”

ANS: B

Chronic fatigue syndrome is considered an illness with an unknown etiology. There are no specific lab results that reveal chronic fatigue syndrome. Stress and mental illnesses may be contributing factors, but are not classified as exact causes of chronic fatigue syndrome.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. The nurse palpates swollen nodes in a patient’s neck who presented to the clinic with complaints of fatigue lasting at least 2 weeks. What is the nurse’s best action? a. Advise patient this finding is normal. b. Review patient’s thyroid lab work. c. Perform deep tendon reflexes. d. Notify the healthcare provider.

ANS: D The nurse should notify the healthcare provider for further evaluation. Palpation is indicated to assess for the presence of lymphadenopathy, thyroid nodules or goiter. These findings could implicate the need to test further for cancer, thyroid disease or infection. These conditions should be ruled out by the healthcare provider. Thyroid nodules or changes in size indicate the need for further assessment of the thyroid. Deep tendon reflexes are part of a neuro-muscular examination and are not directly related to cervical node enlargement.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. The nurse is assessing a patient for risk factors of chronic fatigue syndrome. Which factors N should the nurse identify as placing the patient at risk for chronic fatigue syndrome? (Select all that apply.) a. Feeling tired upon awakening b. Chronic migraines c. Tenderness under the jaw d. 5 episodes tonsillitis/past year e. Swollen, painful knees ANS: A, C, D, E The individual has severe chronic fatigue for 6 or more consecutive months that is not due to ongoing exertion or other medical conditions associated with fatigue (these other conditions need to be ruled out by a doctor after diagnostic tests have been conducted). The fatigue significantly interferes with daily activities and work. The individual concurrently has four or more of the following eight symptoms: • Post exertion malaise lasting more than 24 hours • Unrefreshing sleep • Significant impairment of short-term memory or concentration • Muscle pain • Multi-joint pain without swelling or redness • Headaches of a new type, pattern, or severity • Tender cervical or axillary lymph nodes • Frequent or recurring sore throat

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The occupational health nurse is making rounds in a factory. Which employees need further education about energy conservation strategies? (Select all that apply.) a. Workers reaching up to high shelf often to obtain cleaning supplies b. Workers bending over to lift boxes onto conveyer belt c. Workers who have delegated out parts of their activities d. Workers standing for long periods e. Workers standing at desks at waist level ANS: A, B, D The employee health nurse should provide teaching to employees about energy conservation strategies to protect workers from job-related injuries. These strategies include: placing frequently used items within reach; using proper body mechanics (not bending over and straining the back); and standing for long periods of time. Delegating parts of activities is an appropriate energy conserving strategy. When standing is necessary, it is important that desks or tables are at waist level of the employee to prevent excess reaching or straining.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. The nurse recognizes that which patients are at highest risk for physiologic fatigue? (Select all that apply.) a. Parents of a newborn b. Adolescent with anorexia c. 25-year-old pregnant female d. Grandmother who takes N mile walks e. Businessman who consumes six cups coffee/day ANS: A, B, C, E Physiologic causes of fatigue include: protein–calorie malnutrition, excessive physical activity, sleep deprivation, excessive caffeine or alcohol use, and pregnancy. Parents of a newborn are likely experiencing sleep deprivation. A patient with anorexia is likely not consuming adequate amounts of protein. Consumption of six cups of coffee/day is considered excessive. A mile walk is an appropriate exercise for an older adult and not considered excessive physical activity.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. Which are treatment related causes of fatigue? (Select all that apply.) a. Blood transfusion b. Chemotherapy c. Radiation therapy d. Surgery e. Side effects of medications ANS: B, C, D, E

Cancer treatments, such as chemotherapy and radiation, commonly cause fatigue. A risk of any surgery is blood loss, which can possibly lead to fatigue if the hemoglobin and hematocrit drop significantly. Fatigue is a side effect of many medications. A blood transfusion is more likely to lead to increased energy versus fatigue as the hematocrit and hemoglobin levels would be expected to rise with the transfusion.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

N

Concept 30: Stress and Coping Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patient’s chief complaint? a. The patient is responsible for caring for two school-age grandchildren. b. The patient’s daughter works to support the family. c. The patient is being treated for hypertension and is overweight. d. The patient has recently lost her spouse and needed to move in with her daughter.

ANS: D The stress of losing a loved one and having to move are important contributing factors for stress-related symptoms in older people. Caring for children will increase the patient’s sense of worth. Being overweight and being treated for hypertension are not the most likely causes of insomnia or headache. The patient’s daughter may have added stress due to working, but this should not directly affect the patient.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take? a. Ask the healthcare provider for a psychiatric referral. b. Administer the PRN sedaN tive medication every 4 hours. c. Suggest the use of a home caregiver to the patient’s family. d. Plan to reinforce and repeat teaching about diabetes management.

ANS: D Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated.

Psychiatric referral or home caregiver referral will not be needed for these expected short-term cognitive changes. Sedation will decrease the patient’s ability to learn the necessary information for self-management.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

3. A diabetic patient who is hospitalized tells the nurse, “I don’t understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up.” Which response by the nurse is appropriate? a. “It is probably just coincidental that your blood sugar is high when you are ill.” b. “Stressors such as illness cause the release of hormones that increase blood sugar.” c. “Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times.” d. “Your diet is different here in the hospital than at home, and that is the most likely cause of the increased glucose level.”

ANS: B

The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient’s vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110–120/76–84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30–60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

ANS: C The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Benson’s relaxation response) will counter the sympathetic nervous system’s arousal, normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his body. Other options do not address his physiologic response pattern as directly or immediately.

OBJ: NCLEX Client NeedsNCategory: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function? a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. b. Alter the internal state by modifying electronic signals related to physiologic processes. c. Replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities. d. Reduce catecholamine production and promote the production of additional -endorphins.

ANS: A When the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse, blood pressure, and respiratory rate. Relaxation is achieved when the sympathetic nervous system is quieted and the parasympathetic nervous system is operative. Modifying electronic signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the cognitive approach to stress management. Reducing catecholamine production is the basis for guided imagery’s effectiveness.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A patient tells the nurse, “I’m told that I should reduce the stress in my life, but I have no idea where to start.” Which would be the best initial nursing response? a. “Why not start by learning to meditate? That technique will cover everything.” b. “In cases like yours, physical exercise works to elevate mood and reduce anxiety.” c. “Reading about stress and how to manage it might be a good place to start.” d. “Let’s talk about what is going on in your life and then look at possible options.”

ANS: D In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. As a result, further assessment is indicated before potential solutions can be explored. Suggesting further exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. A patient tells the nurse “My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking.” Which response would be in keeping with the doctor’s recommendations? a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts b. Encouraging the patient to imagine being in calming circumstances c. Teaching the patient to use instruments that give feedback about bodily functions d. Provide the patient with a blank journal and guidance about journaling ANS: A N Meaning-focused coping leads the individual to focus on his/her own values and beliefs to modify the personal interpretation and response to a problem. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient’s manner of thinking.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

8. A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient’s wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

ANS: C

Objective measures tend to be the most reliable means of gauging progress. In this case, the patient’s elevated blood pressure, an indication of the body’s physiologic response to stress, has diminished. The wife’s observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patient’s report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 9. The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress.

Which action should the nurse implement to assist the patient? a. Identifying the cause of fear b. Accessing a community support group c. Identifying relaxation methods d. Reviewing an educational pamphlet ANS: A Identifying the cause of a negative perception is the first step in helping an individual to be able to utilize coping strategies. Accessing a community support group is an example of accessing resources to enhance coping. Identifying relaxation methods is an example of developing an action plan. Reviewing an educational pamphlet is an example of using education to enhance coping.

OBJ:

NCLEX Client NeedsNCategory: Psychosocial Integrity

10. The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy? a. Scheduling a regular exercise program b. Attending a seminar on treatment options c. Identifying a confidant to share feelings d. Attending a support group for families ANS: C Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing community resources or attending educational seminars.

Exercise, emotional support, and support groups are emotion-based strategies that create a feeling of well-being.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

11. The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population? a. Altered vital sign readings b. Inaccurate perceptions of stressors c. Increased risk for suicide d. Decreased access to alcoholic beverages

ANS: C Adolescents with poor coping have increased risk for drug and alcohol use, risky sexual behaviors, and suicide. Pulse, respiratory rate, and blood pressure may change during stress, but patient safety is the priority concern. Adolescents may have inaccurate perceptions of stressors, and this actually increases the risk for unsafe behaviors. Adolescents under stress are more at risk for increasing their access to alcohol and illegal drugs.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

12. A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient? a. Ask if there is another family member who can help at home while the patient is in the hospital. b. Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover. c. Coordinate an ambulance transfer of the family member to an alternate family member’s home. d. Ask social services to assess what the patient’s needs will be after discharge to home.

ANS: A The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the immediate need to provide care for the disabled family member. An Nambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person’s needs, availability to provide the care by another, and distance of the transfer. Assessing the patient’s needs after discharge does not address the immediate need to provide care for the disabled family person.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

13. After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff? a. Ask administration to require staff to meditate daily for at least 30 minutes. b. Have a staff psychologist available on the unit once a week for required counseling. c. Have training sessions to help the staff understand their new responsibilities. d. Ask support staff from other disciplines to complete some nursing tasks to provide help.

ANS: C

Feeling unprepared for work responsibilities contributes to stress and poor coping in the workplace. Administration cannot require that staff participate in meditation or counseling sessions, although these can be recommended and encouraged. Asking other disciplines to assume nursing tasks is not appropriate for their scope of practice.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

14. The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool? a. “This tool will let us compare your stress to other patients in the hospital.” b. “This tool is short because it only measures the negative stressors you are experiencing.” c. “You will need to ask your parents about stressors you had as a child to complete this tool.” d. “This tool will help assess recent positive and negative events you are experiencing.”

ANS: D Coping measurement tools measure recent positive and negative life events as perceived by the individual. There is no objective scale for comparison with other patients because each person reacts differently to stressors. Both negative and positive events are assessed.

Childhood stressors are not part of this type of evaluation as they are intended to measure recently occurring events.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N MULTIPLE RESPONSE 1. Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.) a. Assess for bradycardia. b. Ask about epigastric pain. c. Observe for increased appetite. d. Check for elevated blood glucose levels. e. Monitor for a decrease in respiratory rate.

ANS: B, C, D The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and elevation of blood glucose levels. Stress causes an increase in the respiratory and heart rates.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse is working with a patient who recently lost her spouse after a lengthy illness. The patient shares that she would like to sell her home and move to another state now that her spouse has passed away. Which of the following interventions would be considered a priority for this patient? (Select all that apply.) a. Notify the provider to evaluate for antidepressant therapy.

b. c. d. e. f.

Suggest that the patient consider a support group for widows.

Suggest that the patient learn stress reduction breathing exercises.

Suggest that the patient take prescribed antianxiety medications.

Assist the patient in identifying support systems.

Notify the provider to evaluate the need for antianxiety medications.

ANS: B, C, E Stress prevention management involves counseling, education, and implementation of techniques to manage problem-oriented and emotion-oriented stress. To prevent physical symptoms, relaxation and deep breathing are effective and individuals can learn to prevent the stress response through cognitive behavioral strategies. Medications are not indicated for patients with known stressors unless the stress is prolonged or the patient has ineffective coping mechanisms.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 31: Mood and Affect Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant.

After taking the new medication, the patient states, “This medication isn’t working. I don’t feel any different.” What is the best response by the nurse? a. “I will call your care provider. Perhaps you need a different medication.” b. “Don’t worry. You can try taking it at a different time of day to help it work better.” c. “It usually takes a few weeks for you to notice improvement from this medication.” d. “Your life is much better now. You will feel better soon.”

ANS: C Seeing a response to antidepressants takes 3–6 weeks. No change in medications is indicated at this point of treatment because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that their life is better does not acknowledge their feelings.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A patient who has been diagnNosed with depression is scheduled for cognitive therapy in addition to receiving prescribed antidepressant medication. The nurse understands that the goal of cognitive therapy will be met when what is reported by the patient? a. “I will tell myself that I am a good person when things don’t go well at work.” b. “My medications will make my problems go away.” c. “My family will help take care of my children while I am in the hospital.” d. “This therapy will improve my response to neurotransmitter impulses.”

ANS: A Cognitive therapy helps patients restructure their patterns of thinking to various events or thoughts in a more healthy way. Medication alters neurotransmitters but does not make problems go away. Family support is important but is not the goal of cognitive therapy.

Neurotransmitters are affected by medication and brain stimulation therapy, not by cognitive therapy.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes a monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient? a. Serum blood levels must be regularly monitored to assess for toxicity. b. To prevent side effects, the medication should be administered as an intramuscular injection. c. Eating foods such as blue cheese or red wine will cause side effects.

d. This medication class may only be used safely for a few days at a time.

ANS: C MAOIs have serious food interactions when ingested with tyramine-containing foods such as aged or processed foods. Serum levels are routinely monitored when mood stabilizers such as lithium carbonate are prescribed. It is not necessary to administer this class intramuscularly. This medication takes several weeks to show effectiveness and should not be stopped abruptly; short-term use will not be effective.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. A patient with a diagnosis of depression and suicidal ideation was started on an antidepressant 1 month ago. When the patient comes to the community health clinic for a follow-up appointment he is cheerful and talkative. What priority assessment must the nurse consider for this patient? a. The medication dose needs to be decreased. b. Treatment is successful, and medication can be stopped. c. The patient is ready to return to work. d. Specific assessment for suicide plan must be evaluated.

ANS: D Energy levels increase as depression lifts; this may increase the risk of completing a suicide plan. An increase in mood would not indicate a decrease or discontinuation of prescribed medication. The patient may be ready to return to work, but assessment for suicide risk in a patient who has had suicidal ideation is the priority assessment.

OBJ: NCLEX Client NeedsNCategory: Safe and Effective Care Environment: Safety and Infection Control 5. A patient who is taking prescribed lithium carbonate is exhibiting signs of diarrhea, blurred vision, frequent urination, and an unsteady gait. Which serum lithium level would the nurse expect for this patient? a. 0–0.5 mEq/L b. 0.6–0.9 mEq/L c. 1.0–1.4 mEq/L d. 1.5 or higher mEq/L ANS: D Diarrhea, blurred vision, ataxia, and polyuria are all signs of lithium toxicity, which generally occurs at serum levels above 1.5 mEq/L. Serum levels within the normal range of 0.8–1.4 mEq/L are not likely to cause signs of toxicity.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. A patient newly diagnosed with depression states, “I have had other people in my family say that they have depression. Is this an inherited problem?” What is the nurse’s best response? a. “There are a lot of mood disorders that are caused by many different causes.

Inheriting these disorders is not likely.” b. “Current research is focusing on fluid and electrolyte disorders as a cause for mood

disorders.” c. “All of your family members raised in the same area have probably learned to respond to problems in the same way.” d. “Members of the same family may have the same biological predisposition to experiencing mood disorders.”

ANS: D Research is showing a genetic or hereditary role in the predisposition of experiencing mood disorders. These tendencies can be inherited by family members. Fluid and electrolyte imbalances cause many problems, but neurotransmitters in the brain are more directly linked to mood disorders. Mood disorders are not a learned behavior, but are linked to neurotransmitters in the brain.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient? a. Assess for depression and ask directly about suicide thoughts. b. Ask the care provider to prescribe blood lab work to assess for depression. c. Focus on the presenting problems and refer the patient for a mental health evaluation. d. Interview the patient’s family to identify their concerns about the patient’s behaviors.

ANS: A Assessing directly for thoughts of harm to self or others is a priority intervention for any patient exhibiting signs of a mNe nt al health disorder. It is estimated that 50% of individuals who succeed in suicide had visited a healthcare provider within the previous 24 hours.

Currently there is no serum lab that identifies depression. The risk of self-harm is a priority safety issue that is monitored in all health care within the scope of the nurse. It is important to obtain information directly from the patient when possible, and then validate the information from family or other secondary sources.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

8. An older adult has experienced severe depression for many years and is unable to tolerate most antidepressant medications due to adverse effects of the medications. He is scheduled for electroconvulsive therapy (ECT) as a treatment for his depression. What teaching should the nurse give the patient regarding this treatment? a. There are no special preparations needed before this treatment. b. Common side effects include headache and short-term memory loss. c. One treatment will be needed to cure the depression. d. This treatment will leave you unconscious for several hours.

