Test Bank for Davis Advantage for Wilkinsons Fundamentals of Nursing V2 5E by Treas,Barnett & Smith

TEST BANK

TEST BANK

Unit 1: How Nurses Think Chapter 1. Evolution of Nursing Thought & Action Chapter 2. Clinical Judgment Chapter 3. The Steps of the Nursing Process Chapter 4. Evidence-Based Practice: Theory and Research Chapter 5. Ethics & Values

Unit 2: Factors Affecting Health Chapter 6. Life Span: Infancy Through Middle Adulthood Chapter 7. Life Span: Older Adults Chapter 8. Promoting Wellness: Health & Illness Chapter 9. Stress & Adaptation Chapter 10. Psychosocial Health & Illness Chapter 11. Promoting Family Health Chapter 12. Caring in Multicultural Healthcare Environments Chapter 13. Spirituality Chapter 14. Experiencing Loss

Unit 3: Essential Nursing Interventions Chapter 15. Communicating & Therapeutic Relationships Chapter 16. Patient Education Chapter 17. Interprofessional Partnerships: Documenting & Reporting Chapter 18. Measuring Vital Signs Chapter 19. Health Assessment Chapter 20. Promoting Asepsis & Preventing Infection Chapter 21. Promoting Safety Chapter 22. Facilitating Hygiene Chapter 23. Administering Medications

Unit 4: Supporting Physiological Function Chapter 24. Nutrition

Chapter 25. Urinary Elimination Chapter 26. Bowel Elimination Chapter 27. Sensation, Perception, & Response Chapter 28. Pain Chapter 29. Physical Activity & Immobility Chapter 30. Sexual Health Chapter 31. Sleep & Rest Chapter 32. Skin Integrity & Wound Healing Chapter 33. Oxygenation Chapter 34. Circulation & Perfusion Chapter 35. Hydration & Homeostasis Chapter 36. Care of the Surgical Patient

Unit 5: Nursing Functions Chapter 37. Community & Home Health Nursing Chapter 38. Nursing Informatics Chapter 39. Legal Accountability Chapter 40. Leading & Managing

Chapter 1. Evolution of Nursing Thought & Action Multiple Choice Identify the choice that best completes the statement or answers the question. ____

1. The nurse is working in a community health promotion clinic. Which is an example of an illness prevention activity?

1. Encouraging the use of a food diary 2. Joining a cancer support group 3. Administering immunization for human papillomavirus (HPV) 4. Teaching a diabetic patient about his diet

____

2. A practicing nurse is aware that continuing education courses may be required for license renewal.

Which organization can require nurses to obtain a specified number of continuing education courses?

1. American Nurses Association 2. National League for Nursing 3. Sigma Theta Tau 4. State board of nursing

____

3. An experienced nurse uses knowledge of patients’ medical conditions and intuition to identify problems and fulfill the role of being a resource for other nurses on the unit. According to Benner, which stage has this nurse achieved?

1. Novice 2. Advanced beginner 3. Competent 4. Expert

____

4. Which statement best explains the importance of standards of practice in the nursing profession?

1. Standards of practice for nurses are the same as for other healthcare professionals.

2. Standards of practice are applied exclusively to nurses working in hospital settings.

3. Standards of practice identify the components nurses need to provide safe care.

4. Standards of practice differ among registered nurses, based on the population they serve.

____

5. The nursing instructor is considering becoming a member of the National League for Nursing (NLN). Which primary goal of the NLN will strongly affect the nurse’s decision to become a member?

1. Emphasizing the necessity for registered nurses to promote patient safety 2. Establishing and maintaining identified standards for nursing education 3. Supporting global health policies and improving health worldwide 4. Fostering nursing scholarship, leadership, and service to improve health Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

____

6. The nurse is providing care for a patient after a debilitating stroke. Which service of care will the nurse recognize as the best choice for this patient?

1. Primary 2. Secondary 3. Tertiary 4. Preventive

____

7. The nurse is providing care for an older adult patient in an acute care setting for various agerelated health issues. When planning for discharge, the patient states concern about being able to adequately provide for health maintenance and some self-care needs. Which type of facility does the nurse recognize as best for this patient?

1. Skilled nursing facility 2. Assisted living facility 3. Nursing home facility 4. Independent living facility

____

8. The nurse understands that the most important reason for the development of a definition for the profession of nursing is that it: 1. Will result in more informed people being recruited as nurses.

2. Is a means for evaluating the degree of role satisfaction in nurses.

3. Helps dispel the stereotypical images about nurses and nursing.

4. Differentiates the nursing role from those of other health professionals.

____

9. Which activity provides evidence-based support for the contribution made by advanced practice nurses (APNs) in healthcare?

1. Reduced use of diagnostics using advanced technology 2. Decreased number of unnecessary visits to the emergency department 3. Improved patient compliance with prescribed treatments 4. Increased use of complementary and alternative therapies

____

10. The nurse is providing care for a pediatric patient in an acute care facility. The patient’s parents express concern about the cost of the medical care. The parents state, “We have jobs, but we don’t make a lot of money and have no insurance.” Which medical assistance program does the nurse recognize as being most appropriate for this family?

1. Children’s Health Insurance Program (CHIP) 2. Medicare 3. Medicaid 4. Local charity

____

11. A patient has started to have difficulty with bathing and grooming. Which therapist would assist the patient in regaining these skills?

1. Physical therapist 2. Occupational therapist 3. Speech-language pathologist Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

4. Respiratory therapist ____

12. An older adult patient is diagnosed with type 1 diabetes mellitus. The patient can perform self-care activities but needs assistance with shopping and meal preparation. As well, assistance is necessary for blood glucose monitoring and insulin administration. Which type of healthcare facility is most appropriate for the patient?

1. Acute care facility 2. Ambulatory care facility 3. Extended care facility 4. Assisted living facility

____

13. The nurse in the intensive care unit is providing care for only one patient, who was admitted with a diagnosis of septic shock. Based on this information, which care delivery model is this nurse following?

1. Functional nursing 2. Primary nursing 3. Case method 4. Team nursing

____

14. The nurse is providing care for a patient who needs acute care, which is being rejected by the patient because of financial and family stressors. Which healthcare worker does the nurse consult to counsel this patient?

1. Social worker 2. Occupational therapist 3. Physician’s assistant 4. Technologist

____

15. Which type of managed care provides patients with the greatest choice of providers, medications, and medical devices?

1. Health maintenance organization 2. Integrated delivery network 3. Preferred provider organization 4. Employment-based private insurance

____

16. The registered nurse is discharging a patient to an assisted living facility. Which statement by the nurse is most appropriate for the patient?

1. “Therapists will work with you daily to help you regain your functional abilities.”

2. “You will be provided with 24-hour nursing care for the next 6 weeks.”

3. “Assistance with meals and housekeeping tasks is available to you.”

4. “A nurse will come to your home and provide you with nursing care.”

____

17. Which member of the healthcare team typically serves as the case manager?

1. Unlicensed assistive personnel (UAP) 2. Physician Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

3. Physician’s assistant 4. Registered nurse ____

18. Which nursing function is considered a primary service of a nurse working in a health department?

1. Providing wound care 2. Administering childhood immunizations 3. Providing drug rehabilitation 4. Providing outpatient hernia repair

____

19. A patient who is 80 years of age is in an acute care facility because of a fractured hip resulting from a fall. Previously, the patient lived at home and managed activities of daily living independently. The patient’s goal is to return to the previous living style. If the patient cannot walk or provide self-care, to which type of facility will the patient be transferred?

1. Nursing home 2. Rehabilitation center 3. Outpatient therapy center 4. Home healthcare

____20. Which characteristic would best define a registered nurse?

1. Graduated from an accredited education program and passed the National Council Licensure Exam (NCLEX) 2. Obtained certification permitting the administration of medications in certain healthcare settings 3. Passed an agency competency exam to provide personal care to patients 4. Received advanced education and license to practice under the direct supervision of a physician ____

21. A nurse who has been practicing for 3 years in an acute care facility is caring for a postsurgical patient. The nurse observes an abnormal change in vital signs and associates these changes with a postoperative bleeding problem. Which level of proficiency is the nurse demonstrating?

1. Advanced beginner 2. Competent 3. Proficient 4. Expert

____

22. Which agency is responsible for nurse practice acts?

1. American Nurses Association 2. Institute of Medicine 3. Boards of Nursing 4. National League for Nursing

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

____

23. A nurse is recently hired at an acute care facility. During orientation, the nurse is given a chart describing each person’s role on the assigned unit. The chart reflects that registered nurses are responsible for all admission and discharge assessments and patient treatments. Licensed practical nurses (LPNs) administer medications, and certified nursing assistants (CNAs) obtain vital signs and perform personal care. Which model of care does the nurse recognize?

1. Case method 2. Team nursing 3. Primary nursing 4. Functional nursing

____

24. A patient is in the hospital for exacerbation of a chronic condition and requires a consultation and education on chronic disease management. Which advanced practice nurse would best provide the consultation and education?

1. Clinical nurse specialist 2. Physician’s assistant 3. Nurse practitioner 4. Certified registered nurse anesthetist

____

25. A patient is preparing to be discharged after total knee replacement. The patient tells the case manager, “I feel pretty good, but I am having a hard time getting in and out of the bathroom.”

Which is the most appropriate response by the case manager?

1. “I’ll be sure to teach your family how to help you with this.”

2. “Once you are home for a while, it will get easier.”

3. “I can have a recreational therapist help you take your mind off your concerns.”

4. “An occupational therapist can be ordered to assist you in this area.”

____

26. An older adult patient is preparing for discharge and tells the case manager, “I don’t know what I am going to do when I get home. I cannot afford the medications the doctor has ordered for me.”

Which is the most appropriate response by the case manager?

1. “We can have a social worker see you when you get home.”

2. “Medications are expensive, but you will need to take them.”

3. “I will check if some of the medications can be discontinued.”

4. “The home health nurse will address this when she sees you.”

____

27. A patient in an ambulatory clinic tells the nurse, “Every visit costs me $10, even though I have insurance.” Which is the most appropriate response by the nurse?

1. “I am not involved in your insurance; you need to contact the insurance company.”

2. “Let’s check if this is a copayment described by your insurance plan for each visit.”

3. “Healthcare is expensive, and insurance companies can’t pay all of the costs.”

4. “This charge is actually part of the insurance premium that you pay monthly.”

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

____

28. The nursing staff on a surgical unit expresses to the manager concerns about not having enough time to complete all wound care and dressing changes. Which is the initial action the manager takes?

1. Decrease the patient-to-nurse ratio within budget limits 2. Offer an in-service session on time-management strategies 3. Suggest a continuing quality improvement committee to assess the issue 4. Report to the physician the need to decrease the number of dressing changes

Multiple Response Identify one or more choices that best complete the statement or answer the question. ____

29. Which activities indicate the implementation of direct nursing care? Select all that apply.

1. Bathing a patient 2. Administering a medication 3. Teaching a patient to change a wound dressing 4. Making work assignments for the shift 5. Evaluating patient progress toward goals

____

30.

____

31. To reflect the changes in healthcare and nurses’ expanded roles, the International Council of Nurses revised the definition of nursing. Which statements are consistent with the revised definition of nursing? Select all that apply.

1. Nursing encompasses the autonomous and collaborative care of others.

2. Nursing includes the care of ill, disabled, and dying people.

3. Nursing is involved in shaping health policy and system management.

4. Nursing involves the use of the nursing process to plan care.

5. Nursing requires knowledge regarding the process of nursing education.

____

32. According to the American Nurses Association (ANA), which statements best describe the characteristics of registered nursing? Select all that apply.

1. Nursing practice is individualized.

2. Nursing practice is similar to medical practice.

3. Caring is central to the practice of the registered nurse.

4. Nurses coordinate care by establishing partnerships.

5. Nurses promote health through political involvement.

Which of the following are current trends that are affecting nursing practice? Select all that apply.

1. Providing high-quality care 2. Increasing the older adult population 3. Using complementary and alternative medicine 4. Defining nursing 5. Collaborating on interdisciplinary teams

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

____

33. The field of nursing has struggled to prove that nursing is a profession. Which strategies to improve the status of nursing will promote professionalism? Select all that apply.

1. Standardizing the educational requirements for entry into practice 2. Mandating uniform continuing education requirements for licensure 3. Guaranteeing that all nurses will obtain employment upon graduation 4. Encouraging participation of nurses in professional organizations 5. Educating the public about the true nature of nursing practice

____

34. Which topics are included in the processes of thinking and implementing used by the nurse? Select all that apply.

1. Critical thinking 2. Pain evaluation 3. Clinical judgment 4. Problem-solving 5. Sterile technique

Completion Complete each statement.

35. ____________________ is a health program, administered by the state and funded by federal and state governments, to provide care for low-income people.

36. ____________________ is a federal insurance program designed to fund healthcare for people age 65 years and older, persons with disabilities, and those with end-stage renal disease.

37. ____________________ project is one of the organizations that has identified competencies students are expected to acquire before graduation.

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Chapter 1. Evolution of Nursing Thought & Action Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Name and recognize the four purposes of nursing care.

Page: Vol 1, p. 18 Heading: The Healthcare Delivery System >How Is Healthcare Categorized?>Nursing and Illness Prevention Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 This is incorrect. Illness prevention activities focus on avoiding a specific disease. Keeping a food diary is a health promotion activity.

2 This is incorrect. Although cancer is a disease, it is assumed that a person joining a support group would already have the disease; therefore, it would be treatment and not disease prevention.

3 This is correct. Administering immunization for HPV is an example of illness prevention.

4 This is incorrect. Teaching a diabetic patient about diet is a treatment for diabetes; the patient already has diabetes, so the teaching cannot prevent diabetes.

PTS: 1 CON: Health Promotion 2. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Explain how nursing practice is regulated Page: Vol 1, p. 12 Heading: Contemporary Nursing: Education, Regulation, and Practice >How Do Nurses’ Education Paths Differ?> Other Forms of Formal Education Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Concept: Professionalism Difficulty: Moderate

1

2

3

4

Feedback This is incorrect. The American Nurses Association is a professional organization that creates standards for nursing care. The. ANA does not mandate continuing education. However, the organization may offer continuing education units (CEUs) to fulfill education requirements.

This is incorrect. The National League for Nursing is a professional organization that serves as the voice of faculty and does not mandate continuing education.

However, the organization may offer continuing education units (CEUs) to fulfill education requirements.