ANS: B Common side effects of ECT include headache, sleepiness, short-term memory loss, nausea, and muscle aches. Preparations before and after the procedure are the same as any operative procedure involving the patient receiving anesthesia. Treatment is typically three sessions a week for 4 weeks, not once. Patients are not unconscious after the procedure due to the use of precisely placed electrodes and the use of anesthesia.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE 1. A nurse is developing a plan of care for a patient admitted with a diagnosis of bipolar disorder, manic phase. Which nursing diagnoses address priority needs for the patient?

(Select all that apply.) a. Risk for caregiver strain b. Impaired verbal communication c. Risk for injury d. Imbalanced nutrition, less than body requirements e. Ineffective coping f. Sleep deprivation ANS: C, D, F Risk for injury, poor nutrition, and impaired sleep are priority needs of the patient experiencing mania related to their impulsivity, inability to attend to activities of daily living such as diet and hygiene, and disruption of sleep. Caregiver strain is important to be addressed but is not a priority need on admission for the patient. Verbal communication improves when the mania is managed, and racing thoughts return to normal patterns.

Ineffective coping will require stabilization of the acute phase along with cognitive therapy over time.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control N

Concept 32: Anxiety Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient complains of insomnia during his stay in the hospital. Which nursing diagnosis would be a top priority for this patient? a. Anxiety related to hospitalization b. Ineffective coping related to hospitalization c. Denial related to hospitalization d. High risk for insomnia related to hospitalization ANS: A The information about the patient indicates that anxiety is an appropriate nursing diagnosis.

The patient’s data do not support defensive coping, ineffective denial, or risk-prone health behavior as problems for this patient.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time? a. Massage b. Meditation c. Guided imagery N d. Relaxation breathing ANS: D Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practice and learn.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate? a. “How do you feel about what happened to you as a child?” b. “How do you feel about what is going on right now?” c. “Remember a time when you were calm.” d. “Tap your hands until the feeling goes away.”

ANS: B Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Recalling and remembering being calm or previous experiences is not included in mindfulness training. Eye movement desensitization and reprocessing (EMDR) includes expression of feelings and memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. The nurse is assessing the social support of a patient who is recently divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic? a. Encourage the patient to begin dating again, perhaps with members of her church. b. Discuss how divorce support groups could increase coping and social support. c. Note that being so particular about potential friends reduces social contact. d. Discuss using the Internet as a way to find supportive others with similar values.

ANS: B Use of support groups is a method whereby the individual uses inter-related coping strategies in the presence of a stressor. The nurse should focus on providing the patient with coping strategies aimed at decreasing stress. Resuming dating soon after a divorce could place additional stress on the patient rather than helping them cope with existing stressors.

Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose the patient to predators misrepresenting themselves to take advantage of vulnerable persons.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. A patient reports that he is overwhelmed with anxiety. Which question would be most important to use in assessing the patient during your first meeting? a. “What kinds of things do you do to reduce or cope with your stress?” b. “Tell me about your family history—do any relatives have problems with stress?” c. “Tell me about exercise—how far do you typically run when you go jogging?” d. “Stress can interfere with sleep. How much did you sleep last night?”

N

ANS: A The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. These data would indicate whether his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses such as drinking) and would help you understand how he copes and how well his coping strategies and resources are serving him. Therefore, of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended or broad-opening inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. A patient is newly diagnosed with anxiety and placed on a selective serotonin reuptake inhibitors (SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become effective? a. The medication will become effective immediately. b. The medication may take up to 12 weeks to become effective. c. The medication may take up to 6 weeks to become effective. d. The medication may take up to 4 weeks to become effective.

ANS: B Efficacy may take at least 8–12 weeks. The other options are not realistic.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. The nurse knows that which of the following medical conditions are most commonly associated with anxiety? (Select all that apply.) a. Cancer b. Pancreatitis c. Hypothyroidism d. Dysrhythmias e. Encephalitis f. Hyperthyroidism ANS: A, C, D, E, F Cancer, COPD, dysrhythmias, encephalitis, hypothyroidism, and hyperthyroidism are all associated with anxiety. Pancreatitis is not listed as a condition most commonly associated with anxiety.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. The nurse is reviewing the medication profile of a patient admitted with an anxiety disorder.

Which medications should a lNe r t the nurse to a potential interaction? (Select all that apply.) a. St. John’s Wort b. Kava kava c. Aspirin 81 mg d. Valerian root e. Multi-vitamin ANS: A, B, D Although supplements are available to purchase that “treat” anxiety, they are not under control of the Food and Drug Administration (FDA), so the nurse should obtain additional information relative to the use of any supplements that the patient is taking. Dosage of aspirin relates to a cardiac dose and a multi-vitamin would not pose a problem.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Concept 33: Cognition Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse working in a pediatric clinic recognizes that which child is most at risk for cognitive impairment? a. An infant who is being fed reconstituted powdered formula b. A toddler living in an older home that is being remodeled c. A preschooler who attends a play group 3 days a week d. A school-age child who rides a school bus 5 days a week ANS: B Older homes frequently have lead-based paint; paint chips generated by remodeling put toddlers, who often put foreign objects in their mouths, at risk for exposure to lead which is a known toxic substance that can affect cognitive function. Powdered formulas, attendance at play groups, or riding on a school bus are not known to impair cognitive development.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

2. The nurse is reviewing new medication orders for several patients in a long-term care facility. Which patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed medications? a. The patient prescribed an antibiotic for a urinary tract infection b. The patient prescribed a cholinesterase inhibitor for early Alzheimer disease c. The patient prescribed a N-blocker for hypertension d. The patient prescribed a bisphosphonate for osteoporosis ANS: C Anti-hypertensives such as the -blockers can cause adverse changes in cognition. While an infection can affect cognition, antibiotics do not generally cause cognitive changes. The cholinesterase inhibitors are prescribed to slow the progression in cognitive decline for patients diagnosed with Alzheimer disease. Bisphosphonates are used for osteoporosis and are not generally a risk for altered cognition.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit? a. Allow food selections from a menu with several choices. b. Schedule frequent field trips off the unit for cognitive stimulation. c. Plan for attendance at activities with several other patients on the unit. d. Plan for a structured daily routine of events and caregivers.

ANS: D

Patients with a cognitive impairment benefit from a predictable routine and consistent caregivers. Trips off of the unit may confuse the patient and disrupt their normal routine.

Offering too many selections causes confusion and can lead to agitation. Being in large groups for activities can overstimulate the patient and lead to agitation and fear.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? a. “Don’t worry; the patient should be fine once they are in a familiar environment.” b. “I can make a referral for a home health aide to assist with the patient.” c. “Once the dehydration is corrected, the patient’s confusion should improve.” d. “I can show you how to care for the patient once you return home.”

ANS: C The confusion caused by an underlying medical condition is a temporary condition that can be corrected once the underlying condition is treated, in this case once the patient is rehydrated. It is not necessary to teach home care or make a referral to home health because it is not expected that the patient will be confused at discharge. Telling the daughter that there is nothing to worry about diminishes her concern and may decrease her trust in the nurse.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. An older adult who is cognitively impaired is admitted to the hospital with pneumonia.

Which sign or symptom would the nurse expect to be exhibited by the patient?

N a. Severe headache b. Flank pain c. Increased confusion d. Decreased blood glucose ANS: C Increased confusion is a symptom that occurs in cognitively impaired patients who experience an infection. Severe headache occurs with migraines, meningitis, and other conditions. Flank pain occurs with pyelonephritis. Blood glucose typically increases with an infection.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse’s best response? a. “Hormone therapy will reverse the condition.” b. “Vitamin C and zinc will reverse the condition.” c. “There is no treatment that reverses dementia.” d. “Dementia can be reversed with diet, exercise, and medications.”

ANS: C

Currently there is no proven treatment that has been shown to reverse dementia, although some treatments can slow the progression of the illness. Hormone therapy, vitamin therapy, diet, and exercise are all important for overall health but do not reverse the progression of dementia.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? a. Leave a night light on in the room at all times. b. Leave the television on at night with the volume up. c. Restrain the patient to maintain safety during the confusion. d. Administer a sleeping medication to help the patient sleep.

ANS: A Having a night light on for the patient can help orient them to their surroundings. Having the flickering light and sound from a television will not help a confused patient remain calm or oriented. Restraining a patient will increase their agitation and actually increase their risk of injury if they try to get out of bed. Sleeping medications often increase confusion in cognitively impaired patients.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 8. An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sl e N ep. What data does the nurse consider as a probable cause of the patient’s confusion? a. Pain medication received earlier in the night b. The death of the patient’s spouse 2 years ago c. The patient’s history of diabetes d. The age of the patient ANS: A Medications such as narcotics, hypertensives, sleeping meds, and others can cause disorientation and symptoms of delirium. The death of a spouse is more likely to cause depression than disorientation. A history of diabetes alone does not cause disorientation.

Normal aging alone does not cause disorientation, although it is a risk factor.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE 1. The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which topics would be included in the presentation? (Select all that apply.) a. Do not use substances such as cannabis and alcohol. b. Wear helmets when riding bicycles and motorcycles. c. Complete a Mini Mental Status Exam (MMSE) yearly. d. Correct acid-base imbalances related to underlying disease processes.

e. Wear a seat belt whenever riding in a motorized vehicle. f. Complete a Confusion Assessment Method (CAM) scale yearly.

ANS: A, B, E Primary prevention attempts to prevent injury. Not using chemical substances, wearing a helmet, and wearing a seat belt are all measures to prevent injury to the brain, which protects cognitive function. An MMSE and CAM are secondary prevention, or screening tools performed once symptoms are present. Correcting acid-base imbalances from underlying disease processes is a tertiary prevention level, aimed at minimizing complications for disease already present.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 34: Psychosis Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. What is the nurse’s best response? a. Ignore his remarks and remain silent when providing care. b. Express doubt that there are spiders on the wall. c. Ask the patient if he also sees spiders in the day room. d. Tell the patient there are no spiders and he should stop worrying about it.

ANS: B The patient is experiencing visual hallucinations. Appropriate care for this patient would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.

OBJ: NCLEX Patient Needs Category: Psychosocial Integrity 2. A patient with schizophrenia is admitted to the inpatient unit. Which behavior should the nurse expect to see that is most likely to be associated with this disorder? a. Wringing of hands b. Monotone speech pattern c. Engaged in conversations d. Presence of hallucinationN s ANS: D Individuals who have a clinical diagnosis of schizophrenia present with positive (delusions, hallucinations, disorganized speech and behavior, catatonia, and agitation) as well as negative symptoms (alogia, affective blunting, asocial behavior, anhedonia, and avolition) which distances the patient from society.

OBJ:

NCLEX Patient Needs Category: Psychosocial Integrity

3. The nurse is planning discharge teaching for a patient taking clozapine. Which information is critical to include in the teaching plan? a. Caution about sunlight exposure b. Reminder to call the clinic if fever, sore throat, or malaise develops c. Instructions regarding dietary restrictions d. A chart to record patient weight ANS: B Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.

OBJ: NCLEX Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Which side effect is the highest priority for the nurse to assess for when diphenhydramine is administered to a patient also taking antipsychotic medication? a. Increased psychosis b. Cognitive impairment c. Respiratory depression d. Impaired memory ANS: C Diphenhydramine is an anticholinergic medication that may induce drowsiness or even respiratory depression taken along with anti-psychotic medication. Respiratory depression and airway are always highest priorities of care. While increased psychosis may occur, respiratory depression is highest priority. Cognitive impairment and impaired memory are not well-known effects of diphenhydramine.

OBJ: NCLEX Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend’s apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to Nt hi s patient? (Select all that apply.) a. Allow opportunities for him to express his anger. b. Provide patient and family teaching regarding PTSD. c. Tell the patient that hurting himself will solve nothing. d. Report him to the authorities. e. Exhibit a nonjudgmental attitude. f. Reassure him that everything will be all right.

ANS: A, B, E Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse–patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.

OBJ:

NCLEX Patient Needs Category: Physiological Integrity: Basic Care and Comfort

2. In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) a. Father diagnosed with paranoid schizophrenia b. Rural residence c. Recent immigration from Ecuador d. Occasional cannabis use

e. January birth date f. Physical abuse by the father ANS: A, C, E, F Genetic predisposition has been identified as a risk factor for development of schizophrenia.

Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.

OBJ:

NCLEX Patient Needs Category: Health Promotion and Maintenance

3. Patients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in patients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) a. Hallucinations b. Disorganized speech and behavior c. Anhedonia d. Delusions e. Agitation ANS: A, D, E Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the patient experiences hallucinations, delusions, or agitation.

Negative symptoms are those that cause a loss of normal function, such as when the patient exhibits disorganized speech and behavior and anhedonia.

N OBJ: NCLEX Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Concept 35: Addiction Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is assessing a patient using the CAGE Questionnaire. The patient answers yes to all of the questions. The nurse suspects alcoholism and feels the patient is in denial when the patient makes which statement? a. “I go to meetings once a day and still drink.” b. “My family and friends have been avoiding me lately.” c. “I don’t have a problem with alcohol. I can quit anytime I want to.” d. “I know it will be hard to quit, but I am willing to try.”

ANS: C The patient may need help admitting that there is a problem. The CAGE is designed to objectively assist in assessing problems related to alcohol use. A patient who states they are going to meetings is admitting they have a problem even if they still drink. Admitting that quitting is difficult is acceptance that there is a problem. Reality is setting in for a patient who can see that family and friends are avoiding them.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. A patient who was admitted 24 hours ago has become increasingly irritable and now says there are bugs on his bed. Which condition should the nurse suspect? a. Alcohol-induced psychosis b. Delirium tremens (DTs) N c. Neurologic injury related to a fall d. Posttraumatic stress reaction ANS: B Beginning 6–9 hours after the last alcohol use, patients may experience DTs, as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse rate, and blood pressure measurement and visual and auditory hallucinations.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. To prevent Wernicke’s encephalopathy from heavy alcohol use, the nurse anticipates an order for which medications? a. Benzodiazepine b. Thiamine and B complex c. Vitamins C and D3 d. Klonopin ANS: B The B vitamins will prevent or reverse Wernicke’s if given early enough. Benzodiazepines are often used to prevent and treat DTs and to decrease respiratory depression and hypertension. Vitamins C and D3 are not related to alcohol withdrawal. Klonopin is administered for hypertension and anxiety related to withdrawal.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the highest priority for this patient? a. Describe how the alcohol is causing the withdrawal effects. b. Leave the patient by him/herself so as not to cause agitation. c. Promote a safe, calm, and comfortable environment. d. Refer the patient to an alcohol-abuse counselor.

ANS: C The main priority is the patient’s safety due to risk of harm from seizures, DTs, and anxiety.

The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. The nurse assesses the outcomes of a motivational interview on a patient with a dual diagnosis of alcoholism with delirium tremens (DTs) and determines that the communication was nontherapeutic. What is the nurse’s next priority? a. Encourage the patient to think of ways to change environmental triggers to abuse substances. b. Ask the patient what methods they think would work and encourage participating N in self-help groups. c. Notify provider to obtain order for oxazepam and vitamin B infusion. d. Notify provider to obtain order for CT scan and psychological consult.

ANS: C The patient will need to be treated for the psychosis prior to conducting the motivational interview, because the patient can become violent and nonreceptive to the interventions.

Oxazepam and vitamin B are the two therapies that work for DTs. OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 6. A 45-year-old man is brought to the emergency department presenting with a respiratory rate of 6 breaths/min, and cardiac dysrhythmias. What is the most appropriate question the nurse should ask the patient’s friend? a. “Does he take amphetamines or uppers?” b. “Has he ever used LSD?” c. “Have you two been out of the country in the last 2 days?” d. “Is he using any opioids such as heroin?”