This is incorrect. Sigma Theta Tau is a professional honor society and does not mandate continuing education. However, the organization may offer continuing education units (CEUs) to fulfill education requirements.

This is correct. Continuing education is a professional strategy that ensures nurses remain current in their clinical knowledge. Many states require nurses to engage in a certain number of continuing education requirements to renew their license. Requirements for renewal of a nurse’s license can be found in the state’s nurse practice act (state board of nursing).

PTS: 1 CON: Professionalism 3. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Differentiate between the various forms of nursing education.

Page: Vol 1, p. 12-13 Heading: Contemporary Nursing: Education, Regulation, and Practice >How Do Nurses’ Educational Paths Differ?>Benner’s Model Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. The novice nurse is inexperienced and relies on rules and processes.

2 This is incorrect. The advanced beginner focuses on aspects of a situation and is unable to see the comprehensive perspective.

3 This is incorrect. A nurse functioning at the competent level is able to prioritize to meet patient needs but does not fully grasp the total situation.

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4

This is correct. The nurse who has reached the expert stage of proficiency has a deep understanding of the clinical situation based on knowledge and experience.

The nurse often senses a potential problem in the absence of classic signs and symptoms.

PTS: 1 CON: Professionalism 4. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Explain how nursing practice is regulated.

Page: Vol 1, p. 13 Heading: Contemporary Nursing: Education, Regulation, and Practice > How is Nursing Practice Regulated?>Standards of Practice Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. Nursing standards of practice are exclusive to the profession of nursing; standards of nursing practice are not shared with other healthcare professionals.

2 This is incorrect. The standards of practice for nursing are applicable regardless of the setting in which nursing care is provided.

3 This is correct. Standards of practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. Standards are derived from several sources, including professional organizations and healthcare facilities’ policies and procedures.

4 This is incorrect. The standards of practice for nursing are applicable regardless of the population receiving nursing care.

PTS: 1 CON: Professionalism 5. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Give four examples of influential nursing organizations.

Page: Vol 1, p. 14 Heading: Contemporary Nursing: Education, Regulations, and Practice>What Are Some Important Nursing Organizations? >National League for Nursing Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Difficulty: Moderate Feedback 1 This is incorrect. The American Nurses Association (ANA) is the official professional organization for nurses in the United States. Originally, the ANA focused on establishing standards of nursing to promote high-quality care and working toward licensure to ensure adherence to the standards; both of these actions focus on patient safety.

2 This is correct. The National League for Nursing (NLN) was founded to establish and maintain a universal standard of nursing education. The NLN focuses on faculty development in nursing education programs and is the voice for nursing education.

3 This is incorrect. The International Council of Nursing (ICN) represents more than 20 million nurses on a global level. It is composed of a federation of national nursing organizations from more than 130 nations. The ICN aims to ensure quality nursing care for all.

4 This is incorrect. The goal of Sigma Theta Tau International is to foster nursing scholarship, leadership, service, and research to improve health worldwide.

PTS: 1 CON: Professionalism 6. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe how person-centered care is the foundation of professional nursing Page: Vol 1, p. 18 Heading: The Healthcare Delivery System > How Is Healthcare Categorized?

Integrated Processes: Nursing Process Client Need: Health Promotion and Management Cognitive Level: Analysis [Analyzing] Concept: Health Promotion Difficulty: Difficult Feedback 1 This is incorrect. Primary care involves health promotion and illness prevention.

A patient who has had a debilitating stroke will need more intensive care.

2 This is incorrect. Secondary care is available for patients who require support or rehabilitation over a limited time. A patient may require secondary care after a joint replacement.

3 This is correct. Tertiary care is required for individuals who need long-term care or for those who are dying. After a debilitating stroke, this patient is most likely to require long-term care.

4 This is incorrect. Preventive care is provided as an effort to prevent disease and illness; after a stroke, the patient is no longer considered for preventive care alone.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

PTS: 1 CON: Health Promotion 7. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p. 17 Heading: The Healthcare Delivery System > Where Is Care Provided? > Extended Care Facilities > Assisted Living Facilities Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 This is incorrect. The question does not include information regarding the patient care needs after discharge; therefore, this option is not a good choice.

Skilled care facilities include services of trained professionals who are needed for a limited time after an injury or illness (e.g., wound care, intravenous infusions). Services are provided to clients who no longer need 24-hour acute care services and who can be expected to improve with treatment.

2 This is correct. An assisted living facility is designed to bridge the gap between independence and institutionalization for older adults who have a decline in health status and cannot live independently. Residents of these facilities are able to perform self-care activities but require assistance with meals, housekeeping, or medications. Because skilled care is usually not required, nurses have a limited presence at assisted living sites. The patient expresses concern over the ability to provide adequate self-care.

3 This is incorrect. There is no information to support the patient needing nursing home care, which provides custodial care for people who cannot live on their own but are not sick enough to require hospitalization. They may be a permanent home for people who require continual supervision to ensure their safety. Residents are offered a provider to supervise care, recreational activities, and salon services.

4 This is incorrect. Independent living facilities are designed for seniors 55 years or older who (a) are independent in all aspects and (b) want to live in a community with other senior citizens. Services usually include a peer support network that provides socialization opportunities, structured recreational activities, transportation arrangements, fitness centers, pools, and quiet environments. Nurses may provide periodic health screening and health information. The patient’s expressed concern does not support this type of extended care.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

PTS: 1 CON: Safety 8. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Define nursing in your own words.

Page: Vol 1, p. 9 Heading: Contemporary Nursing: Education, Regulation, and Practice > How is Nursing Defined? > Why Is a Definition Important?

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. A definition of nursing is not likely to increase the number of informed people recruited into nursing.

2 This is incorrect. A definition of nursing would do little to improve the nurse’s role satisfaction.

3 This is incorrect. Although a definition of nursing might contribute to fighting stereotypes of nursing, other, more powerful influences (e.g., media portrayals) exist to counteract it.

4 This is correct. Nursing organization leaders think it is important to develop a definition of nursing to bring value and understanding to the profession, differentiate nursing activities from those of other healthcare professionals, and help student nurses understand what is expected of them.

PTS: 1 CON: Evidence-Based Practice 9. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Delineate the forces and trends affecting contemporary nursing practice.

Page: Vol 1, p. 26 Heading: Factors That Influence Contemporary Nursing Practice >What Are Some Trends in Nursing and Healthcare? > Expanded Career Roles for Nurses > Advanced Practice Nurses (APNs) Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Healthcare System Difficulty: Moderate Feedback 1 This is incorrect. No well-known scientific studies support APNs’ effect on the use of advanced technology.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

2 3

4

This is incorrect. No well-known scientific studies support APNs’ effect on the frequency of emergency department visits.

This is correct. Studies demonstrate that APNs have achieved improved patient outcomes compared with those of physicians, including increased patient understanding and cooperation with treatments and decreased need for hospitalizations.

This is incorrect. No well-known scientific studies support APNs’ effect on the use of alternative therapies.

PTS: 1 CON: Healthcare System 10. ANS: 1 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Discuss issues related to healthcare reform.

Page: Vol 1, p. 21 Heading: The Healthcare Delivery System > How Is Healthcare Financed? > Government (Public) Financing> Children’s Health Insurance Program (CHIP) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Leadership and Management Difficulty: Difficult Feedback 1 This is correct. CHIP is a joint venture between the federal government and states. CHIP provides health insurance to millions of children whose family income exceeds Medicaid eligibility criteria but who cannot afford private insurance and are not covered under a parent’s policy. The nurse recognizes this program as the most appropriate one for this family.

2 This is incorrect. Medicare is a federal insurance program created by Title XVIII of the Social Security Act of 1965. This act is designed to provide insurance coverage for persons age 65 years and older and later expanded to include younger people with permanent disabilities, such as end-stage renal disease.

3

4

This is incorrect. Medicaid was developed under Title XIX of the Social Security Act of 1965 to provide access to healthcare services for people with low incomes and minimal resources. Medicaid offers a fairly comprehensive set of benefits, including prescription drugs, skilled care, and long-term care.

This is incorrect. The nurse is aware that charitable organizations are an increasingly important funding source for healthcare. Community agencies that are funded through networks, such as the United Way, Salvation Army, and Red Cross, provide important resources for children, poor families, older adults, and vulnerable populations, such as the homeless, mentally ill, and victims of violence. This is the second-most appropriate program for this family.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

PTS: 1 CON: Leadership and Management 11. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p. 19 Heading: The Healthcare Delivery System> Who Are the Members of the Interprofessional Healthcare Team?

Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension (Understanding) Concept: Collaboration Difficulty: Moderate

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4

Feedback This is incorrect. Physical therapists focus on the rehabilitation of muscles and bones and helping clients gain optimal functioning in self-care skills for activities of daily living and learn how to use assistive devices.

This is correct. Occupational therapists help patients to regain and maintain function and independence with activities of daily living, such as dressing, bathing, and grooming.

This is incorrect. Speech-language pathologists provide assistance to clients experiencing swallowing and speech disturbances (e.g., developing speech and language skills after neurological impairment).

This is incorrect. Respiratory therapists provide respiratory treatments that have been prescribed by physicians or advance practice nurses (e.g., oxygen therapy, mechanical ventilation).

PTS: 1 CON: Collaboration 12. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p. 17 Heading: The Healthcare Delivery System> Where Is Care Provided?> Extended Care Facilities > Assisted Living Facilities Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Healthcare System Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Difficulty: Moderate Feedback 1 This is incorrect. Acute care facilities focus on preventing illnesses and treating acute problems. These facilities include physicians’ offices, clinics, and diagnostic centers.

2 This is incorrect. Ambulatory care facilities provide outpatient care. Clients live at home or in nonhospital settings and come to the site for care. Ambulatory care facilities include private health and medical offices, clinics, surgery centers, and outpatient therapy centers.

3 This is incorrect. Extended care facilities typically provide long-term care, rehabilitation, wound care, and ongoing monitoring of patient conditions.

4 This is correct. Assisted living facilities are intended for those who are able to perform self-care activities but require assistance with meals, housekeeping, or medications.

PTS: 1 CON: Healthcare System 13. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p. 16 Heading: Contemporary Nursing: Education, Regulation, and Practice> Nursing Practice: Caring for Clients>What Models of Care Are Used to Provide Nursing Care?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Healthcare System Difficulty: Moderate Feedback 1 This is incorrect. When the functional nursing model is employed, care is compartmentalized, and each task is assigned to a staff member with the appropriate knowledge and skills.

2 This is incorrect. In primary nursing, one nurse plans the care for a group of patients around the clock. The primary nurse assesses the patient and develops the plan of care. When this nurse is working, he or she provides care for those patients for whom he or she is responsible. In the absence of this nurse, the associate nurses deliver care. Although the nurse in this case could possibly be a primary nurse, there are not enough data to confidently infer that.

3 This is correct. The nurse is following the case method model of nursing care. In this model, one nurse cares for one patient during a single shift.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

4

This is incorrect. If the team nursing approach is employed, a licensed nurse (registered nurse [RN] or licensed vocational nurse [LVN]) is paired with a nursing assistant. The pair is then assigned to a group of patients.

PTS: 1 CON: Healthcare System 14. ANS: 1 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p. 20 Heading: The Healthcare Delivery System > Who Are the Members of the Interprofessional Healthcare Team?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Heathcare System Difficulty: Moderate Feedback 1 This is correct. The social worker coordinates services and provides psychosocial support.

2 This is incorrect. The occupational therapist helps patients regain function and independence for activities of daily living.

3 This is incorrect. Physician’s assistants work under the physician’s direction to diagnose certain diseases and injuries.

4 This is incorrect. Technologists provide a variety of specific functions in hospitals, diagnostic centers, and emergency care. For example, laboratory technologists aid in the diagnosis and treatment of patients by examining blood, urine, tissue, and body fluids. Radiology technologists perform x-rays and other diagnostic testing.

PTS: 1 CON: Healthcare System 15. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p. 22 Heading: The Healthcare Delivery System> How Have Healthcare Reform Efforts Affected Care?> Managed Care Integrated Processes: Nursing Process Client Need: The Healthcare Delivery System> Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Concept: Healthcare System Difficulty: Moderate Feedback 1 This is incorrect. Health maintenance organizations allow the patient to choose a primary care provider within an organization to coordinate their care. This type of program will reimburse medical care only when the patient has first obtained a referral from the primary provider.

2 This is incorrect. Integrated delivery networks combine providers, healthcare facilities, pharmaceuticals, and services into one system, and the patient must remain within the system to receive care.

3 This is correct. Preferred provider organizations are a form of managed care that allows the patient a greater choice of providers, medications, and medical devices within the designated list.

4 This is incorrect. Employment-based private insurance is not a managed care organization.

PTS: 1 CON: Healthcare System 16. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p.17 Heading: The Healthcare Delivery System > Where Is Care Provided? > Extended Care Facilities > Assisted Living Facilities Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Rehabilitation centers have a team of therapists who work with patients to help them achieve their optimal functional status. This can be an inpatient or outpatient service.

2 This is incorrect. Hospitals, skilled nursing units, and other acute care facilities provide 24-hour nursing care.

3 This is correct. Assisted living facilities are designed to bridge the gap between independence and institutionalization for persons who have a decline in health status. The assistance available will vary, based on the facility, but commonly involves meals and housekeeping tasks.

4 This is incorrect. Home care, even with nurse visitations, is not classified as care with assistance. The question states that the patient is being discharged to an assisted living facility.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

PTS: 1 CON: Communication and Documentation 17. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p.19 Heading: The Healthcare Delivery System> Who Are the Members of the Interprofessional Healthcare Team?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Healthcare System Difficulty: Easy Feedback 1 This is incorrect. UAPs provide custodial care under the direction of nurses and providers in a variety of settings.

2 This is incorrect. Physicians are considered team leaders for an inpatient, and their primary role is to make a medical diagnosis and outline a treatment plan.

Physicians are licensed as medical doctors (MD) or doctors of osteopathy (DO).

Their role is to diagnose and treat diseases and illnesses through medical and surgical services.

3 This is incorrect. Physician’s assistants diagnose and treat certain diseases and injuries. Because they are not independently licensed, they must practice under the supervision of a physician.

4 This is correct. Typically, registered nurses serve as case managers for patients with specific diagnoses. Their role is coordination of care across the healthcare system.

PTS: 1 CON: Healthcare System 18. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p.18 Heading: The Healthcare Delivery System>How Is Healthcare Categorized?

Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

1 2 3 4

This is incorrect. Wound care and drug rehabilitation are examples of tertiary care services.