ANS: D

The clinical manifestations of an opioid overdose include seizures, shock, respiratory depression, dysrhythmias, and altered level of consciousness. An opioid overdose is a medical emergency. Amphetamine overdose is ruled out because it causes hypertension and central nervous system disturbances such as paranoia, panic, and delusions. LSD overdose would also manifest with hypertension and tachypnea along with hallucinations and possible loss of contact with reality. Travel outside the country is unrelated.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

7. During history-taking, a patient tells the nurse that he is addicted to alprazolam and that he takes six 1 mg tablets a day. He quit cold turkey yesterday and now presents with extreme agitation, increased heart rate, and panic. Which disorder should the nurse suspect? a. Stress reaction b. Delirium tremens c. Overdose d. Relapse ANS: A Stress reaction is a withdrawal symptom that can occur when detoxing too quickly. DTs are usually associated with alcohol withdrawal. Overdose of alprazolam would present with extreme drowsiness, confusion, muscle weakness, and loss of balance or coordination. The effects of alprazolam are dizziness, drowsiness, dry mouth, and lightheadedness.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

N

1. Strategies that a nurse could use in a motivational interview to increase the chances of change include which of the following? (Select all that apply.) a. Educating the patient on the physical damage the substance is causing b. Encouraging the patient to think of ways to change environmental triggers to abuse substances c. Asking the patient how they think substance abuse affects their family life d. Explaining to the patient that substance abuse affects everyone in the family and give examples e. Asking the patient what methods they think would work and encouraging participating in self-help groups ANS: B, C, E Empowering the patient by helping them see what effect the abuse has on their life is a key component of motivation. Educating the patient is too much like lecturing and may cause resistance. Explaining how the family responds to the problem may elicit guilt and resistance.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. The nurse recognizes a potential health threat to an alcoholic patient who is using the drug disulfiram when the nurse reads in the health record that the patient is also taking which of the following? (Select all that apply.)

a. b. c. d. e.

Blood thinners Diphenhydramine Alcohol Penicillin Mouthwash

ANS: A, C, E Disulfiram increases the effect of anticoagulants such as warfarin (Coumadin). Ingesting alcohol may cause headache, nausea, vomiting, tachycardia, chest pain, or dizziness.

Mouthwash can have alcohol as one of the main ingredients and should be checked prior to using.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

N

Concept 36: Interpersonal Violence Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse is caring for a patient in the emergency department who has been a victim of intimate partner violence. What is most important for the nurse to include in the plan of care? a. Medication to calm the perpetrator of the violence b. A list of community resources c. A referral for self-defense training d. A referral to the victim’s religious advisor ANS: B Providing education that will address immediate safety needs for the patient is a priority action for the nurse. The nurse is not creating a plan for the perpetrator, nor is it the responsibility of the victim to receive medication for another person. Self-defense training does not meet the immediate safety concern for the patient and may aggravate the perpetrator further. Accessing support from a religious advisor is good for ongoing support, but it does not address the immediate need for safety information.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

2. The nurse working at a women’s health clinic is seeing a teenage female patient who has come in for a refill on her birth control medication and with a complaint of abdominal pain.

When the nurse enters the r o oNm , the patient is sitting in the chair with her head down, rocking back and forth, does not make eye contact, and answers questions with no expression on her face. What assessment question would be most important for the nurse to ask the patient? a. “What brings you to the clinic today?” b. “What can we do to help you today?” c. “Do you feel safe in your current relationship?” d. “Have you changed your diet lately?”

ANS: C This patient is exhibiting signs of being abused. It is important to ask about the safety of the patient. General questions about her visit do not give an opportunity for the patient to discuss her safety needs. While a diet change can cause stomach problems, this assessment would be addressed once safety is addressed.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is seeing a patient who has been in the clinic eight times in the past 6 months for injuries from an abusive partner. The patient states, “I don’t see any way to get away from my partner, and I can’t keep going on like this.” What assessment question is most important for the nurse to ask? a. “Do you have any family in the area that can help?” b. “Have you thought about hurting yourself or someone else?” c. “Have you thought about moving to a different city?”

d. “Have you discussed this with anyone else?”

ANS: B Depression and an increased risk of suicide are common outcomes from individuals experiencing interpersonal violence. It is critical that the nurse specifically assess for the risk of harm to the patient or to others during assessment. Asking if family or friends are available for support is good, but it is more important to assess for the safety concern of suicide or harm to others. It is not helpful to ask if a person who has stated that they don’t see a way out has thought of leaving—their comment indicates that they can’t see any solution. This situation is a high risk for suicide, or even homicide against the perpetrator.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. The nurse is reviewing case files for children at risk for injury resulting in brain injury.

Which child is at most risk for experiencing this type of violence? a. A Caucasian, 6-month-old infant living with a single mother b. An African-American, 24-month-old child living with her grandmother c. A Mexican, 3-year-old child living in an inner city apartment d. A Japanese, 8-year-old child living in a home with three generations of family ANS: A The highest incidence of traumatic brain injury occurs in Caucasian children aged birth to 1 year, and the abuse occurs most often from women.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. Critical Thinking: A crisis in N tervention nurse is training emergency department staff on treatment needs of persons in abusive relationships. What is a common difficulty staff encounter when caring for this population? a. There is not a good legal pathway to help persons in abusive relationships. b. The abused person may return to the abusive home setting. c. Hospital policies do not identify the legal care needed for abused persons. d. Because length of care is short in the emergency department, there is little staff can do for patients who have been abused.

ANS: B Abused persons return to abusive settings because they feel they have no other options or they fear reprisal from the abusive partner. There are policies in all healthcare facilities that describe the legal needs and the legal process that needs to be followed when caring for abused patients. Even in short-stay care settings there are interventions that can be helpful to a patient who has experienced abuse.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

6. The nurse is counseling women at a crisis shelter about risk factors for increased intimate partner violence. What event is most likely to trigger an increase in abusive behaviors? a. Moving to a new community b. Starting a new job c. Becoming pregnant d. The death of a grandfather

ANS: C Abuse is not likely to decrease, and can often increase when a woman becomes pregnant.

Moving, starting a new job, and a death in the family are all stressors, but they are not identified as factors that specifically increase violence more than pregnancy.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE 1. The nurse is admitting a child with a history of abuse. The nurse understands that the child may exhibit what behaviors that are consequences of being in an abusive environment?

(Select all that apply.) a. Reliving abuse incidents b. Sleep disturbance c. Overeating d. Acting out behaviors e. Intermittent fever ANS: A, B, D Posttraumatic stress disorder symptoms, depression symptoms, and aggression are all outcomes that children who are exposed to abuse experience. Overeating may be associated with some stressors, but it is not specifically indicative of abuse. Fever is not associated with abuse.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

Concept 37: Professional Identity Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Which key element is included in the scope of professional practice identity? a. Adhering to a fixed level of practice b. Finding out ways to get done faster with assigned tasks as the key focus of care c. Maintaining professional boundaries d. Remaining at the level of practice upon graduating from nursing school ANS: C The scope of professional identity includes five attributes, doing, and being, acting ethically, flourishing and changing identities. By maintaining professional boundaries, the nurse would be acting ethically. Adhering to a fixed level of practice would not be prudent for it would not allow the nurse to achieve attributes. Finding out ways to get done faster with assigned tasks would be in opposition to the attribute of “being” as the key focus is to do the right thing even when no one is looking. A nurse who remains at the level of practice upon graduation from nursing school would be in opposition to the attribute of flourishing.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A new registered nurse asks the registered nurse (RN) preceptor what could be done to become more professional. What is the preceptor’s best response? a. “Attend nursing educationNal meetings.” b. “Listen to other nurses.” c. “Read the agency newsletter.” d. “Pass the licensing exam.”

ANS: A Knowledge and commitment are essential components of professionalism. Attending nursing educational meetings can promote collaborative learning with peers and maintenance of competence in an ever-changing healthcare environment. Listening can promote professionalism, and communication is certainly a component of professionalism; however, there is also a social sense to listening, and without the educational/learning component, this is not the best answer. An agency newsletter could include information about professional opportunities, but it is not the best answer. The new nurse would have already passed the licensing exam, the legal requirement to be considered a nurse.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The qualities of leadership, clinical expertise and judgment, mentorship, and lifelong learning would best describe which type of nurse? a. Administrator b. Certified nurse specialist c. Practitioner d. Professional

ANS: D The qualities listed are those of a professional nurse. The other options are all nurses who may have these qualities, but the focus of their title includes qualities not essential for the professional nurse. The administrator would have management qualities; the clinical nurse specialist would have specialty area knowledge; and the practitioner would meet legal requirements as a healthcare provider.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The American Nurses Association (ANA) outlines expectations of nurse’s self-care habits in which type of documentation? a. Nurse Practice Acts b. Board of Nursing c. Code of Ethics d. Hospital Facility Protocols ANS: C The ANA focuses on the importance of nurses to develop their own personal self-care habits as part of their ethical code. This information is presented in the ANA Code of Ethics. Nurse Practice Acts define the scope of practice relative to the specific type of health professional.

The Board of Nursing provides minimum competency requirements for specific types of health professionals and identifies licensing, academic and practice requirements. Hospital facilities provide policies and protocols related to members of the interdisciplinary healthcare team.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Which nursing action best exemplifies clinical judgment? a. A nurse after performing an assessment seeks out additional information related to a finding. b. A nurse documents finding in the medical record in a timely manner. c. A nurse contacts the physician to provide the results of an imaging study for a patient. d. A nurse comforts a patient who is on hospice care.

ANS: A Clinical judgment represents a comprehensive well thought out series of action whereby the nurse incorporates assessment data in the context of norms and values. The nurse seeking out additional information to clarify a finding is demonstrating clinical judgment. A nurse who is documenting assessment data in the patients’ medical record in a timely manner is being efficient. A nurse contacting the physician to provide results of an imaging test is demonstrating effective communication. A nurse comforting a patient who is on hospice care is demonstrating compassion.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

6. Nursing demonstrates dedication to improving public health through which avenue? a. Changing healthcare standards b. Legal regulations c. Scope of practice d. Technology ANS: C Through the scope of practice, specialized knowledge, and code of ethics, the discipline of nursing has demonstrated its dedication to improving public health. The changing healthcare environment is one of the challenges to nursing, not an indicator of dedication. Legal regulations are generally promulgated by legislators rather than nurses to protect the public.

A highly technological environment is considered a challenge to nursing rather than an indicator of dedication.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. Components of a professional identity in nursing include which attributes? (Select all that apply.) a. Doing b. Being c. Acting ethically d. Flourishing e. Culture N ANS: A, B, C, D The scope of professional identity in nursing includes: doing, being, acting ethically, flourishing and changing identities. Cultural sensitivity is important to professional nursing; however, culture is an inherent quality of nurses and patients, not a component of the professional identity.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 38: Clinical Judgment Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A student nurse is studying clinical judgment theories and is working with Tanner’s Model of Clinical Judgment. How can the student nurse best generalize this model? a. A reflective process where the nurse notices, interprets, responds, and reflects in action b. One conceptual mechanism for critiquing ideas and establishing goal-oriented care c. Researching best practice literature to create care pathways for certain populations d. Assessing, diagnosing, implementing, and evaluating the nursing care plans ANS: A Looking across theories and definitions of clinical judgment, they all have in common the ability to reflect on data and choose actions. Reflection also considers evaluating the result of the actions to determine whether they were effective. Although critiquing ideas and establishing goal-oriented care could be considered part of a generalized statement of critical thinking, this is not broad enough without the reflection and evaluation. Clinical judgment would most likely be used to create care paths derived from the evidence; however, this is not the cornerstone of the Tanner Model. Clinical judgment is used when engaging in the nursing process, but this is too narrow in focus to capture the essence of critical thinking definitions and theories. Critical thinking is not synonymous with the nursing process.

OBJ: NCLEX Client NeedsNCategory: Safe and Effective Care Environment: Management of Care 2. The nurse is implementing a plan of care for a patient newly diagnosed with type 2 diabetes mellitus. The plan includes educating the patient about diet choices. The patient states that they enjoy exercising and understand the need to diet; however, they can’t see living without chocolate on a daily basis. Using the principles of responding in the Model of Clinical Judgment, how would the nurse proceed with the teaching? a. The nurse explains to the patient that chocolate has a high glycemic index. The nurse then focuses on foods that have low glycemic indexes and provides a list for the patient to choose from. b. The nurse explains that the patient may eat whatever they would like as long as the patient’s glucose reading and A1c remain stable. c. The nurse derives a new nursing diagnosis of Knowledge Deficit and readjusts the plan of care to include additional sessions with the registered dietician. d. The nurse examines the patient’s daily glucose log and incorporates the snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week.

ANS: D

Responding entails adjusting the plan of care to the particular patient issue through one or more nursing interventions. In this case, the nurse is working with the patient’s wishes, knowing that the patient will most likely cheat. The patient will be allowed to “cheat.” The plan will be evaluated to be sure the snack does not elevate the glucose excessively and be readjusted if warranted. While it is true that most chocolate has a high glycemic index, providing a list of foods that do not include the one thing the patient enjoys will most likely lead to nonadherence to the diet. Advising the patient that they can have whatever they want to eat may lead to further dietary indiscretions and cause side effects such as obesity or high glucose readings. Knowledge Deficit is an inaccurate diagnosis for this patient as evidenced by the patient stating they understand the need to exercise and the need to diet.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A new graduate nurse is working with an experienced nurse to chart assessment findings.

The new nurse notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced nurse asks the new nurse what may be going on here. What is the best explanation for this statement? a. Data on the chart can sometimes be documented in a biased manner. b. Data on the chart changes as the patient’s condition changes. c. Data on the chart is usually accurate and can be verified from the patient. d. Reading the chart is not a wise use of time as this can be time consuming and tedious.

ANS: A It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record. N D a t a do indeed change (and need to be charted) as the patient’s condition changes, but this would not be the best answer to this question. Assessment data may at times be difficult to obtain, but that would not occur often enough to warrant a warning about the difficulty in charting it. Also, obtaining data is clearly a different activity from charting it. Charting can be time consuming and tedious, but this is not the most complete answer to this question.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A home care nurse receives a physician order for a medication that the patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient’s condition, questions its appropriateness, and examines alternative treatments. What is the nurse’s best action? a. Call the physician, explain rationale, and suggest a different medication. b. Consult an experienced nurse on whether there are other similar treatments. c. Hold the drug until the physician returns to the unit and can be questioned. d. Question other staff as to the physician’s acceptance of nursing input.

ANS: A

Determining how best to proceed on behalf of a patient’s best health outcomes care may require clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities have been examined. A home care nurse who is using good clinical judgment techniques should have confidence in their decision and may not have another nurse available as this is an autonomous setting. Holding the drug might jeopardize the patient’s health, so this is not the best solution. The nurse working at this level of critical thinking makes choices based on careful examination of situations and alternatives; whether or not the physician is open to nursing input is not relevant.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A patient has been admitted for a skin graft following third degree burns to the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes. When should the nurse initiate the educational plan? a. After the operation and the patient is awake b. On admission, along with the initial assessment c. The day before the patient is to be discharged d. When narcotics are no longer needed routinely ANS: B Initial discharge planning begins upon admission. After the operation has been completed is too late to begin the discharge planning process. The day before discharge is too late for the nurse to gather all pertinent information and begin teaching and coordinating resources.

After a complicated operation, the patient may well be discharged on narcotic analgesics.

Waiting for the patient to notNneed them anymore might mean the patient gets discharged without teaching being done.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse has designed an individualized nursing care plan for a patient, but the patient is not meeting goals. Further assessment reveals that the patient is not following through on many items. Which action by the nurse would be best for determining the cause of the problem? a. Assess whether the actions were too hard for the patient. b. Determine whether the patient agrees with the care plan. c. Question the patient’s reasons for not following through. d. Reevaluate data to ensure the diagnoses are sound.

ANS: B Having patient and/or family provide input to the care plan is vital in order to gain support for the plan of action. The actions may have been too difficult for the patient, but this is a very narrow item to focus on. The nurse might want to find out the rationale for the patient not following through, but instead of directly questioning the patient, which can sound accusatory, it would be best to offer some possible motives. Reevaluation should be an ongoing process, but the more likely cause of the patient’s failure to follow through is that the patient did not participate in making the plan of care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management

of Care 7. A new nurse appears to be second-guessing herself and is constantly calling on the other nurses to double-check their plan of care or rehearse what they will say to the doctor before she call on the patient’s behalf. This seems to be annoying some of the nurse’s coworkers.

What is the nurse manager’s best response? a. Explain to coworkers that this is a characteristic of critical thinking and is important for the new nurse to improve reasoning skills. b. Agree with the staff and have someone follow and work more closely with a preceptor. c. Have a talk with the nurse and suggest asking fewer questions. d. Tell the staff that all new nurses go through this phase, and ignore their behavior.

ANS: A Reflection-on-action is critical for development of knowledge and improvement in reasoning. It is where learning from practice is incorporated into experience. Inquisitiveness is a characteristic of critical thinking and reflects a desire to learn even when the knowledge may not appear readily useful. The manager should promote this. Suggesting the nurse work more closely with a preceptor implies that the manager thinks the nurse needs to learn more and increase confidence. In reality, this nurse is demonstrating a characteristic of critical thinking. Suggesting that the nurse ask fewer questions would hamper the development of the nurse as a critical thinker. All new nurses do go through a phase of asking more questions at one time, but dismissing the nurse’s behavior with this explanation is simplistic and will discourage critical thinking.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management N of Care 8. A nurse has committed a serious medication error and has reported the error to the hospital’s adverse medication error hotline as well as to the unit manager. The manager is a firm believer in developing critical thinking skills. From this standpoint, what action by the manager would best nurture this ability in the nurse who made the error? a. Have the nurse present an in-service related to the cause of the error. b. Instruct the nurse to write a paper on how to avoid this type of error. c. Let the nurse work with more experienced nurses when giving medications. d. Send the nurse to refresher courses on medication administration.

ANS: A

Nurturing critical thinking skills is done in part by turning errors into learning opportunities.

If the nurse presents an in-service on the cause and prevention of the type of error committed, not only will the nurse learn something but many others nurses on the unit will learn from it to. This is the best example of developing critical thinking skills. This option would allow the nurse to learn from the mistake, which is a method of developing critical thinking skills, but the paper would benefit only the nurse, so this option is not the best choice. Letting the nurse work with more experienced nurses might be a good option in a very limited setting, for example, if the nurse is relatively new and the manager discovers a deficiency in the nurse’s orientation or training on giving medications in that system.

Otherwise, this option would not really be beneficial. Sending the nurse to refresher courses might be a solution, but it is directed at the nurse’s learning, not critical thinking. The nurse might feel resentful at having to attend such classes, but even if they were helpful, only this one nurse is learning. Going to generic classes also does not address the specific reason this error occurred, and thus might be irrelevant. Critical thinking and learning can be enhanced by a presentation to the staff on the causes of the error.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nurse is caring for a patient in a long-term care facility who has not been sleeping well.

She notes that the patient is new to the facility, has been refusing therapy, and is also not eating well. The nurse interprets this to mean that the patient has been having trouble adjusting. The nurse decides to meet with the patient’s care team. The team decides to assess the patient’s willingneN s s to participate in group recreational activities. The patient agrees to participate. After 1 week, the nurse reevaluates the plan of care and notes that the patient has been sleeping much better. Which of the following terms best describe processes used in the nurse’s plan? (Select all that apply.) a. Clinical judgment b. Evidence-based practice c. The nursing process d. Collaborative care planning e. Positive reward process ANS: A, C, D Clinical judgment is a reflective process by which the nurse notices, interprets, responds, and reflects in action. The nursing process is a process by which the nurse assesses, diagnoses, implements, and evaluates the nursing care plan. Consulting and gaining input from the healthcare team is collaborative care planning. Evidence-based practice refers to using interventions found in research studies. The positive reward process is not a term used in care planning.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 39: Leadership Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nursing unit director exhibits the definition of leadership in which of the following responses? a. By referring the concern to the Director of the department b. By correcting the concern with the patient directly and not communicating his/her actions to the staff c. By meeting with the staff to discuss the concern and identify solutions d. By telling the staff that they need to correct the situation by tomorrow and leaves the meeting ANS: C Leadership is defined as an interactive process that provides needed guidance and direction which is present in the correct answer. The other choices do not involve an interactive process with staff to resolve the concern.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse who is certified as a Critical Care Registered Nurse (CCRN) represents the unit on the organizational performance improvement team. This is an example of which type of leadership?

N a. Formal b. Unit c. Organizational d. Informal ANS: D Informal leaders are recognized as leaders because of their capabilities and actions. Formal leaders are recognized because of the position they hold such as director or manager. Unit leadership refers to the leader of the particular unit. Organizational leadership refers to any leader within the organization.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The hospital must reduce the number of readmissions from 11% to 8% in the next year.

Which of the following best represents the transformational leadership style in accomplishing this goal? a. The Director communicates the goal of reducing readmissions to the hospital operations team and tells them to submit their action plan by the end of the week. b. The organization charters three work teams to identify solutions for the top three causes for readmissions. These teams are given full authority to implement their solution. c. The Director of Quality develops a vision statement and action plan to achieve the goal. The director works directly with the involved departments to implement the

action plan. d. The Chief Executive Officer (CEO) communicates the goal to the organizational directors and managers and states that they are entrusted to solve the problem.

ANS: C Transformational leaders communicate a vision and motivate employees to accomplish the goal. The Director who communicates the goal of reducing readmissions to the hospital operations team and tells them to submit their action plan by the end of the week leaves the solution to achieve the goal to the followers to develop without motivating them. The solution that is left to the work teams to resolve is not an example of transformational leadership. The CEO entrusts the managers and directors to solve the problem without giving them a vision or engaging in the solution with them.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The new Director of Case Management assessed the need to improve the organization’s patient satisfaction with the discharge process. Which statement below illustrates the vision that would lead the team to this goal? a. “The department will deliver reliable, collaborative, and compassionate discharge planning services to all patients.” b. “The department will hold weekly meetings every Tuesday at 11:00 AM.” c. “There will be implementation of a new uniform policy so staff can be readily identified.” d. “Staff are encouraged to complain about difficult patients, families, and physicians.”

N

ANS: A A vision is a statement about the long-term desired state for the department. The other choices describe specific actions, not a long-term vision statement.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. The clinical nurse leader needs to identify the staff who must go home due to low census.

Which answer below describes a democratic style of decision making? a. The clinical nurse leader identifies the staff person with the most vacation and asks them to go home. b. The clinical nurse leader tells the last person to show up for their shift to go home. c. The clinical nurse leader decides not to send anyone home because it is too difficult to decide who should lose hours. d. The clinical nurse leader asks the group if any of them would like the opportunity to go home and selects staff who volunteer.

ANS: D Democratic leaders use a participatory style of decision making. In the other choices, the clinical nurse leader makes the decision independent of the staff.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

6. A nurse is reviewing decision-making theories. Which statement is accurate according to situational and contingency theory? a. The theory challenges the concept that one leadership style is always best. b. The theory supports employee feelings, morale, and feedback during the change process. c. Motivation through inspiration and recognition is the focus for transforming employee behavior. d. A leader is someone who possesses great intelligence and decision-making authority.

ANS: A Situational and contingency theory challenges the assumption that there is “one best way” to lead. A theory that supports employee feelings, morale, and feedback during the change process describes behavioral leadership. Motivation through inspiration and recognition is the focus for transforming employee behavior describes transformational leadership. A leader is someone who possesses great intelligence and decision-making authority describes Great Man or Trait theory.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. To be an effective nursing leader today requires effective collaboration. Which model below best represents this process? a. The Nursing Manager of the observation unit was certain the psychology department would assist the unit with a motivational plan, so she did not request N their assistance. b. The Nursing Manager of the observation unit worked with the psychology department and physical therapy to develop a motivational plan for patients on the unit. c. The Nursing Director of Behavioral Health Services followed the administrative directive to reduce services and refused to provide services for patients on other units. d. Frustrated by the trend of patients unwilling to work with therapy, the Unit Manager recommended that these patients be placed on another unit.

ANS: B The nursing manager works collaboratively with other departments to solve the patient care issue. In the other choices, the unit manager does not involve collaboration to resolve the patient concern.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. What are the main features of complexity science that are relevant to nursing leadership?

(Select all that apply.) a. Focused on creating organizational change and looking at the whole versus

b. c. d. e.

individual parts Defined by efforts of leadership to mandate organizational change Autocratic in nature with a top-down structure for change Dependent on employees knowing what change is necessary and acting independently Non-linear and dynamic in nature, versus a static process

ANS: A, E Complexity science posits that interactions of the parts within a system are more important than the individual parts. Complexity science, however, recognizes that organizational processes are often non-linear and unpredictable. Through the dynamic interplay of negative and positive feedback an organization is able to make changes to keep abreast of the environmental context. The autocratic top-down decision making and mandates do not create a sustainable change. Being dependent on employees knowing what change is necessary and acting independently lacks interaction of leadership to stimulate change and adaptation among employees.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Concept 40: Ethics Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient suffered a brain injury from a motor vehicle accident and has no brain activity.

The patient has a living will which states no heroic measures. The family requests that no additional heroic measures be instituted for their son. The nurse respects this decision in keeping with which principle? a. Accountability b. Autonomy c. Nonmaleficence d. Veracity ANS: B Patients and families must be treated in a way that respects their autonomy and their ability to express their wishes and make informed choices about their treatment. Accountability is inherent in the nurse’s ethical obligation to uphold the highest standards of practice and care, assume full personal and professional responsibility for every action, and commit to maintaining quality in the skill and knowledge base of the profession. Nonmaleficence is a principle that implies a duty not to inflict harm. In ethical terms, nonmaleficence means to abstain from injuring others and to help others further their own well-being by removing harm and eliminating threats. Veracity means telling the truth as a moral and ethical requirement.

OBJ: NCLEX Client NeedsNCategory: Safe and Effective Care Environment: Management of Care 2. A male patient suffered a brain injury from a motor vehicle accident and has no brain activity. The spouse has come up to see the patient every day for the past 2 months. She asks the nurse, “Do you think when he moves his hands he is responding to my voice?” The nurse feels bad because she believes the movements are involuntary, and the prognosis is grim for this patient. She states, “He can hear you, and it appears he did respond to your voice.” The nurse is violating which principle of ethics? a. Autonomy b. Veracity c. Utilitarianism d. Deontology ANS: B Veracity is the principle of telling the truth in a given situation. Autonomy is the principle of respect for the individual person; this concept states that humans have incalculable worth or moral dignity. Utilitarianism is an approach that is rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Giving the spouse false reassurance is not a good consequence. Deontological theory claims that a decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty. Persons are to be treated as ends in themselves and never as means to the ends of others.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse is faced with an ethical issue. When assessing the ethical issue, which action should the nurse perform first? a. Ask, “What is the issue?” b. Identify all possible alternatives. c. Select the best option from a list of alternatives. d. Justify the choice of action or inaction.

ANS: A The first step in the situational assessment procedure is to find out the technical and scientific facts and assess the human dimension of the situation—the feelings, emotions, attitudes, and opinions. Trying to understand the full picture of a situation is time consuming and requires examination from many different perspectives, but it is worth the time and effort that is required to understand an issue fully before moving forward in the assessment procedure. Identifying alternatives is the second step in the situation assessment procedure.

A set of alternatives cannot be established until an assessment has been completed.

Selecting the best option is actually the third step in the situation assessment procedure.

Options cannot be selected until an assessment has been done to define the issue. Justifying the action or inaction is the final step in the situational assessment procedure. No justification can be made until the assessment and action phases have been completed.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nursing student is conductiNng a survey of fellow nursing students. Which ethical concept is the student following when calculating the risk-to-benefit ratio and concluding that no harmful effects were associated with a survey? a. Beneficence b. Human dignity c. Justice d. Human rights ANS: A Beneficence is a term that is defined as promoting goodness, kindness, and charity. In ethical terms, beneficence means to provide benefit to others by promoting their good.

Human dignity is the inherent worth and uniqueness of a person. Justice involves upholding moral and legal principles. Human rights are the basic rights of each individual.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A nurse on the unit makes an error in the calculation of the dose of medication for a critically ill patient. The patient suffered no ill consequences from the administration. The nurse decides not to report the error or file an incident report. The nurse is violating which principle of ethics? a. Fidelity b. Individuality c. Justice

d. Values clarification ANS: A Fidelity is the principle that requires us to act in ways that are loyal. In the role of a nurse, such action includes keeping your promises, doing what is expected of you, performing your duties, and being trustworthy. Individuality is something that distinguishes one person or thing from others. Injustice is when a person is denied a right or entitlement. Values clarification is a tool that allows the nurse to examine personal values in terms of ethical situations.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. An unconscious patient is treated in the emergency department for head trauma. The patient is unconscious and on life support for 2 weeks prior to making a full recovery. The initial actions of the medical team are based on which ethical principle? a. Utilitarianism b. Deontology c. Autonomy d. Veracity ANS: B Deontology is an approach that is rooted in the assumption that humans are rational and act out of principles that are consistent and objective and that compel them to do what is right.

Deontological theory claims that a decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty. Utilitarianism is an approach that is rooted in the assumption thatNan action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. An attempt is made to determine which actions will lead to the greatest ratio of benefit to harm for all persons involved in the dilemma. Autonomy is the principle of respect for the individual person. People are free to form their own judgments and perform whatever actions they choose. Veracity is defined as telling the truth in personal communication as a moral and ethical requirement.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A drug-addicted nurse switches a patient’s morphine injection with normal saline so that the nurse can use the morphine. The nurse is violating which principles of ethics? (Select all that apply.) a. Autonomy b. Utilitarianism c. Beneficence d. Dilemmas e. Veracity ANS: A, B, C, E

Beneficence is providing benefit to others by promoting their welfare. In general terms, to be beneficent is to promote goodness, kindness, and charity. By taking the patient’s pain medication and substituting saline, the nurse did harm, not good, for the patient. Autonomy is the principle of respect for the individual person; the nurse does not respect someone upon whom the nurse is inflicting harm. Utilitarianism is the principle that assumes that an action is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Because the patient’s pain medication was taken away, the consequences were all bad. Dilemmas are not included as a principle of ethics.

Veracity involves truth-telling.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Concept 41: Patient Education Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. What is the most appropriate resource to include when planning to provide patient education related to a goal in the psychomotor domain? a. Diagnosis-related support groups b. Internet resources c. Manikin practice sessions d. Self-directed learning modules ANS: C A teaching goal in the psychomotor domain should be matched with teaching strategies in the psychomotor domain, such as demonstration, practice sessions with a manikin, and return demonstrations. Diagnosis-related support groups would be most effective with goals in the affective domain. Internet resources would be most effective for goals in the cognitive domain. Self-directed learning modules would be most effective for goals in the cognitive domain.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse educator would identify a need for additional teaching when the student lists which example as a type of learning?

N a. Affective b. Cognitive c. Psychomotor d. Self-directed ANS: D Self-directed is one approach to learning but is not considered a type or domain of learning.

Self-directed would be a cognitive way of learning. Affective (feelings/attitude), cognitive (knowledge), and psychomotor (skills/performance) are the main domains of learning.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that involves which quality? a. Addresses group needs b. Follows formalized plans c. Has standardized content d. Often occurs one-to-one ANS: D

Informal teaching is individualized one-on-one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes.

Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse is preparing to implement a teaching plan. Which factor might be considered to be a barrier to patient education? a. Family resources b. High school education c. Hunger and pain d. Need perceived by patient ANS: C A patient who is hungry or in pain has limited ability to concentrate or learn. Family resources would be considered in developing a plan of care and could be an asset or a barrier to patient education. The patient’s educational level would be considered in planning teaching strategies but would not be a barrier to education. A need perceived by a patient would provide motivation for learning and would not be a barrier.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. A nurse has prepared a dischaNrge teaching plan for an adult patient who is not being compliant. Which strategy should the nurse include to help increase compliance with following discharge instructions? a. Individualized handout b. Instructional videos c. Internet resources d. Self-help books ANS: B An instructional video would provide a visual/auditory approach for discharge instructions.

Repeatedly not following written instructions is a clue that the patient may not be able to read or understand the information. While assessing the literacy level of an adult patient can be challenging, the information that they have not been able to follow previous written instructions would suggest that the nurse use an alternate strategy that does not require a high degree of literacy. An individualized handout would be written, very similar to previous instructions, and would not address a concern about literacy. Internet resources generally require an individual to be able to read, and although videos are available through the Internet, this is not the best response. Self-help books would be appropriate for an individual who reads. There is a question about whether this patient is literate, so these would not be the best choice.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. When planning to evaluate a patient’s satisfaction with a teaching activity, what is the most appropriate strategy? a. Include a survey instrument. b. Observe for level of skill mastery. c. Present information more than one time. d. Provide for a return demonstration.