This is correct. Primary care services focus on health promotion and disease prevention; administering childhood immunizations is one such service.

This is incorrect. Wound care and drug rehabilitation are examples of tertiary care services.

This is incorrect. Outpatient hernia repair surgery is an example of a secondary care service.

PTS: 1 CON: Health Promotion 19. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p.17 Heading: The Healthcare Delivery System>Where Is Care Provided?>Extended Care Facilities Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Healthcare System Difficulty: Difficult Feedback 1 This is incorrect. A nursing home provides custodial care for people who cannot live on their own but who are not sick enough to require hospitalization. It provides a room, custodial care, and opportunity for recreation.

2 This is correct. A skilled nursing facility (e.g., a rehabilitation center) primarily provides skilled nursing care for patients who can be expected to improve with treatment. For example, a patient who no longer needs hospitalization may transfer to a skilled nursing facility until able to return home.

3 This is incorrect. This patient cannot ambulate or perform activities of daily living, so outpatient therapy and home care would not be appropriate.

4 This is incorrect. This patient cannot ambulate or perform activities of daily living, so outpatient therapy and home care would not be appropriate.

PTS: 1 CON: Healthcare System 20. ANS: 1 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Discuss the transitions that nursing education has undergone in the last century.

Page: Vol 1, p.10 Heading: Contemporary Nursing: Education, Regulation, and Practice > How Is Nursing Defined?> Formal Education Integrated Processes: Teaching and Learning Copyright © 2024 by F.A. Davis Company

All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is correct. The best legal description of a nurse is one who has graduated from an accredited nursing education program and has passed the NCLEX-RN exam.

2 This is incorrect. Persons certified to administer medications may be certified medication technicians and not necessarily nurses.

3 This is incorrect. Although nurses learn how to provide personal care in their nursing schools, certified nursing assistants pass a written competency exam on these topics 4 This is incorrect. Practicing under the direct supervision of a physician is descriptive of a physician’s assistant or of a nurse practitioner; both positions require advanced education.

PTS: 1 CON: Professionalism 21. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Define nursing in your own words.

Page: Vol 1, p.12 Heading: Contemporary Nursing: Education, Regulation, and Practice> How Do Nurses’ Educational Paths Differ?> Informal Education > Benner’s Model Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 This is incorrect. The advanced beginner can distinguish abnormal findings but cannot readily understand their significance.

2 This is correct. The nurse is demonstrating competency (competent) level, as evidenced by associating abnormal changes in vital signs with postoperative bleeding. Additionally, this nurse has been practicing for 3 years, which is within the range needed for the competency proficiency level.

3 This is incorrect. The proficient nurse recognizes problems but will immediately gather resources to initiate treatment; there is no evidence in the scenario that the nurse took any actions.

4 This is incorrect. The expert can often recognize a problem in the absence of signs and symptoms.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

PTS: 1 CON: Evidence-Based Practice 22. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Explain how nursing practice is regulated.

Page: Vol 1, p.13 Heading: Contemporary Nursing: Education, Regulation, and Practice> How Is Nursing Practice Regulated?

Integrated Processes: Teaching and Learning Client Need: Safe and Effective Nursing Care Cognitive Level: Comprehension [Understanding] Concept: Professionalism Difficulty: Easy Feedback 1 This is incorrect. The American Nurses Association is a professional organization responsible for guiding and improving nursing practice, usually by setting standards of practice and establishing a nursing code of ethics.

2 This is incorrect. The Institute of Medicine provides information and advice concerning health and science policy, for example, its involvement in the project Quality and Safety Education for Nurses.

3 This is correct. Each state board of nursing is responsible for enacting and enforcing the nurse practice act of its state.

4 This is incorrect. The National League for Nursing sets standards for all nursing education.

PTS: 1 CON: Professionalism 23. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p.16 Heading: Contemporary Nursing: Education Regulation and Practice> Nursing Practice: Caring for Clients>What Models of Care Are Used to Provide Nursing Care?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment Cognitive Level: Application [Applying] Concept: Healthcare System Difficulty: Moderate

1

Feedback This is incorrect. In the case method model, one nurse cares for one patient during a single shift.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

2 3

4

This is incorrect. In the team model, a nurse is paired with an LPN or a CNA. The team is then assigned to a specific group of patients.

This is incorrect. Primary nursing is a method where one nurse manages care for a group of patients. The primary nurse assesses the patient and develops a plan of care. In the absence of the primary nurse, associate nurses deliver care and implement the plan developed by the primary nurse.

This is correct. The nurse recognizes this practice as the functional model of care in which care is compartmentalized and each employee is assigned specific tasks and roles with the associated knowledge and skill.

PTS: 1 CON: Healthcare System 24. ANS: 1 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Name nine expanded roles of nurses.

Page: Vol 1, p.26 Heading: Factors That Influence Contemporary Nursing Practice> What Are Some Trends in Nursing and Healthcare?>Expanded Career Roles for Nurses > Advanced Practice Nurses (APNs) Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension (Understanding) Concept: Evidence-Based Practice Difficulty: Moderate

1

2 3

4

Feedback This is correct. Clinical nurse specialists (CNSs) may provide direct patient care; consult on care; engage in client, family, community, or staff teaching; and/or conduct research.

This is incorrect. A physician’s assistant is not a nursing role.

This is incorrect. Nurse practitioners (NP) assess, diagnose, and treat diseases and illnesses and prescribe medications and treatments independently or in practice with a provider.

This is incorrect. Nurse anesthetists conduct perioperative screening and evaluation for clients, administer anesthesia during surgery, and evaluate clients’ responses to anesthesia in the postoperative period.

PTS: 1 CON: Evidence-Based Practice 25. ANS: 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p.19 Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Heading: The Healthcare Delivery System>Who Are the Members of the Interprofessional Healthcare Team?

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Leaderships and Management Difficulty: Moderate

1

2 3

4

Feedback This is incorrect. Teaching the family how to assist with toileting is not typically the role of the case manager. Additionally, this does not assist the patient regarding the immediate concern of toileting.

This is incorrect. Reassurance is important and positive, but the patient first needs assistance with toileting.

This is incorrect. Recreational therapists promote patients’ physical, social, and emotional well-being through the use of leisure activities. There is no indication that this patient is in need of a recreational therapist.

This is correct. The patient is expressing a concern for managing toileting at home. Upon discharge, the therapy that focuses most closely on activities of daily living is occupational therapy.

PTS: 1 CON: Leadership and Management 26. ANS: 1 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p.20 Heading: The Healthcare Delivery System> Who Are the Members of the Interprofessional Healthcare Team?

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Leadership and Management Difficulty: Moderate

1

Feedback This is correct. Social workers counsel patients on financial, housing, marital, and family issues affecting healthcare. Because of rising healthcare costs and diminished access to healthcare, particularly for aging populations, social workers are increasingly being used to help move clients through the healthcare system.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

2 3

4

This is incorrect. Acknowledging the rising costs of medications does not assist the patient in solving the problem of his ability to pay for medications.

This is incorrect. The case manager cannot make any assumption that to alleviate the patient’s concerns about affording medications, it might be appropriate to have some medications discontinued.

This is incorrect. The home health nurse typically coordinates the care and services but is not typically the healthcare provider addressing financial concerns.

PTS: 1 CON: Leadership and Management 27. ANS: 2 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p.20 Heading: The Healthcare Delivery System> How Is Healthcare Financed?

Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Leadership and Management Difficulty: Moderate

1

2

3 4

Feedback This is incorrect. Most facilities have access to the patient’s coverage plan and can answer immediate questions until the patient is able to follow up with the insurance company.

This is correct. Those who have insurance or government-financed insurance bear some of the expenses of healthcare through cost sharing. Typical cost sharing can be in the form of copays, deductibles, paying a portion of one’s insurance premium, or paying costs above a fixed payment amount. Patients do not always understand cost-sharing methods and may need an explanation at the time of the visit. The best response is for the nurse to explain what a copayment is.

This is incorrect. Stating that healthcare is expensive is merely stating the obvious; it may also be perceived as defensive rather than supportive.

This is incorrect. Copayments are typically not part of an insurance premium and are collected only at the time of a service.

PTS: 1 CON: Leadership and Management 28. ANS: 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p.23 Heading: The Healthcare Delivery System> How Do Providers and Facilities Ensure Quality Care?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Quality Improvement Difficulty: Difficult

1

2

3

4

PTS:

Feedback This is incorrect. There may be a need to look at nurse–patient ratios, and there may be a need to provide an in-service session on time management. However, these are not known until some assessment is completed and data are obtained.

This is not the manager’s initial action.

This is incorrect. Total quality management (TQM) or continuous quality improvement (CQI) projects assist in looking at all aspects of quality and safe care practices. Offering a session on time management may be useful; however, it is not the initial action taken by the manager.

This is correct. The most appropriate action by the nurse manager is to assess the issue through establishing some quality improvement/quality care activities in the form of an appointed committee. Assessment is always the initial action taken when evaluating an issue or concern.

This is incorrect. Reporting the concern to the director of nurses may be indicated, but this will not immediately address the concerns of the staff. The initial action is for assessment. If dressing changes are needed, then they need to be performed to improve outcomes. Physicians should not be notified of the concern.

1

CON: Quality Improvement

MULTIPLE RESPONSE 29. ANS: 1, 2, 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p.14 Heading: Contemporary Nursing: Education, Regulation, and Practice> Nursing Practice: Caring for Clients Integrated Processes: Caring Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

1.

2.

3.

4.

5.

Feedback This is correct. Direct care involves personal interaction between nurses and clients (e.g., bathing a patient, giving medications, dressing a wound, or teaching a client about medicines or care).

This is correct. Direct care involves personal interaction between nurses and clients (e.g., bathing a patient, giving medications, dressing a wound, or teaching a client about medicines or care).

This is correct. Direct care involves personal interaction between nurses and clients (e.g., bathing a patient, giving medications, dressing a wound, or teaching a client about medicines or care).

This is incorrect. Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, or arranging unit staffing).

This is incorrect. Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, evaluating the patient, or arranging unit staffing).

PTS: 1 CON: Professionalism 30. ANS: 2, 3, 5 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective Delineate the forces and trends affecting contemporary nursing practice Page: Vol 1, p. 23-27 Heading: Factors That Influence Contemporary Nursing Practice Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Trends in Nursing Difficulty: Difficult

1.

2.

Feedback This is incorrect. Improving quality of care is not an emerging trend in nursing practice. Nurses do need to participate in quality improvement programs.

This is correct. The number of older adults is increasing and is expected to grow over the next several years.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

3.

4.

5.

This is correct. There is growing interest in complementary and alternative medicine (CAN) for various reasons including the costs of traditional care and increasing cultural diversity in the population.

This is incorrect. It is important for nurses to articulate clearly what nursing is and what nurses do, but this is not a trend.

This is correct. Nursing has changed from a largely supportive role to one of increasing responsibility. Interprofessional teamwork is essential to achieving safe, high-quality client outcomes.

PTS: 1 CON: Trends in Nursing 31. ANS: 1, 2, 3 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Define nursing in your own words.

Page: Vol 1, p. 8 Heading: Contemporary Nursing: Education, Regulation, and Practice>How Is Nursing Defined?

Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

1.

2.

3.

4.

5.

Feedback This is correct. The International Council of Nursing (ICN) definition of nursing includes the autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings.

This is correct. In addition to caring for ill, disabled, and dying persons, nurses are expected to promote health and prevent illness.

This is correct. Key nursing roles include advocacy, education, research, promotion of a safe environment, and participation in shaping health policy and in healthcare systems management.

This is incorrect. The ICN definition does not mention that registered nurses use the nursing process to plan and individualize care.

This is incorrect. The ICN definition does not mention that registered nurses should have knowledge of the process of nursing education.

PTS: 1 CON: Professionalism 32. ANS: 1, 3, 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Define nursing in your own words.

Page: Vol 1, p. 9 Heading: Contemporary Nursing: Education, Regulation, and Practice> How Is Nursing Defined?

Integrated Processes: Teaching and Learning Copyright © 2024 by F.A. Davis Company

All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

1.

2.

3.

4.

5.

Feedback This is correct. In 2010, the ANA acknowledged five characteristics of the registered nurse. Nursing practice is individualized.

This is incorrect. The ANA does not acknowledge that nursing practice is similar to medical practice.

This is correct. In 2010, the ANA acknowledged five characteristics of the registered nurse. Nurses coordinate care by establishing partnerships with others.

This is correct. In 2010, the ANA acknowledged five characteristics of the registered nurse. Caring is central to the practice of the registered nurse.

This is incorrect. The ANA does not acknowledge that nurses promote health through political involvement.

PTS: 1 CON: Professionalism 33. ANS: 1, 2, 4, 5 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Delineate the forces and trends affecting contemporary nursing practice.

Page: Vol 1, p. 9 Heading: Contemporary Nursing: Education, Regulation, and Practice>How Is Nursing Defined?> Is Nursing a Profession, Discipline, or Occupation?

Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

1.

2.

3.

4.

5.

Feedback This is correct. A suggestion to improve the professional status of nursing includes standardizing educational requirements for entry to practice.

This is correct. A suggestion to improve the professional status of nursing includes mandating uniform continuing education requirements.

This is incorrect. There are no regulating bodies or professional organizations that equate guaranteeing employment with improving the status of nursing, nor is it likely it would be possible to do that.

This is correct. A suggestion to improve the professional status of nursing includes encouraging participation of more nurses in professional organizations.

This is correct. A suggestion to improve the professional status of nursing includes educating the public about the true nature of nursing practice.

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

PTS: 1 CON: Professionalism 34. ANS: 1, 3, 4 Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Delineate the forces and trends affecting contemporary nursing practice.

Page: Vol 1, p. 7 Heading: Historical Leaders Who Advanced the Profession of Nursing> Nursing Today: FullSpectrum Nursing>Application of Knowledge, Skill, and Caring Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

1.

2.

3.

4.

5.

PTS:

Feedback This is correct. Critical thinking is a reflective thinking process that involves collecting information, analyzing the adequacy and accuracy of the information, and carefully considering options for action. Nurses use critical thinking in every aspect of nursing care.

This is incorrect. Pain evaluation is a process of assessment involving critical thinking, clinical judgment, and problem-solving.

This is correct. Clinical judgment is a process in nursing that involves observing, comparing, contrasting, and evaluating the client’s condition to determine whether change has occurred. It also involves careful consideration of the client’s health status in light of what is expected based on the client’s condition, medications, and treatment. These actions are collectively known as the nursing process.

This is correct. Problem-solving is a process by which nurses consider an issue and attempt to find a satisfactory solution to achieve the best outcomes. Nurses often use problem-solving in professional life. The nursing process is one type of problemsolving process.

This is incorrect. Sterile technique is a nursing skill based on critical thinking, clinical judgment, and problem-solving abilities.

1

CON: Professionalism

COMPLETION 35. ANS: Medicaid Chapter: Chapter 1 Evolution of Nursing Thought & Action Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p. 20-21 Heading: The Healthcare Delivery System> How Is Healthcare Financed?

Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate Feedback: Medicaid is a health program run by the state and funded by the federal and state governments. It is intended to provide preventive and acute healthcare for individuals, in particular pregnant women and children, who are unable to pay for services.

PTS: 1 36. ANS: Medicare

CON: Health Promotion

Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare.

Page: Vol 1, p. 20 Heading: The Healthcare Delivery System> How Is Healthcare Financed?

Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate Feedback: Medicare is a federal insurance program created by Title XVIII of the Social Security Act of 1965. This act was designed to protect people age 65 years and older from the high cost of healthcare. In 1972, the program was expanded to cover workers with disabilities as well as people with end-stage renal disease.

PTS:

1

CON: Health Promotion

37. ANS: The Quality and Safety Education for Nurses Chapter: Chapter 1 Evolution of Nursing Thought & Action Objective: Discuss the transitions that nursing education has undergone in the last century.

Page: Vol 1, p. 6 Heading: Historical Leaders Who Advanced the Profession of Nursing>Nursing Today: FullSpectrum Nursing > Safe, Effective Nursing Care Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Professionalism Difficulty: Moderate Feedback The Quality and Safety Education for Nurses project (QSEN) is one of the organizations that has identified competencies students are expected to acquire before graduation. It is an initiative that emphasizes quality and safety so students will be able to deliver safe, effective nursing care.

PTS:

1

CON: Professionalism

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Chapter 2. Clinical Judgment Multiple Choice Identify the choice that best completes the statement or answers the question.

1. For which patient would it be most important to perform acomprehensive discharge plan?

1) A teen who is a first-time mother, single, and lives with her parents 2) An older adult who has had a stroke affecting the left side of his body and livesalone 3) A middle-aged man who has had outpatient surgery on his knee and requires crutches 4) A young woman who was admitted to the hospital for observation following an accident ANS: 2 A comprehensive discharge plan should be developed for older adults and anyone who has complex needs, including self-care deficits. The other patientsdo not have the complex needs of the older adult patient who has had a strokethat affects body function.

PTS:1DIF:ModerateREF:p. 83 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis 2. The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful?

1) Start planning at admission.2) Involve the family members.3) Get patient input when making the plan.4) Involve the multidisciplinary team.ANS: 3 The discharge plan may be developed in a timely manner and involve the familyand a multidisciplinary team, but if the patient does not agree with the plan, it will not be successful.

PTS: 1 DIF: Moderate REF: pp. 83| p. 87 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 3. What do initial, ongoing, and discharge planning have in common?1) They are based on assessment and diagnosis.2) They focus on the patients perception of his needs.3) They require input from a multidisciplinary team.4) They have specific timelines in which to be completed.ANS: 1 All planning is based on nursing assessment data and identified nursing diagnoses.

4) The patient should have input, but the planning is based on the nursing assessment.

The different types of planning are intertwined and may or may not be done at distinct, separate times. Discharge planning often requires a multidisciplinary team, but initial and ongoing planning may not. Initial planning is usually

begun after the first patient contact, but there is no specified time for completion; ongoing planning is more or less continuous and is done as the need arises; discharge planning must be done before discharge.

PTS:1DIF:ModerateREF: p. 81-82 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 4. Which client has the greatest need for comprehensive discharge eplanning?

1) A woman who has just given birth to her second child and lives with her husband and 18month-old daughter 2) A man who has been readmitted for exacerbation of his chronic obstructive pulmonary disease 3) A 12-year-old boy who had outpatient surgery on his knee and lives with his mother 4) A woman who was just diagnosed with renal failure and has started peritoneal dialysis ANS: 4 Comprehensive discharge planning should be done for patients who have a newly diagnosed chronic disease or have complex needs. The other patients may require discharge planning but not as comprehensive as someone with anew diagnosis with complex treatment.

PTS:1DIFifficultREF: p. 83 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 5. Which of the following is a benefit of standardized care plans, as defined in your text?

Standardized care plans 1) Apply to every patient on a particular unit2) Include both medical and nursing orders3) Specify patient outcomes for each day4) Help ensure that important interventions are not overlookedANS: 4 Standardized care plans help promote consistency of care and ensure that important interventions are not forgotten. They are not likely to apply to every patient on a unit because they are usually single-problem plans or are used witha particular medical diagnosis. Unlike protocols, they do not include medical orders. Unlike critical pathways, they do not specify predicted patient outcomes for each day.

4) PTS:1DIF:ModerateREF: p. 86 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Recall 6. How are standardized (model) care plans similar to unit standards ofcare?

Standardized (model) care plans 1) Describe the care needed by patients in defined situations2) Include specific goals and nursing orders3) Become a part of the patients comprehensive care plan4)

Usually describe ideal nursing careANS: 1 All of the statements are true for standardized care plans, but only 1 is true of both standardized care plans and unit standards of care. Both describe care needed by patients in defined situations, although unit standards usually describe care for groups of patients (e.g., all women admitted to a labor unit), and standardized care plans are often organized around a particular or all nursing diagnoses commonly occurring with a particular medical diagnosis. Unitstandards are more general and do not have goals for each patient. Unit standards are kept on file in a central place on the unit and do not become a part of the care plan. Unit standards describe minimal, not ideal, care.

PTS: 1 DIF: Difficult REF: p. 87; requires analysis of text discussion.

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 7. The nurse is planning care for a patient. She is using a standardized careplan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient?

1) Validate conflicting data with the patient.2) Transcribe medical orders.3) State the frequency for ambulation. 4) Perform a comprehensive assessment.ANS: 3 Individualizing the care plan means identifying specific problems, outcomes, and interventions and the frequency of those interventions to meet the patients needs. Validating data ensures your assessment is accurate. Transcribing orders is a part of developing and implementing the care plan but not of individualizing the plan.

Performing an assessment is the beginning step to developing a care plan. Assessment 4) helps you to know the ways in which a standardized plan needs to be individualized.

PTS:1DIF:ModerateREF: p. 90 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 8. Which of the following is the best example of an outcome statement? Thepatient will 1) Use the incentive spirometer when awake2) Walk two times during day and evening shifts3) Maintain oxygen saturation above 92% while performing ADLs each morning4) Tolerate 10 sets of range-of-motion exercises with physical therapyANS: 3 Outcome statements should have specific performance criteria and a target time; maintain oxygen saturation is the only one that meets those criteria. Theincentive spirometer goal should say how many times the incentive spirometer should be used each hour as well as the volume. The walking goal should state how far the patient should walk. In the range-of-motion goal, tolerate is a vagueword and is difficult to measure, and the outcome needs to specify how often.

PTS:1DIF:ModerateREF: p. 91-92

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 9. How are critical pathways and standardized nursing care plans similar?Both 1) Specify daily, or even hourly, outcomes and interventions2) Prescribe minimal care needed to meet recommended lengths of stay3) Describe care common to all patients with a certain condition or situation4) Emphasize medical problems and interventionsANS: 3 Both critical pathways and standardized care plans are preplanned documents; they describe care common to all patients who have a certain condition (e.g., allpatients who have a heart attack need some of the same interventions). The other statements are true of critical pathways but not of standardized nursing care plans.

PTS:1DIFifficultREF: pp. 8687; high-level question, answer not given verbatimKEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 10. How is NOC different from the Omaha System?

NOC can be used to write health restoration outcomes.2) NOC can be used in all specialty and practice areas.3) NOC can be used for individuals, families, or groups.4) 4) NOC formulates goals based on nursing diagnoses.ANS: 2 NOC was developed for all specialty and practice areas. The Omaha System was developed for community health nursing. Both address health restoration and can be used for individuals, family, or groups (community). Both base goals on nursing diagnoses, although Omaha does not use the NANDA-I taxonomy.

PTS:1DIF:ModerateREF: p. 95; answer based on analysis of text discussion | V1, p. 98; answer based on analysis of text discussion KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 11. How are short-term goals different from long-term goals? Short-termgoals 1) Can be met within a few hours or a few days2) Are developed from the problem side of the nursing diagnosis3) Must have target times/dates 4) Specify desired client responses to interventionsANS: 1 Short-term goals may be accomplished in hours or days; long-term goals usually are achieved over weeks, months, or even years. The other statements are true for both short-term and longterm goals.

PTS:1DIF:ModerateREF: p. 91 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 12. What do standardized nursing care plans and individualized care planshave in common? They both

1) Reflect critical thinking for a specific patient2) Are preprinted to apply to needs common to a group of patients3) Address a patients individual needs4) Provide detailed nursing interventionsANS: 4 They both provide detailed nursing interventions, although the individualized care plan is more specific to the patients needs and reflects critical thinking, whereas standardized plans do not.

It is not true of individual nursing care plansthat they are preprinted and apply to a group.

PTS: 1 DIF: Moderate REF: pp. 87 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 13. The nurse is individualizing Mr. Wus plan of care by writing a plan for his nursing diagnosis of Anxiety. Why does the nurse need to write goals/outcomes on the plan of care?

Because outcomes describe 1) Desired changes in the patients health status2) Specific patient responses to medical interventions3) Specific nursing behaviors to improve a patients health4) Criteria to evaluate the appropriateness of a nursing diagnosisANS: 1 Outcomes describe changes in the patients health status in response to nursing,rather than medical, interventions. Outcomes relate to patient behavior, not nursing behaviors. Outcomes are a measure of the effectiveness of nursing care for a specific nursing diagnosis, not whether the nursing diagnosis is appropriate.

PTS:1DIF:ModerateREF: p. 91 KEY: Nursing process: Planning | Client need: SECE | Cognitive level:Comprehension 14. Which of the following outcome statements contains the best exampleof performance criteria? The patient will 1) Turn herself in bed frequently while awake2) Understand how to use crutches by day 23) State that pain is decreased after being medicated4) Eat 75% of each meal without complaint of nauseaANS: 4 Performance criteria should be specific and measurable. 75% of each meal isspecific and measurable. Frequently is vague. You cannot observe whether someone understands.

Decreased is vague; a numerical pain rating would bebetter.

PTS:1DIF:ModerateREF: p. 92 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 15. Which of the following is true for goals/outcomes for collaborative problems? 1) They are monitored only by other disciplines.2) They are usually sensitive to nursing interventions.3) They state that a complication will not occur.4) They state only broad performance criteria.ANS: 3

The goal for a collaborative problem is always that the complication will not occur. Other disciplines may be involved in helping to prevent the problem, but nurses still monitor for the complication. The outcomes to collaborative problems are not affected by nursing interventions alone. Goals for collaborativeproblems are specific to the medical condition/treatment.

PTS:1DIF:ModerateREF: pp. 93 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 16. How are NANDA-I problem labels and NOC outcome labels alike? Both describe 1) Health status in terms of human responses2) Patient response before interventions are done3) Patient response in positive terms4) A pattern of related cuesANS: 1 Both NANDA-I and NOC labels are stated as human responses. A NOC label can be used to describe patient responses both before and after interventionNANDA-I before. NOC statements are neutral to allow for positive, negative, or no change in health status; NANDA-I diagnoses describe both problem responses and positive responses (wellness labels). NANDA-I labels are based on patterns of related cues; NOC labels are based on (linked to) NANDA-I labels.

PTS: 1 DIF: Difficult REF: pp. 94; also information about NANDA-I diagnoses from Chapter 4 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 17. The nursing diagnosis is Impaired Memory related to fluid and electrolyte imbalances A.M.B. inability to recall recent events. Which of thefollowing goals/outcomes must be included on the care plan?

1) Checks current medications for mind-altering side effects2) Demonstrates use of techniques to help with memory loss3) Drinks at least 1500 cc of fluid per day4) Takes electrolyte supplements with mealsANS: 2 The essential goal/outcome is aimed at the problem response Impaired Memory.The other goals in this question address the etiology.

PTS:1DIF:ModerateREF: p. 93-94 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 18. A client arrives in the emergency department, pale and breathing rapidly. He immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the patient and decides the first series of actions that areneeded. This scenario demonstrates 1) Formal planning2) Informal planning Ongoing planning4) Initial

planningANS: 2 Informal planning is performed while doing other nursing process steps and isnot written; this nurse is forming a plan in her mind. The end product of formal planning is a holistic plan of care that addresses the patients unique problemsand strengths; this nurse has no time to create a holistic plan of care. Ongoing planning refers to changes made in the plan as you evaluate the patients responses to care; no care has been given at this point. Initial planning does indeed begin with the first patient contact.

However, it refers to the development of the initial comprehensive plan or care; this nurse does not haveenough data for a comprehensive plan, nor does she have time to make such a plan at the moment.

PTS:1DIF:EasyREF:p. 81 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet theAmerican Nurses Association standards for outcomes identification? Choose allthat apply.

1)Developing culturally appropriate outcomes 2) 3) Choosing the best outcome for the patient, regardless of the costs involved inbringing it about 4) Involving the patient and family in formulating the outcomes ANS: 1, 4 ANA standard 3 includes derives culturally appropriate expected outcomes fromthe diagnosis and involves the patient, family . . . in formulating expected outcomes It is acceptable for the nurse to use outcomes on a clinical pathway, but these are not individualized; ANA standard 3 says that the nurse identifies . . . outcomes for a plan individualized to the patient...........................The standard also says that the nurse should consider associated risks, benefits, andcosts. . . .

PTS:1DIF:ModerateREF: p. 82 KEY: Nursing process: Planning | Client need: SECE | Cognitive level:Comprehension

2. Which of the following nursing interventions is an indirect-careintervention?

1)Emotional support 2)Teaching 3) Consulting 4) Physical care ANS: 3 An indirect-care intervention is an activity performed away from the client onbehalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocacy, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care.

PTS:1DIF:EasyREF:pp. 103 KEY: Nursing process: Implementation | Client need: SASE | Cognitive level:Recall

2. Which nursing intervention is considered an independent intervention?

1) Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour 2) Encouraging the postoperative client to perform coughing and deep breathing exercises 3)Explaining his diet to the client; then communicating the teaching with the dietitian 4)Administering morphine sulfate 2 mg IV to the client with postoperative pain ANS: 2 Encouraging the postoperative client to perform coughing and deep breathing exercises is an independent nursing intervention. An independent intervention isone that nurses are licensed to prescribe, perform, or delegate based on their skills and knowledge.