ANS: A A survey or questionnaires can be used to measure affective behavior change as well as patient satisfaction with the teaching experience. Observing for level of skill mastery would evaluate achievement of a psychomotor goal rather than satisfaction with the experience.

Repeating information more than one time or in more than one way may be appropriate strategies to include in the teaching plan but would provide no evaluation data. Providing for a return demonstration would help in evaluating achievement of a psychomotor goal, not satisfaction with the activity.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. A nurse manager is reviewing interrelated concepts to the professional nursing role. Which factor should the nurse manager consider when addressing concerns about the quality of patient education? a. Adherence b. Developmental level c. Motivation d. Technology ANS: D N The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 42: Health Promotion Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Which tertiary prevention measure should be included in the health promotion plan of care for a patient newly diagnosed with diabetes? a. Avoiding carcinogens b. Foot screening techniques c. Glaucoma screening d. Seat belt use ANS: B Foot screening is considered a tertiary prevention measure, one that minimizes the problems with foot ulcers, an effect of diabetic disease and disability. Avoiding carcinogens is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Glaucoma screening is considered secondary screening—measures designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Seat belt use is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. When teaching a patient withNa family history of hypertension about health promotion, the nurse describes blood pressure screening as which type of prevention? a. Illness b. Primary c. Secondary d. Tertiary ANS: C Blood pressure screening is considered secondary prevention. It is a measure designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Illness prevention is considered primary prevention. Primary prevention measures are those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Tertiary prevention measures are those that minimize the effects of disease and disability.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The primary healthcare nurse would recommend screening based on known risk factors, because of which action? a. Eliminate the possibility of developing a condition. b. Identify appropriate treatment guidelines. c. Initiate treatment of a condition or disease. d. Make a substantial difference in morbidity and mortality.

ANS: D Screenings are typically indicated and recommended if the effort makes a substantial difference in morbidity and/or mortality of conditions, and they are safe, cost-effective, and accurate. Ideally a screening measure will accurately differentiate individuals who have a condition from those who do not have a condition 100% of the time; however, there may be a false-negative result, or the patient may develop a condition after the screening was conducted. A screening does not specify treatment guidelines; the screen provides results, and the healthcare provider identifies the treatment. The goal of screening is to identify individuals in an early state of a disease so that prompt treatment can be initiated. The screening results are used for this purpose.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. At the well-child clinic, how does the nurse correctly teach a mother about health promotion activities and describe immunizations? a. Unique for children b. Primary prevention c. Secondary prevention d. Tertiary prevention ANS: B Immunizations/vaccinations are considered primary prevention measures, those strategies aimed at optimizing health and disease prevention in general. Immunizations/vaccinations are primary prevention measures for individuals across the lifespan, not just children.

Secondary prevention measures are those designed to identify individuals in an early state of a disease process so that pro mNpt treatment can be started. Tertiary prevention measures are those that minimize the effects of disease and disability.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. The nurse in a newly opened community health clinic is developing a program for the individuals considered at greatest risk for poor health outcomes. How should the nurse consider this group? a. Global community b. Sedentary society c. Unmotivated population d. Vulnerable population ANS: D Vulnerable populations refer to groups of individuals who are at greatest risk for poor health outcomes. The entire world is the global community. Sedentary refers to the lifestyles of people worldwide who have epidemic rates of obesity and many other related chronic diseases. Unmotivated population refers to the individuals who have not demonstrated interest in changing.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. When there is evidence that supports a screening for an individual patient but not for the general population, the nurse would expect the United States Preventive Services Task Force Grading (USPSTF) to be what? a. No recommendation for or against b. Recommends c. Recommends against d. Strongly recommends ANS: A The USPSTF Grading is an example of how evidence is used to make guidelines and determine priority. When there is evidence that supports a screening for an individual patient but not for the general population, there is no recommendation for or against screening the general population. Recommends is the grading when there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Recommends against is the grading when there is moderate or high certainty that the intervention has no net benefit or that the harms outweigh the benefits. Strongly recommends is the grading when there is high certainty that the net benefit is substantial.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. A nurse manager is reviewing interrelated concepts to professional nursing. Which concepts should the nurse manager consider when addressing concerns about the quality of health promotion? (Select all that apply.) a. Culture N b. Development c. Evidence d. Nutrition e. Health policy ANS: C, E The interrelated concepts to professional nursing include evidence, healthcare economics, health policy, and patient education. Culture is a patient attribute concept. Development is a patient attribute concept. Nutrition is a health and illness concept.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 43: Communication Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A patient states, “I had a bad nightmare. When I woke up, I felt emotionally drained, as though I hadn’t rested well.” Which response by the nurse would be an example of interpersonal therapeutic communication? a. “It sounds as though you were uncomfortable with the content of your dream.” b. “I understand what you’re saying. Bad dreams leave me feeling tired, too.” c. “So, all in all, you feel as though you had a rather poor night’s sleep?” d. “Can you give me an example of what you mean by a ‘bad nightmare’?”

ANS: D The technique of clarification is therapeutic and helps the nurse examine meaning. The distracters focus on patient feelings but fail to clarify the meaning of the patient’s comment.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. The nurse is admitting a patient to the medical/surgical unit. Which communication technique would be considered appropriate for this interaction? a. “I’ve also had traumatic life experiences. Maybe it would help if I told you about them.” b. “Why do you think you had so much difficulty adjusting to this change in your life?” c. “You will feel better afterNgetting accustomed to how this unit operates.” d. “I’d like to sit with you for a while to help you get comfortable talking to me.”

ANS: D Because the patient is newly admitted to the unit, allowing the patient to become comfortable with the setting is a technique that can assist in establishing the nurse-patient relationship. It helps build trust and conveys that the nurse cares about the patient. The nurse should not reveal their life experiences as this is not therapeutic. Asking why the patient is having difficulty may provide insight; however, this would be best saved for an established relationship with the patient. Assuring the patient that they will feel better may not be true depending on the reason for the admission.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is seeking clarification of a statement that was made by a patient. What is the best way for the nurse to seek clarification? a. “What are the common elements here?” b. “Tell me again about your experiences.” c. “Am I correct in understanding that …” d. “Tell me everything from the beginning.”

ANS: C

Clarification ensures that both the nurse and the patient share mutual understanding of the communication. The distracters encourage comparison rather than clarification and present implied questions that suggest the nurse was not listening.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. A nurse is conducting a therapeutic session with a patient in the inpatient psychiatric facility. Which remark by the nurse would be an appropriate way to begin an interview session? a. “How shall we start today?” b. “Shall we talk about losing your privileges yesterday?” c. “Let’s get started discussing your marital relationship.” d. “What happened when your family visited yesterday?”

ANS: A The interview is patient centered; thus, the patient chooses issues. The nurse assists the patient by using communication skills and actively listening to provide opportunities for the patient to reach goals. In the distracters, the nurse selects the topic.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. The nurse and the patient are conversing face to face. What communication technique is being demonstrated? a. Linguistic b. Paralinguistic c. Explicit N d. Metacommunication ANS: A Conversing face to face, reading newspapers and books, and even texting are all common forms of linguistic communication. Paralinguistics include less recognizable but important means of transmitting messages such as the use of gestures, eye contact, and facial expressions. Explicit communication is not a therapeutic communication technique.

Metacommunication factors that affect how messages are received and interpreted would include internal personal states (such as disturbances in mood), environmental stimuli related to the setting of the communication, and contextual variables (such as the relationship between the people in the communication episode).

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE 1. The nurse is working with a patient diagnosed with posttraumatic stress disorder related to childhood sexual abuse. The patient is crying and states, “I should be over this by now; this happened years ago.” Which response(s) by the nurse will facilitate communication? (Select all that apply.) a. “Why do you think you are so upset?” b. “I can see that this situation really bothers you.” c. “The abuse you endured is very painful for you.”

d. “Crying is a way of expressing the hurt you’re experiencing.” e. “Let’s talk about something else, since this subject is upsetting you.”

ANS: B, C, D Reflecting and giving information are therapeutic techniques. “Why” questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

N

referral for physical therapy.

ANS: D Professional collaboration includes team management and referral to needed providers to meet patient needs. Each discipline retains responsibility for their own scope of practice but recognizes the expertise of other providers. Working separately does not develop a comprehensive plan of care. Casual mentioning of patient needs does not follow professional communication channels and frequently delays needed interventions.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A registered nurse (RN) is reviewing the concept of collaboration. Which statement correctly describes the RN nursing’ role in collaboration? a. State boards of nursing mandate that collaboration can only occur in hospitals. b. Collaboration should occur only with physicians. c. Collaboration occurs only between nurses with the same level of education. d. Collaboration may occur in health-related research.

ANS: D RNs collaborate with many different persons, including patients, managers, educators, and researchers. Collaboration does not occur only with physicians or nurses of equivalent educational background, but with anyone who is working toward meeting patient goals.

Collaboration occurs in any healthcare setting as well as community and home settings.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

N 5. A nurse manager is looking to promote a culture of safety on the medical unit. Which action should the nurse manager implement? a. Focus on the number of medication errors occurring on the unit. b. Focus on adapting system changes. c. Providing incentives to nurses who don’t make any medication errors. d. Placing nurses on restricted duty who have made medication errors.

ANS: B The Institute of Medicine (IOM) and QSEN initiative have switched their perspective from medication errors to systematic changes that focus on safety aspects. The nurse manager should not use rewards or incentives to motivate change of behavior as that would not promote a culture of safety if individuals feared retaliation or were treated differently for safe behavior practices.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. The nurse and physician are explaining that home care that will be needed by a patient after discharge. The patient’s spouse states angrily that it will not be possible to provide the care recommended. What is the best response by the nurse? a. “Let me review what is needed again.” b. “It is important that you do what the physician has prescribed.” c. “What concerns do you have about the prescribed care?”

d. “I can come back after you talk with your spouse about the care.”

ANS: C The patient needs to be the focus of developing care plans, and communication is an important part of collaboration with the patient to discover barriers for the patient to follow recommendations. It is important to either provide solutions to the barriers or present other options. Reviewing the care again does not demonstrate willingness to have the patient be part of the team. Insisting that the patient do what is prescribed is autocratic and does not recognize the role the patient has in their care. Leaving the patient and spouse with the situation unresolved fosters distrust and more anger.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

7. The nurse is caring for a patient with a progressive, degenerative muscle illness. The patient states that she would like to remain in her home with her daughter as long as possible. What action should the nurse take? a. Teach the patient muscle strengthening and stretching exercises. b. Tell the patient to make plans to move to an assisted-living facility. c. Discuss resources to help the patient and make appropriate referrals. d. Ask the patient to come in for daily physical therapy.

ANS: C To honor the patient’s request to stay at home the nurse should make appropriate referrals for needed evaluation and assistance. Most nurses will not have the expertise to teach appropriate exercises for degenerative illness. Asking the patient to move to an assisted-living facility does not account for the patient’s request. The patient has not been assessed for the need of dailyNtherapy, and it is not likely that a patient with a degenerative illness will be able to make daily appointments for treatment as the illness progresses.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

8. A patient has been admitted to an acute care hospital unit. The nurse explains the hospital philosophy that the patient be an active part of planning their care. The patient verbalizes understanding of this request when they make which statement? a. “I will have to do whatever the physician says I need to do.” b. “Once a plan is developed, it cannot be changed.” c. “My insurance will not pay if I don’t do what you want me to do.” d. “We can work together to adjust my plan as we need to.”

ANS: D Treatment plans need to be developed, evaluated, and adapted as needed based on the patient status and willingness to complete the prescribed care. Stating that the patient has to do whatever the care provider prescribes does not include the principle of collaboration.

Care plans can be altered based on patient status. Insurance providers do not determine a patient’s ability to complete prescribed care, although they do reimburse for standard care given.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

9. The management of a community hospital is trying to encourage a more collaborative environment among staff members. Which concept is most important for management to develop first? a. Post educational posters about how well collaboration is being performed b. Highlight that no single profession can meet the needs of all patients c. Provide meetings for each department on how their role affects patients d. Begin implementing evaluations of collaborative skills on annual performance reviews ANS: B Recognizing that collaboration needs all professions to provide patient-centered care is an important first step to implementing a different philosophy in the hospital. Posting an evaluation of performance before education will not encourage participation. Collaboration requires an understanding of more than your own discipline. It is unfair to evaluate staff on a requirement that they have not been introduced to.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. Which activities are appropriate for the nurse to collaborate with a patient? (Select all that apply.) a. Prescribing a new medication dose b. Health promotion activities c. End-of-life comfort decisions N d. Interpreting laboratory results e. Lifestyle changes to improve health ANS: B, C, E Nurses should include patients and their families when exploring health promotion activities, end-of-life decisions, lifestyle changes, and treatment options. Prescribed medication doses are initiated by educated professionals, although the patient gives feedback on the effectiveness of medications. Patients are not trained to interpret lab results, but patients rely on health professionals to explain results to them.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

3. A nurse administers an incorrect medication to a patient. In reviewing this medication error, the nurse finds out that incorrect medication was placed in the Pyxis system. What type of error has the nurse committed? a. Latent error b. Blunt end c. Did not follow nursing process d. Latent error resulting in active error ANS: D The situation described is a latent error which resulted in an active error as incorrect medication was placed in the Pyxis system. Latent errors are also referred to as blunt end whereas active errors are applied as occurring at the sharp end. There is no provided information to suggest that the nurse did not follow nursing process.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Prior to drug administration the nurse reviews the seven rights, which include right patient, right medication, right time, right dose, right education, right documentation, and what other right? a. Room b. Route c. Physician d. Manufacturer

N

ANS: B The right route (e.g., oral or intramuscular) is an essential component to verify prior to the administration of any drug. The patient does not need to be in a specific location. There may be a number of physicians caring for a patient who prescribe medications for any given patient. A similar drug may be made by a number of different companies, and checking the manufacturer is not considered one of the seven rights. However, the nurse will want to be aware of a difference, because different companies prepare the same medication in different ways with different inactive ingredients, which can affect patient response.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. Which nursing action indicates that a nurse is more likely to incur a medication error during medication administration? a. Checks the original medication order on the patient’s chart b. Asks the patient to state his/her name and date of birth c. Does not scan the barcode of the patient prior to administering the medication d. Does not provide the patient with a glass of water ANS: C

Use of barcode scanning of both the medication and the patient’s hospital band is critical to maintaining safe practice during medication administration. The nurse by not scanning the barcode is not maintaining the required elements and as a result is more likely to incur a medication error. Checking the original order and asking the patient to provide identification are required elements. Not providing a glass of water to the patient is not related to a medication error but does not represent best practice unless the patient is NPO except meds which would require sips of water.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control | NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. To promote safety, the nurse manager sensitive to point of care (sharp end) and systems level (blunt end) exemplars works closely with staff to address which point of care exemplar? a. Care coordination b. Documentation c. Electronic records d. Fall prevention ANS: D The most common safety issues at the sharp end include prevention of decubitus ulcers, medication administration, fall prevention, invasive procedures, diagnostic workup, recognition of/action on adverse events, and communication. These are the most common issues the staff nurse providing direct patient care encounters. Each of the other options is classified as systems level exemplars.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. Aspects of safety culture that contribute to a culture of safety in a healthcare organization include which component? a. Communication b. Fear of punishment c. Malpractice implications d. Team nursing ANS: A Aspects that contribute to a culture of safety include leadership, teamwork, an evidence base, communication, learning, a just culture, and patient-centered care. Fear of professional or personal punishment and concern about malpractice implications are considered barriers to a culture of safety. No model of nursing care has been related to a culture of safety.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A staff nurse reports a medication error due to failure to administer a medication at the scheduled time. What is the charge nurse’s best response? a. “We’ll conduct a root cause analysis.” b. “That means you’ll have to do continuing education.”

c. “Why did you let that happen?” d. “You’ll need to tell the patient and family.”