Administering IV fluid or morphine sulfate are dependent interventions; they require an order from a physician or advanced practice nursebut are carried out by the nurse.

Explaining to the client how sodium intake affects his heart failure and then communicating the teaching with the dietitian is an interdependent intervention, one that is carried out in collaboration with other healthcare team members.

PTS:1DIF:ModerateREF: p. 103 KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application 3. A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write?

1)Collaborative 2) Interdependent 3) Dependent 4) Independent ANS: 4 Writing an order to reposition the client in a comfortable position is an example of an independent nursing intervention, one that does not require a physician’s order. The nurse is licensed to prescribe, perform, or delegate the intervention based on her knowledge and skills.

A collaborative or interdependent intervention is one that is carried out in collaboration with other health team members, such as providing the client with a sodium-restricted diet. A dependent intervention is prescribed by a physician or advanced practice nurse; for example, administer oxygen at 2 L/min via nasal cannula.

PTS:1DIF: Moderate REF: p. 103 KEY: Nursing process: Interventions | Client need: Physiological integrity |Cognitive level: Application 4. The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not currently have any respiratory problems. The nurses teaching plan includes coughing and deep breathing exercises. Which type of nursing intervention is the nurse performing?

1) Health promotion2) Treatment3) Prevention4) AssessmentANS: 3 The nurse is teaching the client coughing and deep breathing exercises, whichhelp prevent postoperative pneumonia. Therefore, the nurse is utilizing a prevention intervention. Prevention interventions are used to help prevent complications, such as postoperative pneumonia. Health-promotion interventions promote a clients efforts to achieve a higher level of wellness.Treatment interventions treat disorders, relieve symptoms, and carry out medical orders. Assessment interventions detect changes in the clients condition and detect potential problems.

PTS:1DIF:ModerateREF: p. 106 KEY: Nursing process: Interventions | Client need: Physiological integrity |Cognitive level: Application 5. Which standardized intervention vocabulary was designed specifically for community health nurses?

1) Omaha System2) Clinical Care Classification3) Nursing Interventions Classification4) International Classification for Nursing PracticeANS: 1 The Omaha System was designed specifically for community health nurses to use in caring for individuals, families, community groups, or entire communities.The Clinical Care Classification was developed for home healthcare. The NursingInterventions Classification system is applicable in all settings, including home health and community nursing. The International Classification for Nursing Practice system was designed to describe nursing practice of individuals, families, and communities worldwide.

PTS:1DIF:EasyREF: p. 110 KEY: Nursing process: Planning | Client need: SASE | Cognitive level: Recall 6. A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Whichof the following is an appropriate, correctly written nursing order for this patient?

1) 7/12/13 Encourage use of the incentive spirometer every hour while the client isawakeD.

Goodman, RN 2) By 7/12/13, uses incentive spirometer 10 times every hour while awake to 1000mL 3) Incentive spirometer hourly while awake4) Offer incentive spirometer to the clientJ. Smith, RNANS: 1 The option beginning with a date and ending with the RNs signature contains necessary information.

It contains the date the order was written along withspecific instruction for the nurse that is written in terms of nursing behavior. Uses incentive spirometer 10 times . . . is an example of an expected outcome.Incentive spirometer hourly . . . is an example of a medical order. Plus, the dateand nurses signature are missing. Offer incentive spirometer . . . does not provide the nurse with enough detailed instruction. Therefore, it is a poorly written nursing order.

PTS:1DIF:ModerateREF:pp. 111-112 KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitivelevel: Application 7. A client newly diagnosed with diabetes is admitted to the hospitalbecause her diabetes is out of control. Which of the following is an appropriate direct-care intervention for this client during her stay?

1) Consulting the diabetic nurse educator for help with a teaching plan2) Making arrangements for the client to join a diabetic support group3) Demonstrating blood glucose monitoring and insulin administration to the client4) Consulting with the dietician about the clients dietary concernsANS: 3 Demonstrating blood glucose monitoring and insulin administration is an appropriate direct-care intervention for this client. Direct-care interventions are performed through intervention with the client and include interventions such asphysical care, emotional support, and client teaching. Indirect-care activities include consulting the diabetic nurse educator, making arrangements for the client to join a diabetic support group, and consulting with the dietitian about the clients dietary concerns. Indirect-care activities are performed away from but on behalf of the client.

PTS:1DIF:ModerateREF:p. 103 KEY: Nursing process: Interventions | Client need: Physiological integrity |Cognitive level: Application 8. Which definition best describes a critical pathway?1) Standardized plan of care for frequently occurring conditions Deficient Fluid Volume related to excessive fluid loss. An individualized nursing Systematically developed statement to assist practitioners and patients inmaking decisions 3) Systematic review of clinical evidence for an intervention4) Set of interrelated concepts that describes or explains somethingANS: 1 Critical

pathways are standardized plans of care for commonly occurring health conditions (e.g., myocardial infarction) for which similar outcomes and interventions are appropriate for the majority of patients with the condition.

Clinical practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for a particular disease or procedure. Evidence reports are systematic reviews on clinical topics for the purpose of providing evidence for guidelines, quality improvement, quality measures, and insurance coverage decisions. A theory is aset of interrelated concepts that describe or explain something.

PTS:1DIF:EasyREF: p. 104 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 9. A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan?

1) Determine airway adequacy hourly and as needed.2) Administer oxygen as needed.

Monitor arterial blood gas values.4) Place the client in a high Fowlers position.ANS: 1 For any acute respiratory problem, prior to implementing interventions, the nurse would assess breathing status of the patient by checking the respiratory rate and depth. When devising a plan of care for the client, nursing interventionsshould be listed according to priority. Airway always takes precedence, as ventilation, oxygenation, and positioning will be ineffective without a patent airway.

PTS: 1 DIF: Difficult REF: p. 107 KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitivelevel: Analysis 10. Who is the primary decision maker when caring for healthy adultclients? 1) Physician2) Family3) Deficient Fluid Volume related to excessive fluid loss. An individualized nursing Client4) NurseANS: 3 The client is the primary decision maker in the care of healthy clients. The nurse functions as a teacher and health counselor. The physician plays a role in health promotion and screening. The family may give input, but the client is the decision maker.

PTS:1DIF:EasyREF: p. 110 KEY: Nursing process: Planning | Client need: Health promotion | Cognitive level: Comprehension 11. A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate anddepth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, what should the

nurse do first?

1) Identify several interventions likely to achieve the desired outcomes.2) Review the problem and etiology of the nursing diagnosis.3) Choose the best interventions for the patient.4) Review the goals she has written.ANS: 2 The process of choosing interventions is review the nursing diagnosis, review the desired outcomes, identify several interventions or actions, choose the bestinterventions for the patient, and then individualize standardized interventions to meet the patients unique needs.

12. The nurse is using electronic care planning. He enters the patients nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions the program generates, he sees that none of them fit this patientsindividual needs. What should the nurse do?

1) Reject them all and type in appropriate interventions.2) Select the interventions from the program that are most suitable.3) Ask another nurse to assess the patient and give her recommendation.4) Restart the computer; it is probably a program malfunction.ANS: 1 The nurse can reject all the suggested interventions if they do not address patient needs. Nearly all computer programs have a screen that allows you to type in interventions and nursing orders. It is the nurses responsibility to chooseinterventions: He cannot abdicate this responsibility and let the computer choose. As a professional, this nurse has already validated the data, nursing diagnosis, and goals, so he can feel reasonably certain that there is nothing wrong with the plan to that point. Although consultation with other nurses can be wise and prudent at times, the nurse caring for the patient would likely have the most familiarity with the healthcare needs and is in a better position to make sound judgments than another nurse who does not know the patient.

Deficient Fluid Volume related to excessive fluid loss. An individualized nursing Therefore, it might not be productive or efficient to consult another nurse orrestart the computer.

Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which statement(s) about nursing interventions is/are true? Select allthat apply. 1) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN.2) The best nursing interventions are based on tradition.3) Nursing interventions should be individualized and culturally sensitive.4) Standardized nursing interventions improve care for a specific client.ANS: 1, 3 Some nursing interventions and activities can be delegated to the LPN/LVN or nursing assistive personnel (NAP); however, writing nursing orders is the responsibility of the registered nurse. Nursing interventions should always be individualized and culturally sensitive.

Whenever possible, nursing interventionsshould be based on scientific evidence, not tradition.

Standardized interventionsare not customized to improve care for a specific client.

PTS:1DIF:ModerateREF: pp. 103104

KEY: Nursing process: Interventions | Client need: SASE | Cognitive level:Application 2. An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of goal identified for this client is The client will maintain urine output of at least 30 mL/hour.

Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct.

1) Measure and record urine output every hour; report an output of less than 30mL/hour. 2) Monitor skin turgor and moistness of mucous membranes every shift.3) Administer IV fluids as prescribed.4) Keep oral fluids within the patients reach, and encourage the patient to drink.ANS: 1, 3, 4 Measuring and recording urine output allow for direct evaluation of the goal urine output 30 mL/hour. Administering IV fluids adds fluid to correct dehydration, improve blood flow through the kidneys, and increase urine production. Intake of oral fluids has the same effect.

Monitoring skin turgor and mucous membranes are ways to assess for dehydration, but it does not directlyapply to the goal of maintaining urine output. It is an intervention aimed at the etiology of this nursing diagnosis, rather than the problem.

PTS:1DIF:ModerateREF:p. 106-107; high-level question; answer not givenverbatim KEY: Nursing process: Interventions | Client need: Physiological integrity |Cognitive level: Analysis

Chapter 3. The Steps of the Nursing Process Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The nurse is collecting data on a new patient at an adult clinic. Which data does the nurse need to validate?

1. The client’s weight is 185 lb (83.9 kg) at the clinic.

2. The client’s liver function test results are elevated.

3. The client states that blood pressure (BP) of 160/94 mm Hg is typical.

4. The client reports eating processed foods on a low-sodium diet.

2. After collecting data on a client, the nurse reviews and sorts the information. Which example includes both objective and subjective data?

1. The client’s blood pressure reading is 132/68 mm Hg, and heart rate is 88 beats/min.

2. The client’s cholesterol is elevated, and he admits to liking and eating fried food.

3. The client reports having trouble sleeping and admits drinking coffee in the evening.

4. The client verbally reports having frequent headaches and taking aspirin for the pain.

3. The nurse manager in an acute care facility is orienting new graduate nurses to a patient care unit.

While reviewing The Joint Commission standards, a discussion begins about assessment. Which type of assessment is to be performed on all patients in compliance with The Joint Commission?

1. Nutritional status 2. Pain 3. Cultural 4. Wellness 4. The nurse is providing care for a variety of patients in an acute care facility. Which of the following constitutes an ongoing assessment?

1. Obtaining a patient’s temperature 1 hour after giving acetaminophen 2. Examining a patient’s throat after soreness with swallowing is reported 3. Requesting a patient to rate pain intensity level using a scale of 0 to 10 4. Asking a patient the details of a plan to return to normal exercise activities 5. Each time the nurse comes into contact with a patient, a systematic observation is made. For which reason is this type of assessment performed so frequently?

Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

1.

2.

3.

4.

Time constraints support small portions of assessment at a time.

Validating an absence of change decreases the need to document.

Critical changes are less likely to occur with constant observation.

Repetition makes it less likely the nurse will miss an assessment area.

6. The nurse is obtaining the health history of a client. Which question is an example of the nurse using an open-ended question?

1. “Have you had surgery before?”

2. “When was your last menstrual period?”

3. “What happens when you have a headache?”

4. “Do you have a family history of heart disease?”

7. The nurse is interviewing a patient being admitted for gastrointestinal issues. The patient informs the nurse that he has persistent vomiting and diarrhea. Which type of assessment is the nurse performing by asking, “When did you first begin to have the vomiting and diarrhea?”?

1. Comprehensive assessment 2. Ongoing focused assessment 3. Special needs assessment 4. Initial focused assessment 8. The nurse is currently performing the initial assessment on a newly admitted client. The nurse receives notification of another client’s admission to the unit. Which professional standard influences the nurse’s decision about who will be assigned to perform the assessment of the second client?

1. The state board for nursing-assistant testing 2. The American Nurses Association (ANA) 3. The facility policy and procedure committee 4. The bargaining committee for facility nurses 9. The nurse is obtaining information from a newly admitted patient during the initial nursing assessment. Which difference does the nurse recognize between the nursing history and the medical history?

1. A nursing history focuses on the patient’s responses and needs to the health problem.

2. The same information is gathered in both; the difference is in who obtains the information.

3. A nursing history is gathered by using a specific format.

4. A medical history collects more in-depth information.

10. During the initial assessment of a newly admitted client, the nurse asks about use of nutritional and herbal supplements. For which reason is it important for the nurse to obtain this specific Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

information?

1. To determine what type of therapies are acceptable to the client 2. To identify whether the client has a nutrition deficiency 3. To help the nurse understand the client’s cultural and spiritual beliefs 4. To be aware of potential interaction with prescribed medication 11. After completing an initial patient assessment, for which reason does the nurse utilize a nursing assessment model?

1. To sort and cluster assessment data into specific categories 2. To organize assessment data according to body systems 3. To validate the use of the nursing process to collect data 4. To follow the American Nurses Association (ANA) Standards of Care 12. For which reason does the nurse use nondirective interviewing as an assessment technique?

1. Allows the nurse to have control of the interview 2. Is an efficient way to interview a patient 3. Facilitates open communication 4. Helps focus the attention of patients who are anxious

13. A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate a need for further instruction?

1. “My patient is a young adult, so I plan to talk to her without her parents in the room.”

2. “Because my patient is old enough to be my grandfather, I will address him with ‘Mr.’” 3. “When reading my patient’s health record, I thought of a few questions to ask.”

4. “When I give my patient his pain medication, I will have time to ask questions.”

14. A patient comes to the urgent care clinic because of injury from stepping on a rusty nail. Which type of assessment does the nurse perform?

1. Comprehensive 2. Ongoing 3. Initial focused 4. Special needs 15. The nurse is providing care to a patient who has left-sided weakness because of a recent stroke.

Which type of special needs assessment is most important for the nurse to perform?

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Family Functional Community Psychosocial

16. The nurse is interviewing a patient with a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which comment by the nurse is best when beginning to gather data about the headaches?

1. “When did your migraines begin?”

2. “Tell me about your family history of migraines.”

3. “What are the things that trigger your headaches?”

4. “Describe for me what your headaches feel like.”

17. The nurse is conducting an assessment interview with a newly admitted client. When asking open-ended questions, which action by the nurse indicates an active listening behavior?

1. Taking frequent notes 2. Asking for more details 3. Leaning toward the patient 4. Sitting comfortably with legs crossed 18. A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching?

1. “I find it difficult to avoid using phrases like ‘the patient tolerated the procedure well.’”

2. “It’s confusing to have to remember which abbreviations this hospital allows.”

3. “I need to work on charting assessments and interventions right after they are done.”

4. “My patient was really quiet and didn’t say much, so I charted that he acted depressed.”

19. The nurse prefers to review patient data on a graphic flow sheet, when possible. Which situation is the best example of the reason a graphic flowsheet is superior to other methods of recording data?

1. Provides easy documentation of routine vital signs 2. Visually reflects the patterns of a patient’s fever 3. Describes symptoms accompanying vital sign changes 4. Enables a quick check for patient tolerance of care Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

20. The nurse is aware that patient data are often difficult to analyze. Which is the most obvious reason for using a framework for collecting and recording patient data?

1. Prioritizes collection of assessment data 2. Organizes and clusters data efficiently 3. Separates subjective and objective data 4. Identifies both primary and secondary data 21. The nurse is preparing to conduct an admission interview with an adult client who is alert and oriented. The client’s spouse and two children are visiting and are watching television. Which action by the nurse is conducive to a successful interview?

1. Provide enough chairs for the family to sit facing the client.

2. Ask the client’s preference for how to be addressed by the nurse.

3. Ask if the client is willing to answer questions after the family leaves.

4. Give the client the option of having the interview while the family watches television.

22. The nurse obtains information from a patient during admission. The patient is noted to be alert and oriented, be married, have a history of heart disease. Obtaining this information is an example of which process?

1. Collecting data 2. Analyzing data 3. Categorizing data 4. Physical assessment 23. The nurse on a medical-surgical unit receives the third admission over a period of 1.5 hours. A certified nursing assistant (CNA) offers to assist the nurse with the assessment process. Which response by the nurse is the most appropriate?

1. “Thank you. I am having a busy day, and I can use your help.”

2. “I’m sorry, but nurses are responsible for all patient assessments.”

3. “If you start an assessment on the last patient, I will continue it later.”

4. “If you could obtain and record the vital signs, it would be a big help.”

24. During the assessment process, the patient tells the nurse, “I am having numbness and tingling in my right arm.” Which type of data does the nurse recognize on the basis of the patient’s statement?

1. Subjective data 2. Objective data 3. Secondary data 4. Comprehensive data 25. The nurse is performing an initial interview with an older adult patient. Which statement by the patient indicates a need for a special needs assessment by the nurse?

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“I don’t go to church as much as I used to, but I watch services on TV.” “I have fallen twice at home in the past 6 months, but I have not injured myself.”

“I don’t eat much red meat anymore, but I get my protein from other foods.”

“I had a toothache recently, so I made an appointment to see the dentist.”

26. A patient comes to the emergency department to be evaluated after feeling ill at home. Which is the first question the nurse asks in the initial nursing interview with the patient?

1. “Do you live alone?”

2. “Are you having any pain?”

3. “What is your past medical history?”

4. “Why did you come to the hospital today?”

27. The patient comes to the emergency department complaining of chest pain. Which question by the nurse will encourage the patient to provide the most details about the pain?

1. “When did your chest pain begin?”

2. “On a scale of 0 to 10, what is your pain level?”

3. “Can you give a description of the pain you are having?”

4. “Have you taken any medication for your pain?”

28. Nurses are aware that documentation is essential in monitoring and validating appropriate patient care. Which statement is the best example of high-quality nursing documentation?

1. “Patient breathing is normal. No pain noted. Urine output is adequate at this time.”

2. “Good strength in both lower extremities. Ambulating with walker in the hall.”

3. “Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting.”

4. “Patient seems upset with visiting spouse. Physical assessment planned at a later time.”

Multiple Response Identify one or more choices that best complete the statement or answer the question.

29. The nurse is conducting an interview with a patient in a clinic setting. Which questions will be effective for obtaining information from the patient? Select all that apply.

1. “How did this happen to you?”

2. “What was your first symptom?”

3. “Why didn’t you seek healthcare earlier?”

4. “When did you start having symptoms?”

5. “Why did you decide to seek help now?”

30. A nurse, with a large caseload of patients, needs to delegate some assessment tasks to other Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

members of the healthcare team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) instead of a registered nurse (RN). Which sources does the nurse consult for clarification related to delegation? Select all that apply.

1. Nurse practice act of the nurse’s state 2. American Medical Association (AMA) guidelines 3. Code of Ethics for Nurses 4. American Nurses Association (ANA) Scope and Standards of Practice 5. Facility policy and procedure guidelines

31. Which of the following are cues rather than inferences? Select all that apply.

1. Patient ate 50% of the meal.

2. Patient feels better today.

3. Patient states, “I slept well.”

4. Patient’s white blood cell (WBC) count is 15,000/mm3.

5. Patient does not appear to be in pain.

32. Nurses use the professional standards of nursing assessment when formulating patient care. Which statements regarding professional standards of nursing assessment are true? Select all that apply.

1. Assessment is a professional nursing responsibility.

2. Assessment helps the nurse identify problems and priorities.

3. Assessment helps the nurse formulate the medical diagnosis.

4. Assessment of pain is focused on patients indicating the presence of pain.

5. Assessments can be delegated according to state practice acts and agency policies.

33. The nurse recognizes which examples of objective data? Select all that apply.

1. Blood pressure of 120/80 mm Hg 2. Pain rated as 6 on a pain scale of 0 to 10 3. Moderate amount of yellow drainage from right ear 4. Spouse stating the client is not sleeping well at night 5. Patient reporting the presence of stomach pain 34. The nurse manager is reviewing documentation performed by newly hired nurses. Which of the examples does the nurse manager recognize as high-quality nursing documentation? Select all that apply.

1. Patient states, “I feel dizzy in the morning.”

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Patient is alert and oriented to person, place, and time.

Drainage from midline abdominal incision appears normal.

Patient appears angry and is refusing to talk to the spouse.

Patient expresses no complaints of pain at this time.

35. The nurse is conducting a patient interview in an acute care setting. Which statements made by the nurse during the interview are appropriate? Select all that apply.

1. “You shouldn’t be smoking cigarettes; you have already had one heart attack.”

2. “Why don’t you take your blood pressure medications? Your blood pressure remains high.”

3. “I can see you are in pain. I will bring pain medication and complete the interview later.”

4. “If it is a good time for you, we can complete your interview now.”

5. “Have you noticed any changes in your ability to sleep or patterns of sleeping?”

Chapter 3. The Steps of the Nursing Process Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter: Chapter 3 Assessment Objective: Describe circumstances in which you should validate data.

Page: 45 (V1) Heading: Types and Sources of Data Integrated Processes: Nursing Process Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback This is incorrect. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale.

This is incorrect. Validation is not necessary for laboratory data unless the nurse suspects an error has been made in the results. Retesting needs a prescription from the physician.

This is incorrect. If data, such as blood pressure, are gathered by using an objective method, validation is not necessary. The patient’s comment does not affect the validity of the data one way or another.

This is correct. Validation is done when the client’s statements are inconsistent, as in the client reporting consumption of processed foods on a low-sodium diet.

PTS: 1 CON: Patient-Centered Care 2. ANS: 2 Chapter: Chapter 3 Assessment Objective: Identify the following types of data: subjective, objective, primary source, secondary source.

Page: 45 (V1) Heading: Types and Sources of Data Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback This is incorrect. Objective data can be observed by someone other than the patient (e.g., from physical assessments or laboratory and diagnostic tests).

Subjective data are information given by the client. Blood pressure and heart rate measurements are both objective.

This is correct. Elevated cholesterol is objective data, and the patient’s stated food preference is subjective.

This is incorrect. When the patient verbally expresses trouble sleeping and the consumption of coffee in the evening, all of the data are subjective.

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This is incorrect. When the patient verbally reports frequent headaches and of treating the pain with aspirin, all the data are subjective.

PTS: 1 CON: Patient-Centered Care 3. ANS: 2 Chapter: Chapter 3 Assessment Objective: Name three requirements of The Joint Commission regarding patient assessment.

Page: 44 (V1) Heading: What Do Professional Standards Say About Assessment?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback This is incorrect. The Joint Commission does not require assessment on nutritional status unless cues indicate there are risk factors.

This is correct. The Joint Commission requires that assessments for pain and the risk for falls be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors.

This is incorrect. The Joint Commission does not require a cultural assessment.

This is incorrect. The Joint Commission does not require a wellness assessment.

PTS: 1 CON: Patient-Centered Care 4. ANS: 1 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessments.

Page: 45 (V1) Heading: Types and Sources of Data Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. An ongoing assessment occurs when a previously identified problem is being reassessed—for example, taking an hourly temperature when a Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

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patient has a fever.

This is incorrect. Examining a patient’s throat is a focused assessment to explore the possible source of pain with swallowing.

This is incorrect. Asking for a pain rating using a scale of 0 to 10 is a focused assessment.

This is incorrect. Asking a patient for details of a plan to return to normal exercise activities is a special needs assessment. There is no way to determine if this assessment will be ongoing.

PTS: 1 CON: Patient-Centered Care 5. ANS: 4 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessments.

Page: 46 (V1) Heading: Nursing Assessment Skills Integrated Processes: Nursing Process Client Need: Safe and Effective Nursing Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 This is incorrect. Systematic observation, like other types of assessment, is not performed in a parameter of time constraints. Complete assessments at the beginning of a shift are a vital tool to identify change.

2 This is incorrect. Systematic observation is a type of assessment focused on patient well-being; it does not influence the need to document.

3 This is incorrect. In itself, systematic observation does not prevent critical changes in a patient’s status; however, the process does alert the nurse to changes in a timely manner.

4 This is correct. By making systematic observations each time the nurse is with a patient, the nurse is less likely to miss an assessment area and/or overlook changes in the patient’s status.

PTS: 1 CON: Patient-Centered Care 6. ANS: 3 Chapter: Chapter 3 Assessment Objective: Compare open-ended and closed questions, including definitions, uses, advantages, and disadvantages.

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Page: 47 (V1) Heading: Types of Interviews Integrated Processes: Communication and Documentation Client Need: Safe and Effective Nursing Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Questions that require a simple answer, such as a “yes” or a “no,” are considered closed-ended questions. This question would be open ended if the nurse asked, “What surgeries have you had?”

2 This is incorrect. Questions that require a specific answer, such as a date, is considered closed-ended question. This question would be open ended if the nurse asked, “What can you tell me about your menstrual periods?”

3 This is correct. Open-ended questions—for example, “What happens when you have a headache?”—are broadly worded to encourage the patient to elaborate.

4 This is incorrect. Questions that require a simple answer, such as a “yes” or a “no,” are considered closed-ended questions. This question would be open ended if the nurse asked, “Who are your family members with heart disease?”

PTS: 1 CON: Communication 7. ANS: 4 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessments.

Page: 46 (V1) Heading: Types of Assessment Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

Feedback

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This is incorrect. A comprehensive assessment provides the nurse with holistic information about the client’s overall health status; enables identification of client problems and strengths; enhances the nurse’s sensitivity to a patient’s culture, values, beliefs, and economic situation; and uses the nursing skills of observation, physical assessment, and interviewing.

This is incorrect. An ongoing focused assessment is used to evaluate the status of existing problems and goals. The nurse performs ongoing focused assessment periodically throughout the period of providing patient care.

This is incorrect. A special needs assessment is a type of focused assessment that provides in-depth information about a particular area of client functioning and often involves using a specially designed form. The nurse will perform a special needs assessment any time assessment cues suggest risk factors or problems for a client, such as nutrition status or pain management.

This is correct. An initial focused assessment is used to follow up on client-reported symptoms or unusual findings during the first examination. The nurse is seeking additional information about specific symptoms reported by the patient—in this scenario, vomiting, and diarrhea.

PTS: 1 CON: Patient-Centered Care 8. ANS: 2 Chapter: Chapter 3 Assessment Objective: State the ANA position on delegating assessment.

Page: 44 (V1) Heading: What Do Professional Standards Say About Assessment?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Managing Care Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. Most states have a method of testing for nursing assistant personnel, but it is not necessarily the state board of nursing. Nurse aides or other unlicensed assistive personnel (UAP) may collect certain information, such as vital signs, pain reports, and finger stick blood glucose levels. However, it is the professional nurse’s responsibility to assign those tasks, validate the data collected, conduct the interview, and complete the physical assessment.

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This is correct. The ANA’s Scope and Standards of Practice (2015), which applies to professional nurses (registered nurses [RNs]), identifies assessment as a professional responsibility. The Joint Commission, the National Council of State Boards of Nursing (NCSBN), and nurse practice acts support the ANA standard.

This is incorrect. Agency policies/procedures state which caregivers can collect and document specified data within that agency/facility. However, the parameters of professional standards are observed with the development of agency policy/procedures.

This is incorrect. Bargaining committees for a facility’s nurses will observe the parameters of professional standards. Not all care facilities will have bargaining committees.

PTS: 1 CON: Professionalism 9. ANS: 1 Chapter: Chapter 3 Assessment Objective: Discuss the relationship between the nursing process and collaborative care.

Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Nursing Process Client Need: Safe and Effective Nursing Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback This is correct. A nursing history focuses on the patient’s responses to and perception of the illness/injury or health problem, the patient’s coping ability, and the patient’s resources and support.

This is incorrect. A medical history focuses on the patient’s current and past medical/surgical problems.

This is incorrect. Nursing history formats vary, depending on the patient, the agency, and the patient’s needs. Both nursing and medical histories typically use a specific format.

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This is incorrect. A medical history does not necessarily contain more in-depth information. A nursing history can be thorough, covering a wide range of topics, including biographical data, reason(s) patient is seeking healthcare, history of present illness, patient’s perception of health status and expectations for care, past medical history, use of complementary modalities, and review of functional ability associated with activities of daily living.

PTS: 1 CON: Patient-Centered Care 10. ANS: 4 Chapter: Chapter 3 Assessment Objective: Identify the following types of data: subjective, objective, primary source, secondary source.

Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

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Feedback This is incorrect. The information alone does not specifically address the client’s acceptance of certain types of therapy.