ANS: A In a just culture the nurse is accountable for their actions and practice, but people are not punished for flawed systems. Through a strategy such as root cause analysis the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences. Requiring continued education may be an appropriate recommendation but not until data is collected about the event. Telling the patient is part of transparency and the sharing and disclosure among stakeholders, but it is generally the role of risk management staff, not the staff nurse.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 9. To promote a culture of safety, the nurse manager preparing the staff schedule considers the anticipated census in planning the number and experience of staff on any given shift. Which is the human factor primarily addressed with this consideration? a. Available supplies b. Interdisciplinary communication c. Interruptions in work d. Workload fluctuations ANS: D Including an adequate number of staff members with experience caring for anticipated patients is a strategy to manage the workload and potential fluctuations. A safety culture requires organizational leaderNship (e.g., the nurse manager) that gives attention to human factors such as managing workload fluctuations. This strategy also applies principles of crew resource management in that it addresses workload distribution. Lack of supplies can create a challenge for safe care but could not be addressed with the schedule. Concerns with communication and coordination across disciplines, including power gradients, and excessive professional courtesy can create hazards but would not be the best answer.

Strategies to minimize interruptions in work are essential but would not be the best answer in this situation.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 46: Technology and Informatics Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The staff nurse who uses informatics in promoting quality patient care is most likely to access data in which domain? a. Certified clinical information systems (CIS) b. Clinical healthcare informatics c. Public health/population informatics d. Translational bioinformatics ANS: B Clinical healthcare informatics and the subset, nursing informatics, provides for the development of direct approaches to patients and their families which can be used by the staff nurse to promote quality patient care. Certified CIS refers to the tools for achieving quality outcomes, including electronic health records, clinical data repositories, decision support programs, and handheld devices—not the data. Public health/population informatics is the domain which relates information, computer science, and technology to public health science to improve the health of populations; this domain would provide data for the nurse working with communities. Translational bioinformatics refers to the research science domain where biomedical and genomic data are combined; it is a new term that describes the domain of where bioinformatics meets clinical medicine, generally for healthcare research rather than direct patient care.

OBJ:

NCLEX Client NeedsNCategory: Health Promotion and Maintenance

2. When discussing the purposes of healthcare informatics with a nurse during orientation, the nurse educator would be concerned if the nurse orientee stated that which is one purpose of informatics? a. Develop a cognitive science. b. Improve disease tracking. c. Improve the health provider’s work flow. d. Increase administrative efficiencies.

ANS: A Cognitive science is one of the theories that play a role in the implementation of informatics.

Its development is not a purpose, and the nurse educator would use this incorrect response of the orientee to plan additional teaching about the purposes of healthcare informatics.

Purposes of information health technology include to improve health provider work flow, improve healthcare quality, prevent medical errors, reduce healthcare costs, increase administrative efficiencies, decrease paperwork, and improve disease tracking.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. To design and implement a decubitus ulcer risk management protocol in the electronic health record, the informatics nurse would first perform which action? a. Build the screens in the electronic health record.

b. Determine evidence supporting decubitus ulcer risk management. c. Develop the training program for staff. d. Select the appropriate standardized language.

ANS: B Collecting the evidence related to the issue is the first step in addressing a problem (remember the nursing process, the foundation of nursing practice). Based on the evidence, an assessment tool or tools and data needed from a patient perspective would be identified.

The screens in the electronic record would be based on the workflow surrounding the patient assessment. A training program could not be developed until the protocol is adopted. The appropriate standardized language is selected based on what needs to be documented and what has been approved for use by the agency (e.g., ANA recognized terminologies).

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The application of information processing that deals with the storage, retrieval sharing, and use of healthcare data, information, and knowledge for communication and decision making is the definition of which area? a. Computer science b. Health informatics c. Health information technology d. Nursing informatics ANS: C This is the definition of health information technology. Computer science is a branch of engineering that studies compNutation and computer technology, hardware, software, and the theoretical foundations of information and computation techniques. Health informatics is a discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. The nurse manager of a medical/surgical unit wants to increase the use of healthcare technology on the unit and is working with an ANA-certified informatics nurse to reduce which barriers to health information exchange? a. Basic informatics knowledge and skills b. Offering the best set of tools c. Privacy and security policies d. Unit-specific terminology ANS: D

Unit-specific terminology would be a barrier to sharing health information because there could be confusion about terms. Standardized terminology within the electronic health record is critical for communicating care to the interprofessional team and exchanging health information. Competency in informatics including basic informatics knowledge and skills could facilitate the use of informatics; lack of competency could be a barrier. Offering the best set of tools could promote the ease of data entry and access. Privacy and security policies reduce legal and ethical concerns about sharing data, thus reducing barriers to health information exchange.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse is reviewing concepts related to documentation in the electronic health record.

Which statement best represents the concept of “meaningful use”? a. Allows for privacy of information b. Uses individualized log on for access c. Completes charting in a timely manner d. Meets established criteria related to technological use ANS: D The concept of “meaningful use” refers to the establishment of criteria related to technological use of the electronic health record as determined by federal guidelines.

HIPAA policy mandates privacy of personal information and patient medical records. Use of an individualized log on to access relates to security concerns. Completing charting in a timely manner is an expectation of prudent practice.

OBJ: NCLEX Client NeedsNCategory: Safe and Effective Care Environment: Management of Care 7. Which are exemplars of the health informatics concept? a. Clinical research informatics b. Hardware and software c. Privacy and security d. Standard terminology ANS: A Exemplars of the health informatics concept include clinical healthcare informatics, clinical research informatics, public/population health informatics, and translational bioinformatics.

Hardware and software, privacy and security, and standardized information systems and terminology are considered attributes related to the concept, not exemplars.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 47: Evidence Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. One of the first nurse researchers to document evidence-based practice for nursing was Florence Nightingale. What did Nightingale incorporate into her practice that made her practice different from her colleagues? a. Nightingale gathered scientific data. b. Nightingale calculated statistics to report her findings. c. Nightingale communicated her findings to powerful others. d. Nightingale based her nursing practice on her findings.

ANS: D Florence Nightingale had tried to develop the role of researcher by using evidence from her practice and implementing these findings. Evidence-based practice (EBP) includes conducting quality studies, synthesizing the study findings into the best research evidence available, and using that research evidence effectively in practice. Although gathering scientific data, calculating statistics to report findings, and communicating findings to powerful others are all important components of conducting research, Nightingale’s action that most appropriately reflects the current nursing research priority is that she based her nursing practice on her findings.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N 2. The nurse administrator is doing a study that entails gathering data about new employees over a 10-year period. Which research method would be the best one to use for this type of study? a. Quantitative longitudinal cohort b. Qualitative longitudinal c. Qualitative interview d. Qualitative case study ANS: A Quantitative research has been defined as being “focused on the testing of a hypothesis through objective observation and validation.” The types of studies that make up this category include randomized controlled studies, cohort studies, longitudinal studies, case-controlled studies, and case reports. The other options are examples of quantitative, not qualitative, studies.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse in the outpatient setting would like to conduct a research study that compares patients who take tramadol (Ultracet) to patients who take oxycodone hydrochloride and acetaminophen (Percocet) for managing back pain. Which quantitative research method should yield the best results? a. Longitude study

b. Randomized controlled study c. Systematic reviews/meta-analysis d. Survey study ANS: B A randomized controlled study is a type of quantitative research that seeks to control and examine the variables to determine effectiveness. In this case, the variables would be those that were administered tramadol (Ultracet) and those that were administered hydrochloride and acetaminophen (Percocet) for managing back pain. Correlational research methods help determine association between or among variables. A longitudinal study examines variables over a designated course of time. A systematic review/meta-analysis is a type of literature review and not a research method. A survey study is a type of qualitative research method.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The nurse in the psychiatric unit is involved in a research study for a depression medication.

In the study, patients are randomly assigned to one depression medication and the other group is receiving no medication to treat the depression. What method of research are the patients involved with? a. Descriptive b. Correlational c. Quasi-experimental d. Experimental ANS: D Experimental tests an interveN ntion and includes both a control group and random assignment. This research study tests an intervention and includes both a control group and random assignment. Descriptive defines the magnitude of a concept and its characteristics.

Correlational determines association between or among variables. Quasi-experimental tests an intervention and lacks either a control group or random assignment.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. How does the Iowa model transcend mere nursing care? (Select all that apply.) a. It includes formalized internal feedback loops. b. Its triggers can have their origins practically anywhere. c. It generates change in practice solely through research. d. It implies a layer of policy development. e. It addresses multiple disciplines’ impacts on quality.

ANS: A, B, D, E

The triggers addressed within the Iowa model process can be problem focused and evolve from risk management data, process improvement data, benchmarking data, financial data, and clinical problems. The triggers can also be knowledge focused, such as new research findings, change in a national agency’s or an organization’s standards and guidelines, expanded philosophy of care, or questions from the institutional standards committee.

Because the Iowa model is often implemented at a fairly high level of nursing or hospital administration, it scrutinizes the input of nursing and other disciplines in its process. Its output is applied as widely as possible throughout the organization, and it can affect policy within a multihospital system and even across systems. The success of EBP is determined by all involved, including healthcare agencies, administrators, nurses, physicians, and other healthcare professionals.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. Which statements are true about the Iowa model of EBP? (Select all that apply.) a. It addresses utilization of research findings at an individual level. b. It addresses the relevance of the question to the organization. c. Individual nurses enact an Iowa decision tree when they examine risk management data. d. It identifies triggers capable of posing hazard or benefit. e. It reiterates that innovators embrace change far earlier than laggards.

ANS: B, D The Iowa model of EBP provides direction for the development of EBP in a clinical agency and as such focuses on the relevance of the question to the organization. In a healthcare agency, there are triggers t h a N t initiate the need for change, and the focus should always be to make changes based on best evidence. The Iowa model of EBP was revised in 2015 to provide additional feedback loops, detailed instructions, and inclusion of patient preferences.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse is conducting a review of the literature for pain management techniques. Which of the following should the nurse consider when conducting research that yields solid EBP? (Select all that apply.) a. Search the literature to uncover evidence to answer the question. b. Evaluate the outcome. c. Use the nursing process to evaluate evidence. d. Evaluate the evidence found. e. Develop an answerable question. f. Develop a question that has not been answered. g. Apply the evidence to the practice situation.

ANS: A, B, D, E, G To facilitate the use of evidence, steps have been developed to systematically approach a question of patient care. The steps are outlined as follows: • Develop an answerable question.

• Search the literature to uncover evidence to answer the question.

• • • •

Evaluate the evidence found.

Apply the evidence to the practice situation.

Evaluate the outcome.

The nursing process is a method of problem solving and can be used to develop a plan of care. Formulating a question that has not been answered in the research would be considered primary research. Therefore, there is no evidence in which to draw from.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

4. What are two major foci of The Joint Commission (TJC) in the delivery of health care? a. Cost containment, safety b. Safety, quality c. Quality, assessment d. Assessment, evaluation ANS: B The focus of TJC is quality and safety for patient care. TJC does not address cost containment, assessment of care, or evaluation of care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A student nurse and clinical instructor are discussing quality in health care. The instructor knows the student understands when the student makes which statement? a. “Quality is apparent in all health care.” b. “Quality is an outcome of health care.” c. “Quality is seen and unseen in health care.” d. “Quality is achieved by collaboration in health care.”

ANS: C Quality in health care is tangible and intangible. Quality in health care is not apparent in all health care, as many areas of health care are lacking. Quality of care does not always affect the outcome of care; the patient may recover no matter what care is given. Quality is not always achieved by collaboration.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. The focus of quality health care should be on which of the following items? (Select all that apply.) a. Excellent services b. Comprehensive communication c. Private hospital rooms d. Health team collaboration e. Culturally competent care ANS: A, B, D, E Excellent services, communication, collaboration, and culturally competent care bring quality to the health care delivered to the patient. Private hospital rooms may be a preference by some patients, but they do not add to the quality of care.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

2. What are the major attributes of health-care quality? (Select all that apply.) a. Conforms to standards b. Sound decision making

c. High acuity patients d. Low health-care costs e. Identifies adverse events ANS: A, B, E Major attributes of health-care quality include conformation to standards set by regulatory agencies, sound decision making regarding care, and identifying potential adverse events.

High acuity of patients does not contribute to quality health care, because the care demand is increased, and low health-care costs mean fewer services may be available.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Concept 49: Care Coordination Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Student nurses are being questioned by the nursing instructor about the health-care coordination system. The instructor knows the students understand health-care delivery when making which statement? a. “Health care is available for everyone at every time.” b. “Health-care needs are best met with a collaborative effort.” c. “Health care is adequately meeting the needs of the homeless populations.” d. “Health care needs are mostly in third world countries.”

ANS: B Health-care needs many times are not met by one discipline. When a collaborative effort is used, the patient is better served. Health care is not available for everyone, nor is it meeting the needs of the homeless population. Health-care needs are worldwide, not just in third world countries.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. For children and teens, which model includes school-based services? a. Social b. Integrated c. Medically-oriented N d. Nurse-oriented ANS: A The social models focus on community-based services, and the other models do not.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. Which statement is true regarding the concept of care coordination? a. There is minimal risk for individuals across the life cycle. b. Due to enhanced technological ability, services are able to be provided to all those in need. c. Most vulnerable populations have the highest need. d. Costs of services are easily maintained.

ANS: C The concept of care coordination is an important aspect for all individuals as there is the potential for everyone to experience a risk at one time that may require at best a temporary need for coordination of services. Although technological advances have advanced, there are still limitations and barriers to providing coordination of care services to all in need.

Vulnerable populations have the highest need and costs of services are cost-intensive.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. The nurse is discussing care coordination with a patient. The patient asks the nurse to explain care coordination. What is the nurse’s best response? a. “Care coordination is a cost effective method created by the community.” b. “Care coordination forces the health-care facilities in the community to work together.” c. “Care coordination exists for the children and uninsured in the community.” d. “Care coordination allows health-care services to work together in the community.”

ANS: D Care coordination allows all health-care/community services to work together so that patient and family needs can be met. Care coordination does not focus on cost methods. Cost coordination does not exist just for children or the uninsured. No one service is forced to work with another service.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

5. Nurses work to serve the population, and they know that which priority population needs to be served by care coordination? a. Most vulnerable and the frail b. Uninsured and the very young c. Underinsured and the elderly population d. Whole population of the community ANS: A The priority population is the most vulnerable and the frail, because they have the most health-care needs. Other popuNlations do need health care, but they do not always have immediate need of the health-care system.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

6. A nursing instructor is talking about care coordination with nursing students. The instructor stresses which of the following to the students concerning care coordination? a. “A patient must ask for what they need in order to coordinate care.” b. “The nurse does most of the work in care coordination.” c. “Medical diagnoses are an integral part of care coordination.” d. “Collaboration is a significant part of care coordination.”

ANS: D Collaboration is a big part of care coordination. Without the collaboration, there would be no care coordination. Patients asking for their needs to be met does not collaborate care.

Nurses do not do all the work in care collaboration. Medical diagnoses are one small part that drives the need for care collaboration.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. Care coordination models should be adopted in health-care facilities. If models are not put into practice, the shortcomings of the health-care system may display which of the following items? (Select all that apply.) a. Decrease in patients b. Fragmented services c. Low birth weight newborns d. Cost inefficiencies e. Poor health outcomes f. Increased pharmacy costs ANS: B, D, E Fragmented services, cost inefficiencies, and poor health outcomes may be some of the shortcomings seen in health care without the proper model in place to guide the health-care delivery system.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 50: Caregiving Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The community health nurse is assessing a family who has a chronically ill child. The child needs special care, and the nurse has to coordinate the care for the home setting. What behavior will the nurse assess for to know that the family can care for the child? a. The family is willing to learn about the care and share the caregiving needs. b. The mother is going to care for the child and the family herself. c. The older siblings are going to care for the child while the parents are at work. d. An outside agency will be coming to the home three times a week to give care.

ANS: A The nurse will look for a family who is willing to provide care plus support each other in this need. Having a situation where just siblings or a mother or an outside agency give care puts an undue burden on the caregiver and brings disharmony to the family.

OBJ:

NCLEX Client Needs Category: Physiological Integrity

2. A young wife is talking with the nurse about her husband who is returning from the military.

The wife confides that her husband is physically okay but is behaving differently. What is the nurse’s best response? a. “He is just trying to adjust to civilian life again; he’ll be okay.” b. “You should observe him closely, because he could attack you.” c. “Many times people needNcare for emotional trauma.” d. “Talk with your physician to get medication, and then put it in his food.”

ANS: C The nurse is alerting the young wife to the fact that people who have experienced emotional trauma need care too. The nurse does not know how the husband is adjusting so the other options are incorrect.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

3. The nurse is counseling a woman who is caring for her 83-year-old father. The father has had mental changes and is becoming more confused. The father lives with the daughter in her home. The nurse knows the daughter understands the father’s care needs when she states which of the following? a. “Dad will only need my help for a short time, and then he will get better.” b. “I can leave dad alone during the day; I’ll just deadbolt the door.” c. “I can send dad to the adult daycare; that way I can work and care for him at night.” d. “Dad misses mom since she passed; he will be okay in a few weeks.”

ANS: C

The father will be cared for at the adult daycare, and it is a nice alternative for the daughter.

She will be able to work and know that her father is safe during the day. The daughter thinking the father will be okay in a few days is not realistic, nor can she deadbolt the door and lock him in the house.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

4. Many middle-aged adults are called the “sandwich” generation because they are caring for their children and their aging parents. What is the priority reason for aging parents needing care? a. Mental clarity b. Immobility c. Blindness d. Multiple chronic illnesses ANS: D Multiple chronic illnesses come with the aging process. Middle-aged adults are becoming the caregivers for the generation before them and the one after them. Mental clarity is a positive aspect of aging and does not need care. Immobility and blindness do not always mean that the person needs direct care.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

5. A mother is talking with the community-based nurse concerning her adult son. The son is mentally challenged and not able to live on his own. The mother is concerned about her son’s welfare when she is no longer able to care for him. What is the best response by the N nurse? a. “Let’s look into the community resources that are available to assist you.” b. “You have raised your son well, and he will be okay on his own.” c. “Contact your distant relatives to see if anyone would take your son.” d. “There are places for mentally challenged adults; let’s place him there.”

ANS: A The mother, with the assistance of the nurse, can research resources in the community that will service and care for her son when she is no longer able to do so. How the son is raised does not mean that he will be okay on his own. Distant relatives may not want or be able to care for the son, so this may not be a viable option. Placing the son is too general of an option, and he may not do well in this setting.

OBJ:

NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE 1. Many grandparents today are caring for grandchildren in place of a parent. Identify the reasons why this phenomenon is happening. (Select all that apply.) a. Children prefer living with their grandparents. b. Parents are incarcerated. c. Parents are deceased. d. Grandparents are better caregivers.

e. Parents are mentally ill. f. Parents are substance abusers.

ANS: B, C, E, F Grandparents are usually caring for children because the parents are deceased, in prison, substance abusers, or mentally ill and cannot care for the children. The fact that children prefer to live with the grandparents or the grandparents may be better caregivers is not a main reason for this phenomenon to happen.

OBJ: NCLEX Client Needs Category: Psychosocial Integrity 2. Caregivers are often categorized by their relationship to the person being cared for. Which of the following are the roles? (Select all that apply.) a. Grandparent b. Spouse c. Parent d. Adult children e. Neighbor/friend f. Young children ANS: A, B, C, D, E All of these options can provide care whether it is on a temporary or permanent basis.

Young children do not provide care.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 51: Palliative Care Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. Palliative care is used in the management of a patient with symptomatic chronic obstructive pulmonary disease (COPD). Which option does the nurse identify as being accurate? a. Palliative care is used when the patient is beginning to die. b. Palliative care is used to help manage the symptoms that often accompany COPD. c. Hospice nurses must be involved to provide palliative care in a cancer patient. d. Patient must be enrolled into the Medicare Hospice Benefit to receive palliative care.

ANS: B Palliation is the relief or management of symptoms without providing a cure. To palliate is to reduce the severity of an actual or potential life-threatening condition or a chronic debilitating illness. Palliation is not equivalent to cure, but it is the reduction of undesirable effects resulting from the incurable disease or condition.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

2. Today most patients are living for several years before dying with multiple chronic conditions, such as COPD, congestive heart failure, diabetes, and obesity. These concomitant diseases contribute to multiple symptoms that interfere with the patient’s quality of life. What type of care would you consider for this patient?

N a. End-of-life care b. Supportive care c. Comfort care d. Palliative care ANS: D Palliative care provides optimal symptom management in the setting of multiple chronic conditions. The relief and management of these symptoms help to promote improved quality of life for the patient and help to maintain physical functioning.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort

3. What is the most prominent goal of palliative care? a. Integrate into chronic disease management sooner rather than later. b. Enroll the patient into the Medicare Hospice Benefit. c. Ensure that the patient has a 6-month prognosis. d. Reserve this type of care until the patient is actively dying.

ANS: A The goal of palliative care is to integrate symptom management interventions earlier into the course of chronic disease sooner rather than later. This helps to promote optimal quality of life.

OBJ:

NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The student demonstrates a lack of understanding of palliative care when making which statement? a. “Palliative care is designed to promote comfort.” b. “Palliative care is designed to reduce disease exacerbations.” c. “Palliative care is designed to decrease acute care hospital admissions.” d. “Palliative care is designed to promote a cure for chronic disease.”

ANS: D Palliation is the reduction of symptoms without elimination of the cause. Palliative care refers to the provision of care for patients who are diagnosed with a disease or condition without a cure.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort 5. Which is one of the biggest challenges facing current nursing practice? a. The number of aging Americans living with chronic disease b. The number of patients entering into hospice programs c. The number of cancer patients receiving supportive care d. Reduced length of stay in hospice care ANS: A Millions of Americans are living with one or more chronic debilitating diseases, and 7 out of 10 can expect to live with their diseases several years before dying. When coupled with the advancing age of the eight million baby boomers who now qualify for Medicare, this will soon create a huge demand on health-care resources and community-based services.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. When considering the trajectory of a specific disease, what is the most important concept? a. Hospital admissions b. Physical functioning c. Quality of life d. Symptom management ANS: B The disease trajectory occurs from the onset of a life-limited diagnosis until death. Physical functioning determines the decline in the patient’s physical status. Decline in status is used to determine when to intervene with palliative and end-of-life care.

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The interprofessional core team includes members from which disciplines? a. Nursing, medicine, volunteers, and nutrition b. Medicine, nursing, social work, and clergy c. Medicine, nursing, physical therapists, and volunteers d. Nursing, home health aides, volunteers, and clergy ANS: B

An interprofessional team approach involving healthcare professionals from different disciplines is central to optimal palliative care practice and quality outcomes. The interdisciplinary core team includes members from medicine, nursing, social work, and clergy. Ancillary disciplines are also included. Volunteering is not considered a discipline in health care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N

Concept 52: Health Disparities Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The nurse is caring for a Chinese patient diagnosed with cancer who is suffering from pain, yet refuses analgesia administration. What type of health disparities is this patient exhibiting? a. Avoidable and acceptable b. Avoidable and unacceptable c. Unavoidable and acceptable d. Unavoidable and unacceptable ANS: B Health disparities that are avoidable and unacceptable unfortunately occur in healthcare settings and these are the targets of interventions. For example, a disparity in cancer pain management exists between Asians and Whites. This difference is attributable to Asian cultural values and attitudes related to cancer pain and pain medication distinguished from the cultural values of Whites. The disparity is avoidable if Asian cancer patients are adequately educated and instructed on cancer pain management strategies including pain medication and complementary and alternative medicine. Also, this disparity is unacceptable because this gives an unnecessary burden of pain to Asian cancer patients that could be easily managed by using existing strategies.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management N of Care 2. An experienced nurse tells the student nurse, “I have found that most Hispanic immigrants live in unsanitary conditions but are hard workers.” How should the student nurse best classify this statement? a. Stereotyping b. Prejudice c. Discrimination d. Misinformed ANS: A Stereotyping often leads to biased clinical decision making. Stereotyping refers to the process by which people use social categories (e.g., gender or race/ethnicity) in acquiring, processing, and recalling information about others. Both implicit and explicit negative attitudes and stereotypes of healthcare providers significantly shape interactions with patients, influence how information is recalled, and guide expectations and inferences in systematic ways. Stereotyping often occurs subconsciously, unlike prejudice or discrimination. Prejudice, which refers to unjustified negative attitudes based on a person’s group membership, is another source of biased clinical decision making. Discrimination refers to the actual mistreatment of individuals based on race, gender, ethnicity, etc. The nurse is not misinformed as the nurse has practiced for some time and made a statement based on observation and experience.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment: Management

of Care 3. Which type of health disparities are most frequently encountered by nurses in clinical and community settings? a. Avoidable and acceptable b. Avoidable and unacceptable c. Unavoidable and acceptable d. Unavoidable and unacceptable ANS: B Although there are many types of health disparities, the avoidable and unacceptable health disparities are the ones that healthcare providers, including nurses, frequently encounter in clinical and community settings. Furthermore, these are the health disparities that healthcare providers need to target to intervene.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The nurse is caring for diverse population groups at a health clinic. Which of the following patients demonstrates a potential health disparity group? a. A 26-year-old woman who is receiving follow-up after a car accident b. A 30-year-old immigrant who does not speak English c. A 28-year-old man who needs a tetanus booster d. A 12-month-old with an appointment for immunizations ANS: B Poor health literacy skills areNan example of a health disparity that limits an individual’s ability to access or communicate about healthcare needs. Patients who are receiving needed care are not experiencing a gap between health need and actual care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Which is the best strategy the nurse manager should include when working to reduce healthcare disparities on a medical-surgical unit? a. Less diverse workforce b. Increase interpreter availability c. Authoritarian leadership d. Annual staff training ANS: B Key elements are cultural competence that can reduce health disparities including: a diverse workforce; interpreter availability; finding common ground versus authoritarian leadership; frequent staff training and updating staff as needed throughout the year.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A new nurse requires further teaching when failing to identify which practice as a health disparity?

a. b. c. d.

Annual mammogram Early prenatal care Blood pressure screening Frequent fast food meals

ANS: D Preventive care, screening, and health promotion activities are not considered health disparities. Examples include mammograms, prenatal care, and blood pressure checks.

Frequent fast food meals, containing high fat content, are considered a health disparity due to possible lack of money or access to healthy meals.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. Before beginning work on a culturally diverse hospital unit, the nurse should perform which action first? a. Improve self-awareness of one’s own biases. b. Attend an anti-discrimination rally or march. c. Build rapport and trust with the patients. d. Take a foreign language class.

ANS: A Before working with culturally diverse groups, the nurse should first identify own biases and assumptions in order to objectively and competently care for patients. Attending a rally or march may not raise awareness of various biases. The nurse should establish rapport and trust when working with patients, after self-awareness is appreciated. Taking a foreign language may be helpful; how Neve r the first step is self-awareness.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

8. The nurse who has been hired to work on an oncology unit identifies which group of women as being at highest risk of developing breast cancer? a. African b. Caucasian c. Asian d. Hispanic ANS: C Breast cancer is the most common cancer in Asian women in the United States, but Asian women have relatively lower rates of breast cancer screening than African American and white women in the United States. Furthermore, disparities in breast cancer screening reportedly result from low income, lack of a local mammography center, lack of transportation to a mammography center, lack of a usual healthcare provider, lack of a recommendation from a healthcare provider to get mammography screening, lack of awareness of breast cancer risks and screening methods, and cultural and language differences.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE 1. A healthcare provider whose native country is India is explaining the treatment plan to a patient. The patient tells the nurse she is having trouble understanding the provider but is embarrassed about asking to repeat the information over and over. The nurse should assess for which results due to this disparity in provider-patient communication? (Select all that apply.) a. Patient dissatisfaction b. Optimal health outcome c. Poor adherence d. Increased patient confidence e. Improved communication ANS: A, C When sociocultural differences between healthcare providers and patients are not appreciated or communicated effectively in clinical encounters, patient dissatisfaction, poor adherence, poorer health outcomes, and racial/ethnic disparities in healthcare easily happen.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse in the immunization clinic should place emphasis on educating and reaching which groups about the disease preventing effects of immunizations? (Select all that apply.) a. Caucasian b. All individuals living below the federal poverty level regardless of race or ethnicity N c. Low income d. Parents of children e. High income ANS: B, C, D It is important to reach out to all individuals living below the federal poverty level (parents and children) as they are most likely not to have completed the specified immunization schedule. Research obtained from the Center for Disease Control (CDC) in 2014 suggests that those living below the federal poverty level were less likely to have the full series of vaccination coverage.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

Concept 53: Population Health Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse is reviewing the concept of population health. Which statement best represents the concept? a. Individuals who live in the United States b. Individuals with common characteristics related to health co-morbidities c. Individuals who use emergent care facilities as their primary source of health care d. Individuals with no symptoms of disease ANS: B Population health refers to individuals who reside in a geographic area that have similar characteristics related to health. Population by itself refers to a specific group location.

Choice of emergent care facilities as their primary source of health care does not define population health. Individuals within the population may have symptoms of disease.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse is reviewing the concept of population health. What method should the nurse utilize in order to maintain health equity for a given population? a. Ask each member of the group if they need an interpreter. b. Calculate group statistics for delivery of healthcare services. c. Make sure that all documN entation is accurate. d. Offer health screenings to all group members.

ANS: D The concept of population health is to maintain/improve health status, reduce disparities and create health equity. By offering health screenings to all group members, this allows for primary prevention. There is no information provided that indicates there is a language barrier, so asking each member of the group if they need an interpreter is not necessary.

While it is important to obtain statistical information relative to the group, this in itself does not provide for health equity. Making sure that documentation is accurate is important in the context of health care but it does not help to maintain health equity.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 3. A public health nurse is caring for a patient in the community who has been exposed to tuberculosis. What aspect of care is the public nurse providing? a. Health protection b. Health promotion c. Disease prevention d. Community nursing ANS: C

A nurse working as a public health nurse, who is providing care to a patient who has been exposed to a disease such as tuberculosis, would be providing disease prevention. Health protection would include providing educational materials to patients. Health promotion would include providing healthy educational programs. Community nursing is considered a specialty area of practice not an aspect of care.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

4. A parent asks the nurse to explain the term “herd immunity.” How should the nurse respond? a. “As long as your child receives his/her immunizations, they will be protected by this concept.” b. “It is important for 90% of the population to maintain their vaccination status for herd immunity to be effective.” c. “The term applies to individuals who have decided not to immunize but instead use isolation practices to maintain health.” d. “The term relates to individual groups of patients who are immunized.”

ANS: C The concept of herd immunity refers to 90% of the population being immunized in order for it to be effective on a population level. Although it is important for individual children to be immunized, the overall population must maintain a high immunization status to be effective.

Immunization is the key to the concept and the term does not relate to individual groups.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 5. A nurse is reviewing factors tNh a t lead to prevention of non-communicable diseases. Which intervention would be most effective for the nurse to implement for a group of patients? a. Check the patient’s immunization records. b. Maintain scheduled appointments with their healthcare provider. c. Offer information related to smoking cessation. d. Check patient’s medication record.

ANS: C Health promotion is an essential aspect of population health. Offering information related to smoking cessation would be most effective. Although it is important to check the patient’s immunization record, this relates to communicable diseases. Checking the patient’s medication record and maintaining scheduled appointments with their healthcare provider are important as well but in terms of health promotion, providing smoking cessation information would be more important.

OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A nurse is reviewing health promotion strategies with regard to population health. Which non-communicable disease processes linked to high morbidity and mortality can be addressed through health promotion? (Select all that apply.) a. Cardiac disease

b. c. d. e.

Diabetes End stage renal disease Stroke Chronic lower respiratory disease

ANS: A, B, C, D, E Of the ten leading causes of death, five of them are linked to non-communicable diseases: heart disease, diabetes, end stage renal disease, stork and chronic lower respiratory disease.

Each of which can be addressed via health promotion measures.