This is incorrect. Physical assessment and laboratory tests are needed to assess a nutritional deficiency.

This is incorrect. To identify the client’s cultural and spiritual beliefs and well as what therapies are acceptable to the client, the nurse would need more than just information about nutritional and herbal supplements.

This is correct. Herbs and nutritional supplements can interact with prescription medications, and complementary and alternative treatments can interfere with conventional therapies.

PTS: 1 CON: Patient-Centered Care 11. ANS: 1 Chapter: Chapter 3 Assessment Objective: Use nursing frameworks to organize data.

Page: 50 (V1) Heading: How Can I Organize Data?

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Integrated Processes: Nursing Process Client Need: Safe and Effective Nursing Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

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Feedback This is correct. Nursing assessment models categorize or cluster data into functional health patterns, domains, or categories to make the data easier to use.

This is incorrect. None of the nursing assessment models cluster data according to body systems.

This is incorrect. Assessment is the first step in the nursing process; however, the nurse does not use the entire nursing process in data collection.

This is incorrect. The ANA Standards of Care describe a competent level of clinical nursing practice based on the nursing process; nursing models are not based on the ANA Standards of Care.

PTS: 1 CON: Professionalism 12. ANS: 3 Chapter: Chapter 3 Assessment Objective: Describe the differences between directive and nondirective interviewing.

Page: 49 (V1) Heading: Table 3-3: Comparison of Directive and Nondirective Interviews Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is incorrect. With the use of nondirective interviewing, the patient controls the subject matter.

2 This is incorrect. Because nondirective interviewing puts the patient in control of the subject matter, the process can be very time consuming (inefficient) and produce information that is not relevant.

3 This is correct. Nondirective interviewing helps build rapport between the nurse and the patient and facilitates the use of open communication.

4 This is incorrect. Directive interviewing is used to focus the attention of anxious patients. The method focuses on obtaining factual, easily categorized information. The process is especially useful in an emergency situation.

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PTS: 1 CON: Patient-Centered Care 13. ANS: 4 Chapter: Chapter 3 Assessment Objective: Discuss how to prepare for and conduct an interview.

Page: 50 (V1) Heading: Preparing for an Interview Integrated Processes: Communication and Documentation Client Need: Safe and Effective Nursing Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback This is incorrect. It is appropriate to interview patients without family/friends around; this decision does not require further instruction.

This is incorrect. In nearly every culture, addressing a patient with “Mr.” or “Mrs.” shows respect and is, therefore, correct and does not require further instruction.

This is incorrect. Reading the patient’s health record is appropriate preparation for an interview. This decision does not require further instruction.

This is correct. A patient should be comfortable when interviewing. The pain medication should have time to work before the nurse would consider interviewing the patient, so asking questions when giving the medication is not a good idea. This decision requires further instruction.

PTS: 1 CON: Patient-Centered Care 14. ANS: 3 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessment.

Page: 47 (V1) Heading: Focused Assessments Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

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Feedback This is incorrect. A comprehensive assessment is holistic and is usually done upon the client’s admission to a healthcare facility.

This is incorrect. An ongoing assessment is a follow-up procedure after an initial database is completed or a problem is identified.

This is correct. An initial focused assessment is performed during a first examination for specific abnormal findings.

This is incorrect. A special needs assessment is performed when there are cues that more in-depth assessment is needed.

PTS: 1 CON: Patient-Centered Care 15. ANS: 2 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessments.

Page: 48 (V1) Heading: Special Needs Assessments Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. A family assessment is helpful to evaluate the patient’s support systems. This is probably the second-most important special needs assessment for the nurse to make for this patient.

2 This is correct. A functional assessment is the most important assessment because of discharge needs (e.g., self-care ability at home) and patient safety.

3 This is incorrect. A community assessment is helpful to evaluate community services available to assist the patient. However, this is not the most important special needs assessment.

4 This is incorrect. A psychosocial assessment is helpful to evaluate a patient’s understanding of and coping with the recently diagnosed stroke. However, this is not the most important special needs assessment for the nurse to perform.

PTS: 1 CON: Patient-Centered Care 16. ANS: 1 Chapter: Chapter 3 Assessment Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Objective: Describe the differences between directive and nondirective interviewing.

Page: 47 (V1) Heading: Table 3-3: Comparison of Directive and Nondirective Interviews Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is correct. For someone who is anxious, it is best to use closed-ended questions. A closed-ended question can be answered in one or very few words and has a very specific answer.

2 This is incorrect. This statement requires the patient to give a detailed response, which is not suitable for interviewing an anxious patient.

3 This is incorrect. Asking what triggers the patient’s migraine is an open-ended question, which requires a detailed response. This is not suitable for interviewing an anxious patient.

4 This is incorrect. Asking the patient for a description of how the headaches feel requires a detailed response, which is not suitable for interviewing an anxious patient.

PTS: 1 CON: Patient-Centered Care 17. ANS: 3 Chapter: Chapter 3 Assessment Objective: Discuss how to prepare for and conduct an interview.

Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Easy

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Feedback This is incorrect. Taking frequent notes makes it difficult for the nurse to maintain eye contact with the client.

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This is incorrect. Asking for more details may seem like idle curiosity to the client.

This is correct. The nurse is exhibiting active listening behaviors by leaning toward the client; facing the patient; exhibiting an open, relaxed posture without crossing the arms or legs; and maintaining eye contact.

This is incorrect. When the nurse is sitting with legs crossed, it may indicate to the client that the nurse is not receptive to the client.

PTS: 1 CON: Communication 18. ANS: 4 Chapter: Chapter 3 Assessment Objective: Describe circumstances in which you should validate data.

Page: 53 (V1) Heading: How Should I Document Data?

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate

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Feedback This is incorrect. Chart specific data, not vague phrases; the student is acknowledging the importance of this.

This is incorrect. There are no universally accepted phrases, just agency-approved abbreviations; the student is acknowledging the need to use agency-approved abbreviations.

This is incorrect. The student is correct that charting should be completed as soon after data collection as possible.

This is correct. When charting data, chart only what was observed, not what it meant. Inferences should not be made about a patient’s behavior during data collection (“he acted depressed”), so this response reflects the student’s lack of knowledge and need for teaching.

PTS: 1 CON: Communication 19. ANS: 2 Chapter: Chapter 3 Assessment Objective: Describe circumstances in which you should validate data.

Page: 53 (V1) Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Heading: Tools for Recording Assessment Data Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate

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Feedback This is incorrect. Flowsheets can be used to record various types of information, such as routine documentation of vital signs.

This is correct. To easily and graphically see trends over time, the graphic flowsheet is superior to other methods of documentation, allowing quick assessment of patient changes in status. The pattern of a patient’s fever is the best example of the superiority of a graphic flowsheet.

This is incorrect. A description of the symptoms accompanying changes in vital signs is narrative information for which a graphic flowsheet may not be suitable.

This is incorrect. Patient tolerance of care is most likely to be documented in narrative form and not on a graphic flowsheet.

PTS: 1 CON: Communication 20. ANS: 2 Chapter: Chapter 3 Assessment Objective: Use nursing frameworks to organize data.

Page: 50 (V1) Heading: How Can I Organize Data?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This is incorrect. During the assessment phase, the nurse is collecting and recording data, not prioritizing data.

2 This is correct. The major concept of a framework is to assist the nurse to organize and cluster data to find patterns.

3 This is incorrect. A framework includes subjective and objective data but does

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4

not help the nurse to separate the two types of data.

This is incorrect. A framework includes primary and secondary data but does not help the nurse to separate the two types of data.

PTS: 1 CON: Patient-Centered Care 21. ANS: 3 Chapter: Chapter 3 Assessment Objective: Discuss how to prepare for and conduct an interview.

Page: 50 (V1) Heading: Preparing for an Interview Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

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Feedback This is incorrect. Family members may offer information that may or may not be pertinent and may distract the client from the interview. The presence of family members may also inhibit full disclosure of information by the client.

This is incorrect. The nurse always needs to ask the client’s preference for how they are addressed. However, this action alone does not ensure a successful interview.

This is correct. The interview should be done when the client is comfortable and there are no distractions.

This is incorrect. The family watching television during the nurse’s interview of the client may be distracting to both the nurse and the client.

PTS: 1 CON: Communication 22. ANS: 1 Chapter: Chapter 3 Assessment Objective: Identify at least four components of a nursing health history.

Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

1 2 3 4

Feedback This is correct. The nurse is collecting data on this patient; however, the data provided indicate that further data collection is warranted.

This is incorrect. Data are analyzed to formulate nursing diagnoses and a plan of care.

This is incorrect. After assessment, data are categorized to organize the information and add clarity.

This is incorrect. The information in the scenario indicates that a comprehensive physical assessment has not been completed.

PTS: 1 CON: Patient-Centered Care 23. ANS: 4 Chapter: Chapter 3 Assessment Objective: State the ANA position on delegating assessment.

Page: 47 (V1) Heading: What Do Professional Standards Say About Assessment?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. In making decisions about which parts of an assessment can be delegated to the CNA, the nurse must consider agency policies and the regulations of the state board of nursing.

2 This is incorrect. Certain assessment activities, such as vital signs, weighing the client, and maintaining output and intake measures, can be assigned to qualified CNAs. 3 This is incorrect. Nursing regulatory bodies specify that client assessment is the responsibility of the registered nurse. Therefore, the CNA cannot be instructed to start an assessment that will be completed by the nurse.

4 This is correct. In most states, the CNA can obtain vital signs and record them in the patient’s chart; however, the ability to perform this task must first be validated by the nurse. The nurse is also responsible for validating the documentation of the information by the CNA. PTS: 1 CON: Professionalism 24. ANS: 1 Chapter: Chapter 3 Assessment Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Objective: Identify the following types of data: subjective, objective, primary source, secondary source.

Page: 45 (V1) Heading: Types and Sources of Data Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Moderate

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Feedback This is correct. The patient’s statement about experiencing numbness and tingling down the right arm is an example of subjective data because the statement is in the patient’s own words.

This is incorrect. Objective data are overt and gathered by the nurse through physical assessment, laboratory findings, or diagnostic testing results.

This is incorrect. Secondary data are obtained through a source other than the patient, such as a family member This is incorrect. There is not enough information in the patient’s statement to categorize it as comprehensive data because the nurse would have to complete a physical assessment and obtain all data.

PTS: 1 CON: Professionalism 25. ANS: 2 Chapter: Chapter 3 Assessment Objective: Describe and differentiate initial, ongoing, comprehensive, focused, and special needs assessments.

Page: 46 (V1) Heading: Types of Assessment Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback This incorrect. The patient verbalizes that he misses church but adds that he is able to view services on television.

This is correct. An older adult who has fallen twice in 6 months has a safety risk. There is no indication that a walker has been obtained. Falling and the risk for falls require the nurse to perform a special needs assessment related to functional status. The lack of injury does not diminish the need.

This is incorrect. The patient verbalizes eating less red meat but adds that protein is obtained from other sources. The nurse may want to determine what the other protein sources are before performing a special needs assessment.

This is incorrect. The client verbalizes a physiological concern regarding a toothache, but the patient has addressed the issue by making an appointment to see the dentist.

PTS: 1 CON: Patient-Centered Care 26. ANS: 4 Chapter: Chapter 3 Assessment Objective: Describe the differences between directive and nondirective interviewing.

Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1 This is incorrect. It is appropriate to ask the patient about the home situation; however, this question can be addressed later when taking the health history and performing the physical assessment.

2 This is incorrect. It is appropriate to ask the patient about pain, but this question can be addressed later when taking the health history and performing the physical assessment or by following the patient’s lead.

3 This is incorrect. It is appropriate to ask the patient about the medical history; however, this question can be addressed later when taking the health history and performing the physical assessment.

4 This is correct. The nurse should first ask in the initial interview why the patient is seeking nursing or medical assistance. This broad question will elicit the most information because it is open ended.

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PTS: 1 CON: Professionalism 27. ANS: 3 Chapter: Chapter 3 Assessment Objective: Describe the differences between directive and nondirective interviewing.

Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Moderate

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Feedback This is incorrect. Asking when the patient’s pain began will only elicit a short answer specific to that question. Each question is asked in pain assessment; however, the question that will elicit the most information is the one that asks the patient to tell the nurse more about the pain.

This is incorrect. Asking to rate the level of pain on a scale of 0 to 10 will only elicit a short answer; of greater importance is the description of the pain present with chest pain.

This is correct. The most information is gained by asking the patient to tell the nurse more about the pain. This is an open-ended question and will give the nurse more information about the pain.

This is incorrect. Although asking the patient about medication taken for the pain is appropriate, the question will elicit only a short answer with a limited amount of information about the characteristics of the pain.

PTS: 1 CON: Professionalism 28. ANS: 3 Chapter: Chapter 3 Assessment Objective: Use assessment skills to gather data during a nursing assessment.

Page: 53 (V1) Heading: How Should I Document Data?

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

1 2 3 4

PTS:

Feedback This is incorrect. Noting that patient breathing is normal and urine output is adequate does not give enough information about either function.

This is incorrect. “Good strength in both lower extremities” is vague as the word good is subjective.

This is correct. “Started on solid foods. Ate 75% of dinner. No complaints of nausea or vomiting” is clear, concrete, and specific.

This is incorrect. “Patient seems upset” does not give enough information and involves an assumption by the nurse. Also, the nurse does not document what things have not been done; this action can be used to show inadequate nursing care if litigation is ever initiated.

1

CON: Communication

MULTIPLE RESPONSE 29. ANS: 1, 2, 4 Chapter: Chapter 3 Assessment Objective: Discuss how to prepare for and conduct an interview.

Page: 50 (V1) Heading: Preparing for an Interview Integrated Processes: Communication and Documentation Client Need: Communication and Documentation Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Difficult

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Feedback This is correct. “How,” “what,” and “when” are acceptable lines of questioning. It will be beneficial for the nurse to ascertain how a patient’s issue occurred.

This is correct. “How,” “what,” and “when” are acceptable lines of questioning.

This is incorrect. Asking “why” can put the patient on the defensive and may suggest disapproval, limiting the amount of information the patient is willing give.

Questioning the patient’s judgment for seeking care is inappropriate.

This is correct. “How,” “what,” and “when” are acceptable lines of questioning.

This is incorrect. Asking “why” can put the patient on the defensive and may suggest

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disapproval, limiting the amount of information the patient is willing give. Why the patient decided to seek help at this time is of least importance.