OBJ:

NCLEX Client Needs Category: Health Promotion and Maintenance

N

Concept 54: Health Care Organizations Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. A nurse is interviewing at an agency owned by a national religious organization that serves homeless and uninsured patients. A large poster display shows a proposed addition that would add 16 beds to the facility that will be funded from profits of the previous 3 years of operation. The nurse recognizes that the agency is most likely what type of agency? a. For-profit b. Not-for-profit c. Publicly-owned d. Investor-owned ANS: B Many religious organizations are privately owned and administer not-for-profit health facilities, where profits are returned into the facility for improvements or equipment.

For-profit agencies distribute profits to shareholders. Publicly-owned facilities are government supported and not linked to religious organizations. Investor-owned agencies would be for-profit agencies with profits distributed to investors.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nurse is reported for taking prescribed patient medications for their personal use. Who has direct authority over decidingNif the nurse may keep their professional license to continue practicing as a nurse? a. The hospital where the nurse is currently employed b. The American Nurses Association c. The National League for Nursing d. The State Board of Nursing who issued the license ANS: D Decisions related to practice are the responsibility of the licensing body, or State Board of Nursing, who is charged with protecting the public. The hospital does not determine who is eligible for a professional license. The National League for Nursing is active in nursing education standards. The American Nurses Association helps develop standards of care and is politically active, but it does not enforce standards for individuals.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The annual report for a hospital shows that external environment factors are affecting the amount of new staff hired. What is a likely factor contributing to this outcome? a. The recent implementation of becoming a not-for-profit institution b. The implementation of a hospital electronic medical record system c. A national recession that has been occurring for 3 years d. The closure of a hospital-based school of nursing due to lack of funding

ANS: C External environmental factors that affect organizations are conditions or events that occur outside the control of the agency, such as new health laws, governmental regulations, or economic trends. Internal environmental factors occur within the organizational structure and include such factors as technology issues, changes in personnel roles, or the implementation of new policies.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse manager recognizes that systems theory identifies that there is a social component within an organization that affects the overall functioning of the system. What indicator would demonstrate to the nurse manager that the social needs of an organization are being met? a. Most employees from the organization attend an annual holiday celebration. b. Separate eating areas for each discipline are set up in the cafeteria. c. Nurse managers are planning to move to a centralized area away from the care units. d. The summer softball teams are canceled due to lack of interest.

ANS: A Systems theory focuses on the needs and desires of people who work in the organization.

Good attendance at a work-sponsored function indicates that staff enjoy interacting and are meeting social and relationship roles. Separating disciplines does not foster a sense of team.

Moving administration away from staff limits interaction and informal conversations that build trust. Lack of participation in sponsored events such as a softball team indicates that staff relationships are not stroNng, and a social component is not being achieved within the work environment.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A hospital organization is working to improve a feeling of being valued and respected among all staff members. Which action by administration would reinforce the feeling of being valued? a. Create professional pathways that require advanced education for any advancement of staff. b. Seek staff input when planning a remodeling project of patient rooms. c. Form committees that consist of upper management to plan organizational goals. d. Consistently schedule required staff meetings at the same time each month.

ANS: B Including staff at all levels of an organization in planning and projects demonstrates respect for the intelligence and creativity of the individual. Requiring advanced education for any advancement limits those with barriers to attending additional schooling; advancement should be available in a variety of ways to show the value of the individual. Committees that only consist of upper management cause a feeling of disconnect between staff and administration. Scheduling meetings at the same time does not consider those who work shifts and either have to come in on their day off or must disrupt sleep to attend.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A quality improvement committee is reviewing discharge surveys. Results show that patients and their families have difficulty finding departments and areas of the hospital.

What action by the committee would best address this concern for the organization? a. Continue to review future surveys to monitor the situation. b. Give additional training to the receptionists and switchboard personnel to give better directions. c. Form a multidisciplinary committee to identify options to help travel through the hospital. d. Send a work order to the maintenance department requesting that brighter lights be installed.

ANS: C Successful organizations respect the input of all disciplines when searching for solutions for problems. Continuing to gather data delays solving a problem. There is no indication that verbal directions will solve the problem; additional measures may be required. Merely providing additional light may not solve the problem—multi-language signs or even remodeling may be identified by the committee as being needed.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse manager finds an unsigned note reporting that patient care standards are not consistently being followed. Within the organizational structure, what is the best action for N the manager? a. Schedule a staff meeting to ask staff who left the note. b. Send an email reminder that all staff need to review the policy and procedure book. c. Wait for a staff member to come forward who is willing to be identified. d. Form a small group to explore why staff are not comfortable reporting errors.

ANS: D There are significant problems in an organization where staff are not willing to openly discuss problems, especially problems that affect patient care. A focus group can help identify what is preventing a sense of comfort to reveal problems. Scheduling a meeting is unlikely to have the person admit to complaining about care provided by coworkers in front of coworkers. A request to review policies and procedures is so broad the staff will not be able to identify a specific problem that needs to be corrected. Unless organizational changes are made, it is unlikely that staff will decide to come forward when they would not do so in the first place.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A hospital is experiencing a drop in patient admissions, resulting in the implementation of a hiring freeze. What is a potential critical consequence of this internal organizational decision? a. A decrease in the availability of future nurses to hire b. A savings of salaries and benefits

c. Increased scholarships to nursing students from the local high school d. Increased cross-training of current staff ANS: A In an economic climate where hospitals are not hiring, nursing schools may limit enrollment which will limit the availability of future nurses available to be hired when the current nurses retire or reduce their hours. Salary savings is minimal as the number of patients, staffing, and revenue are closely aligned. Scholarships will decrease as hiring commitments to scholarship holders will no longer be in effect. Cross-training may occur, but it is not a critical consequence of a hiring freeze.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A hospital organization is applying for Magnet© status to show excellence in nursing practice. What components would indicate that the hospital is meeting Magnet© principles?

(Select all that apply.) a. The education budget for nursing has been cut to provide for new laboratory equipment. b. On average, 40% of new nurses are leaving within 1 year of hire. c. Nurses are active participants on all major hospital committees. d. Quality improvement projects are planned and evaluated by nurses. e. Patient care outcome data are reported in the annual executive board meeting.

N ANS: C, D To gain Magnet© status, an organization must show that nurses are active participants in the organization administrative structure, fully involved in quality improvement projects, and are recognized as a valuable resource.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Other countries fund the healthcare system so that every citizen may have health care. In addition they provide the option that citizens may purchase private health care too. The United States has a combination of private companies and government agencies funding health care, so money is not coming from just the private sector. The older person in the population receives care according to the insurance coverage they have, but the care is not before anyone else.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. Which of the following statements is true about health care in the United States? a. The United States spends more money on health care than any other nation. b. The United States provides health care to every citizen. c. The United States relies on government funding to treat most citizens. d. The United States spends less money on pediatric care than other nations.

ANS: A The United States spends more money on health care than any other country. The United States does not provide health care to every citizen, nor does it rely entirely on government funding. The United States does not spend less money on pediatric care but usually more than other countries.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Two nurses are discussing managed healthcare organizations. The two nurses know which to be true about managed h eaNl t h care? a. Care is mostly provided by nurses. b. Prices for care are negotiated by the patient. c. Providers may encounter additional cost if care provided exceeds reimbursement. d. Patients can select any healthcare provider for treatment without additional costs.

ANS: C Managed healthcare organizations include both PPO (Preferred Provider Organizations) and HMO (Health Maintenance Organizations). Fees are determined by the insurance company with a provided listing of healthcare providers who are in-network. Delivery of care is physician based. Additional costs to the patient may be incurred if the patient decides to see an out-of-network healthcare provider. Providers are paid a preset reimbursement for each patient and may suffer losses if their cost exceeds this stipulated amount.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A student nurse is discussing Medicare coverage with the clinical instructor. The instructor knows the student understands Medicare when the student makes which statement(s)?

(Select all that apply.) a. Medicare covers all patients while they are in the hospital.

b. c. d. e.

Medicare is funded by the federal government.

Medicare is for persons 65 years old and older.

Medicare is partially funded by private third-party payers.

Medicare is for patients who are disabled and/or have end-stage renal disease.

ANS: B, C, E Medicare is funded by the federal government. It covers people who are 65 years old and older, disabled people, and patients who have end-stage renal disease. It does not cover all patients in the hospital, because some patients do not qualify for Medicare. It is not funded by third-party payers.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. An Accountable Care Organization (ACO) seeks to deliver which of the following aspects of health care? (Select all that apply.) a. Lessen Medicare payments b. Integrate care c. Enhance evidence-based practices d. Manage acute conditions e. Support hospice charges ANS: B, C ACOs work to integrate care, manage chronic conditions, and enhance the use of evidence-based practices. They do not have any involvement with Medicare payments, the management of acute conditions, or hospice care.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

Concept 60: Health Care Law Giddens: Concepts for Nursing Practice, 4th Edition MULTIPLE CHOICE 1. The new nurse correctly defines a law when stating which information? a. “Law is a fundamental concept for healthcare professionals.” b. “Law’s rule is developed by the employee’s organization.” c. “Law’s rule is enacted by a government agency that defines what must be done in a given circumstance.” d. “Law is a mandate from the Joint Commission or other accrediting agency.”

ANS: C This is the correct definition of a law.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. Which of the following is true about healthcare legislation? a. The U.S. Constitution addresses healthcare law specifically to give the federal government the ability to license professionals and institutions. b. The power of the U.S. Constitution does not have a direct relationship to health care and reserves most of the power to the states. c. State laws are considered the highest source of healthcare law and trump the federal laws. d. The federal government aNsserts its power over healthcare legislation through the U.S. Constitution.

ANS: B The power of the U.S. Constitution does not have a direct relationship to health care and reserves most of the power to the states. The other statements are false. The U.S. Constitution does not address health care specifically. Either state or federal laws can be considered the highest source of law depending on which law has the stricter regulation or rule.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 3. Which is an example of the regulatory power to make law? a. Joint Commission establishing a medication reconciliation standard b. Centers for Disease Control and Prevention (CDC) developing recommendations for childhood immunizations c. Institute of Medicine (IOM) defining the approximate number of medication errors that result in significant patient harm or death d. Centers for Medicare and Medicaid Services (CMS) enacting rules for restraint and seclusion for participating hospitals ANS: D

The Centers for Medicare and Medicaid Services (CMS) enacting rules for restraint and seclusion for participating hospitals refers to the enactment of law, while the other answers discuss the development of standards and recommendations that do not have the authority of law. There are some healthcare rules that may define expected behavior, but if these rules were not created by a government entity with legal authority, then they are not healthcare laws.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 4. What is one of the major attributes of healthcare law? a. It defines the expected behavior of persons in the business of health care. b. The law or rule is easy to interpret and comply with. c. It is established by any healthcare authority. d. The creator must be an expert in health care.

ANS: A A healthcare law or rule defines expected behavior of persons in the business of health care or in healthcare relationships. Healthcare law is not easy to interpret or comply with and can only be established by organizations with legal authority for law making. Creators of healthcare law are often not experts in health care.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. The Board of Nursing (BON) is reviewing a nurse’s practice based on a reported violation of the Nurse Practice Act. W hNa t action can the BON take if the complaint is found to be unsupported? a. Censure the nurse. b. Assess a penalty in the form of monetary cost. c. Reinstate the nurse’s license. d. Dismiss the complaint.

ANS: D The Board of Nursing (BON) in each state defines and interprets the Nurse Practice Act. The BON is responsible for investigating and providing actions based on complaints and/or violations of the Nurse Practice Act. If the BON finds that the complaint is not supported by evidence, then the complaint will be dismissed with no disciplinary action taken. Actions allowable by the BON with a supported complaint and/or violation range from censure, talking additional courses, paying a fine/penalty, probation, suspension, and revocation to denial of licensure.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 6. Which of the following is an example of a nurse violating the Health Insurance Portability and Accountability Act (HIPAA) of 1996? a. The nurse asks the unit clerk to look up lab values for her relative recently admitted to the hospital. b. A group of fellow employees are discussing a patient’s clinical status in a public

4. Which of the following components are included in health policy at the state level? a. Americans with Disabilities Act of 1990 b. Scope of nursing practice c. Health Insurance Portability and Accountability Act (HIPAA) of 1996 d. Patient Safety and Quality Improvement Act of 2005 ANS: B The scope of nursing practice is correct, because it is controlled at the state level by state boards of nursing. The Americans with Disabilities Act of 1990, the HIPAA of 1996, and the Patient Safety and Quality Improvement Act of 2005 are all regulated at the national level.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 5. Which of the following is the intent of HIPAA? a. Release patient information for purposes of insurance reimbursement. b. Prevent healthcare providers from billing for procedures done for the insured person. c. Protect patients from reviewing their own medical records. d. Limit the ability of healthcare providers to sell patient information to outside sources.

ANS: D The intent of HIPAA is to protect patient information and prevent it from being sold to outside agencies. The right ofNheath care providers to bill for services is necessary for patient payment and is not prohibited. Patients have the right to view their own patient information.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. Nurses can be health advocates in which of the following ways? (Select all that apply.) a. Supporting their professional nursing organization when discussing upcoming legislation b. Discussing the upcoming classes with a neighbor c. Rallying for coverage for childhood immunizations d. Arranging for a patient to meet with case management for home health care e. Discussing a patient they are concerned about with a fellow student in the public cafeteria ANS: A, C, D

Supporting a professional nursing organization, rallying for coverage for childhood immunizations, and arranging for a patient to meet with case management are examples of how nurses can be a positive influence on healthcare policy. Discussing an upcoming class with a neighbor is not effective because it could be determined to be negative. Talking about a patient in a public area is an example of inappropriate communication between healthcare workers and is a violation of patient confidentiality.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nursing student is preparing a care plan for an assigned patient. When accessing the electronic medical record, what is acceptable information to view? (Select all that apply.) a. Laboratory data of the assigned patient b. Admission diagnosis for a patient who is a former neighbor c. The patient’s age, date of birth, and gender d. The history and physical of the assigned patient e. A classmate’s brother’s chest x-ray report ANS: A, C, D The laboratory data, age, date of birth, gender, history, and physical of an assigned patient are necessary for identification and care of the patient so it is acceptable to view this information in the electronic medical record. The patient information in the medical record, whether electronic or print, is only to be viewed by those who have a legitimate role in the patient’s care. Viewing information on patients other than the assigned patient is not appropriate, because the student does not have a need to view the information for patient care. These are violations of patient privacy.

N OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

place. The nurse manager requests that they step into private room to complete the discussion. c. After entering the progress notes on a patient’s electronic medical record, the nurse logs off the computer to allow her coworker to use the terminal. d. As a family approaches the nursing desk, the nurse removes the patient census sheet from view on the counter.

ANS: A When the nurse asks the unit clerk to look up lab values for her relative recently admitted to the hospital, the nurse is accessing protected health information not required for the nurse to perform his or her job. This is a violation of privacy even if it is a relative. The other choices are all actions that are consistent with protecting a patient’s privacy right as defined by HIPAA. OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care 7. In which of the following answers is the hospital in compliance with the Consolidated Omnibus Budget Reconciliation Act and Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA)? a. The emergency department staff asks a patient to stay in the waiting room until the patients with insurance are treated. b. The emergency registration personnel explain to a patient that they must have proper identification to receive treatment. c. A patient with chest pain is triaged directly to a room for evaluation and registration information is obtained after the patient is stabilized. d. The emergency departmeN nt physician discharges and instructs a patient who is actively suicidal to go to the neighborhood facility that has psychiatric services.

ANS: C EMTALA requires that any hospital that operates an emergency department and receives Medicare funds provide an appropriate screening exam to anyone who presented and stabilize any emergency medical condition prior to transfer to another facility. The other choices are in conflict with EMTALA because a medical screening exam must be provided without consideration of the patient’s insurance, whether the patient has identification, or the facility’s services.

OBJ:

NCLEX Client Needs Category: Safe and Effective Care Environment

8. Which of the following is false regarding state licensure laws? a. These laws establish the requirements for licensure to practice. b. Licensure is not necessary if the individual has completed training. c. The state regulatory agencies such as the state board of nursing are responsible for creating and enforcing these rules. d. The scope of practice defines what the professional can and cannot do within the scope of their licensure.

ANS: B

Licensure is required to practice after the completion of all required training for the profession. The state laws establish the requirements to practice and the state regulatory agencies are responsible for creating and enforcing the rules. The scope of practice defines what activities the professional is legally authorized to perform.

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

N