PTS: 1 CON: Communication 30. ANS: 1, 4 Chapter: Chapter 3 Assessment Objective: State the ANA position on delegating assessment.

Page: 47 (V1) Heading: What Do Professional Standards Say About Assessment?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult

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Feedback This is correct. State nurse practice acts specify which portions of the assessment can legally be completed by individuals with different credentials. The practice acts will vary from state board to state board.

This is incorrect. The AMA provides guidelines and standards for physicians, not nurses.

This is incorrect. The Code of Ethics for Nurses merely states that the nurse should delegate tasks appropriately; it does not speak directly to the specific credentials of personnel.

This is correct. The ANA’s Scope and Standards of Practice provides professional guidance for determining who is ultimately responsible and qualified to collect assessment data.

This is incorrect. The facility policy and procedure index should reflect the professional nursing standards of practice; however, this is not the best source of validating delegation guidelines.

PTS: 1 CON: Professionalism 31. ANS: 1, 3, 4 Chapter: Chapter 3 Assessment Objective: Use assessment skills to gather data during a nursing assessment.

Page: 47 (V1) Heading: Guidelines for Recording Assessment Data Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Copyright © 2024 by F.A. Davis Company All rights reserved. This material is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Use of this content outside your academic institution is expressly prohibited and enforceable by law.

Concept: Patient-Centered Care Difficulty: Difficult

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Feedback This is correct. Cues are what the client says and what the nurse observes. The nurse can observe the percentage of the meal eaten by the client.

This is incorrect. When the nurse states, “The patient feels better,” the nurse is making an inference. What did the nurse observe to validate that the client feels better? Those observations are cues.

This is correct. Cues are what the client says and what the nurse observes. When the client states, “I slept well,” it is a verbal fact stated by the client and is a cue.

This is correct. A laboratory value is a factual statement and, therefore, a cue.

This is incorrect. When the nurse notes that the patient “does not appear to be in pain,” the nurse is making an inference. What validating cues does the nurse recognize?

PTS: 1 CON: Patient-Centered Care 32. ANS: 1, 2, 5 Chapter: Chapter 3 Assessment Objective: Discuss professional standards affecting nursing process (e.g., American Nurses Association, The Joint Commission).

Page: 44 (V1) Heading: What Do Professional Standards Say About Assessment?

Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

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Feedback This is correct. Assessment is a professional responsibility as designated by professional standards.

This is correct. Assessment is a professional responsibility that assists the nurse to identify problems and prioritize care.

This is incorrect. Assessment helps the nurse formulate a nursing diagnosis; a medical diagnosis is not within the nurse’s scope of practice.

This is incorrect. All patients are assessed for pain.

This is correct. Parts of the assessment may be delegated, depending on state boards of nursing and agency policies.

PTS: 1 33. ANS: 1, 3

CON: Patient-Centered Care

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Chapter: Chapter 3 Assessment Objective: Identify the following types of data: subjective, objective, primary source, secondary source.

Page: 45 (V1) Heading: Types and Sources of Data Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

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Feedback This is correct. A blood pressure reading is an example of objective data. Such data are obtained by the nurse through assessment and can be validated.

This is incorrect. Pain that is rated on a scale of 0 to 10 is still considered subjective because it is rated on the patient’s opinion. Objective data about pain includes crying, grimacing, or posturing.

This is correct. The presence and description of drainage is an example of objective data. Such data are obtained by the nurse through assessment and can be validated.

This is incorrect. The spouse’s statement about the patient’s quality of sleep is indicative of secondary data, which is vague and subjective.

This is incorrect. The patient’s report about the presence of stomach pain is subjective. Objective validation would include physical manifestations of pain.

PTS: 1 CON: Patient-Centered Care 34. ANS: 1, 2, 5 Chapter: Chapter 3 Assessment Objective: Use assessment skills to gather data during a nursing assessment.

Page: 53 (V1) Heading: How Should I Document Data?

Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Difficult

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Feedback This is correct. Recording the patient’s statement in the patient’s own words is an example of high-quality documentation. The statement is not vague or subjective.

This is correct. When the nurse documents validation of orientation and the means of evaluation, the documentation is an example of high-quality documentation.

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This is incorrect. The statement regarding the patient’s incision is vague because what is considered normal cannot be measured.

This is incorrect. Noting that the patient is angry and refuses to talk with the spouse is subjective and unclear.

This is correct. Documentation that includes the patient’s response to an assessment of pain is an example of high-quality documentation.

PTS: 1 CON: Communication 35. ANS: 3, 4, 5 Chapter: Chapter 3 Assessment Objective: Discuss how to prepare for and conduct an interview.

Page: 49 (V1) Heading: Interviewing to Obtain a Nursing Health History Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Difficult

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PTS:

Feedback This is incorrect. Criticizing the patient’s behavior and citing a medical situation diminishes the possibility of establishing a positive rapport between the patient and the nurse.

This is incorrect. When the nurse asks a “why” question, it is often offensive to the patient. The nurse needs to use therapeutic communication skills to determine the patient’s noncompliance with medical treatment.

This is correct. Observing that the patient is in pain, offering pain medication, and postponing the interview are appropriate when performing the nursing interview.

Pain and use of medication will make the interview process more difficult and possibly less accurate.

This is correct. Asking the patient about the timing of the interview is appropriate and accommodating.

This is correct. Asking the patient about sleeping patterns is appropriate when performing the nursing interview.

1

CON: Communication

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Chapter 4. Evidence-Based Practice: Theory and Research Identify the choice that best completes the statement or answers the question.

1. A physician prescribes oral aripiprazole 10 mg daily for a client with schizophrenia.

This medication is unfamiliar to the nurse, and she cannot find itin the hospital formulary or other references. How should she proceed?

1) Administer the medication as prescribed.2) Hold the medication and notify the prescriber.3) Consult with a pharmacist before administering it.4) Ask the patients nurse for information about the medication.ANS: 3 The nurse must recognize when she does not have the knowledge or skill needed to implement an order. Because the nurse is unfamiliar with the medication, that does not mean she should hold it and delay patient treatment. It is wisest to first consult with the pharmacist for information before administering the medication to ensure safe practice. Administering the medication as prescribed, without knowing its expected actions and side effects,at the least prevents adequate reassessment; at the most, it is dangerous.

Holding the medication and notifying the prescriber prevents the client from receiving timely treatmentmany drugs are less effective if a consistent scheduleis not maintained.

Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adversereactions to the medication.

PTS:1DIF:ModerateREF:p. 118 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Analysis 2. Which task can be delegated to nursing assistive personnel (NAP)?1) Turn and reposition the client every 2 hours.2) Assess the clients skin condition.3) Change pressure ulcer dressings every shift.4) Apply hydrocolloid dressing to the pressure ulcer.ANS: 1 The nurse can delegate turning the client every 2 hours to the NAP. Assessingthe clients skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment.

PTS:1DIF:ModerateREF:pp. 122124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Application 3. The nurse has just finished documenting that he removed a patientsnasogastric tube.

Which is the next logical step in the nursing process?

4) Assessment2) Planning3) Evaluation4) DiagnosisANS: 3 The implementation phase ends when you document nursing actions on the clients chart.

Implementation evolves into the evaluation step when you document the clients response to your interventions. As a general rule, the stepsin order are as follows: assessment diagnosis, planning outcomes, planning interventions, implementation, and evaluation.

PTS:1DIF:EasyREF:p. 125

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension 4. Which nursing intervention is best individualized to meet the needs of aspecific client?

1) Suction the client every 2 hours per unit policy.2) Use incentive spirometry every hour while awake per postoperative protocols.3) Institute swallowing precautions.

Move client out of bed to the chair daily; client prefers to be out of bed fordinner. ANS: 4 Positioning the client in the chair for meals considers the clients desire to be outof bed for dinner, so it is obviously individualized. An intervention performed according to unit policy or protocols is not necessarily individualized. Institute swallowing precautions does not provide instructions for the specific actions needed to do that for this particular client.

PTS:1DIF:ModerateREF:p. 118; high-level question, answer not given verbatim KEY: Nursing process: Planning interventions | Client need: SECE | Cognitivelevel: Application 5. The primary provider prescribes an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurseproceed?

1) Ask a colleague for help, because the nurse cannot safely perform the procedurealone. 2) Gather the equipment and prepare it before informing the client about theprocedure. 3) Obtain an order to restrain the client before inserting the urinary catheter.4) Inform the provider that the nurse cannot perform the procedure because theclient is confused.

Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the primary provider that the procedure cannot be performed because the clientis confused is inappropriate because the procedure can very likely be done with assistance.

PTS:1DIF:ModerateREF:p. 118 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Analysis 6. A patient underwent surgery 3 days ago for colorectal cancer. The patients critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. Howshould the nurse proceed?

1) Postpone the teaching session until the patient is more receptive.2) Follow the critical pathway for patient teaching about ostomy care.3) Administer a prescribed antidepressant and notify the physician.

A depressed affect and poor eye contact likely indicate that the client is havingdifficulty coping with the new colostomy. At this time, the client would not be physically and psychologically ready to obtain the most benefit from teaching pertaining to ostomy care. Therefore, the nurse

should postpone the teaching session for this client until the client is receptive to receiving the information.

The nurse should not perform the teaching session simply because the critical pathway indicates it is appropriate. Simply administering an antidepressant doesnot address the clients readiness to participate in a teaching session and ultimately self- care of the ostomy. The nurse should encourage the client to verbalize his feelings.

Client education is not effective unless the client is receptive to the information. Readiness to learn is important. Proceeding with teaching when the client is struggling with coping is not sensitive to the clientsindividual needs.

PTS:1DIF:ModerateREF:p. 120 KEY: Nursing process: Implementation | Client need: PHI | Cognitive level:Application 7. Before inserting a nasogastric tube, the nurse reassures the client.Reassuring the client requires which type of nursing skill?

1) Psychomotor2) Interpersonal3) Cognitive Reassuring the client is an interpersonal skill. Inserting the nasogastric tuberequires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills.

PTS:1DIF:ModerateREF: p. 120 KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Comprehension 8. Which intervention depends almost entirely on the clients adhering to the therapy?

1) Inserting an IV catheter2) Turning a client every 2 hours3) Shortening a surgical drain4) Following a low-fat, low-calorie dietANS: 4 Instituting and adhering to a low-fat, low-calorie diet is an intervention thatdepends almost entirely on the clients adhering to the therapy. Client cooperation is necessary for performing the other interventions, but the interventions do not depend on the client to the same extent.

PTS:1DIF:EasyREF: p. 122 KEY: Nursing process: Planning interventions | Client need: SECE | Cognitivelevel: Analysis 9. The nurse is caring for a client who was newly diagnosed with type 2diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?

1) Teaching the client that he must lose weight to control his blood sugar2) Informing the client he must exercise at least three times per week3) Explaining

to the client that he must come to the diabetic clinic weekly4) Determining the clients main concerns about his diabetesANS: 4 Determining the clients main concerns promotes cooperation with the treatmentregimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure.

Although it is often important for a diabetic client to exercise and lose weight tocontrol blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the clients support systems and resources, not just tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention.

Remember that knowledge does not necessarily change behavior.

PTS:1DIF:ModerateREF: p. 122 KEY: Nursing process: Planning interventions | Client need: PHSI | Cognitive level: Analysis 10. Which statement accurately describes delegation?1) Transferring authority to another person to perform a task in a selected situation2) Collaborating with other caregivers to make decisions and plan care3) Scheduling treatments and activities with other departments4) Performing a planned intervention from a critical pathwayANS: 1 Delegation is the transfer to another person of the authority to perform a task ina selected situationthe person delegating retains accountability for the outcomeof the activity.

Collaboration is described as working with other caregivers to plan, make decisions, and perform interventions. Coordination of care involves scheduling treatments and activities with other departments. Implementation is the process of performing planned interventions.

PTS:1DIF:EasyREF: p. 122 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Knowledge 11. Which statement by the nurse best demonstrates clear communicationto nursing assistive personnel (NAP) about delegating a task?

1) Record how much the patient drinks today, please.2) Take the patients vital signs every 2 hours today.3) Take the patients temperature every 4 hours; notify me if it is greater than100.5F (38.1C).

4) Assist the patient with all of her meals.ANS: 3 Clear communication about a task (such as Take the patients temperature . . . ) tells the NAP exactly what the task is, the specific time it needs to be done, andthe method for reporting the results to the registered nurse. The other options are vague and leave room for misinterpretation.

PTS:1DIF:ModerateREF:p. 124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Analysis 12. Who is responsible for evaluating the outcome of a task delegated tothe nursing assistive personnel (NAP)?

1) Nurse who delegated the task2) Licensed practical nurse working with the NAP3) Unit nurse manager4)

Charge nurse for the shiftANS: 1 The nurse who delegates the task is responsible for supervising and evaluatingthe outcomes of tasks performed by the NAP. Another registered nurse, such as a staff nurse, nurse manager, or charge nurse, can answer questions andprovide help, if necessary.

PTS:1DIF:EasyREF: p. 124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Recall 13. Which criterion might be used in structure evaluation?1) Staff refrains from sharing computer password.2) Healthcare provider washes hands with each client contact.3) A defibrillator is accessible on each client care area.4) Nurse verifies client identification before initiating care.ANS: 3 The criterion that states a defibrillator is present on each client care area is associated with structure evaluation. Refrains from sharing computer password, washes hands before each client contact, and verifies client identification beforeinitiating care are criteria associated with process evaluation.

PTS:1DIF:ModerateREF: p. 127 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis 14. Which of the following is a client outcome criterion?1) Central venous catheter site infection does not occur (90% of cases). 2) Client will sit out of bed in a chair for 20 minutes three times per day.3) Postoperative phlebitis does not occur (95% of cases).4) Falls will decrease by 2% between January 1 and March 30.ANS: 2 A client outcome criterion states the client health status or behaviors one wishesto effect.

Client will sit out of bed . . . is a client outcome criterion. The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution.

PTS:1DIF:ModerateREF: pp. 127-128 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level:Application 15. When should the nurse collect evaluation data for this expectedoutcome: Patient will maintain urine output of at least 30 mL/hour?

1) At the end of the shift2) Every 24 hours 3) Every 4 hours 4) Every hour ANS: 4 The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patients urine output everyhour because the goal statement specifies an hourly rate (30 mL/hour). The unitof measurement in the goal guides how often

the nurse would reassess the patient.

PTS:1DIF:EasyREF: pp. 127-128 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 16. Which type of client-centered evaluation is performed at specific,scheduled times?

1) Intermittent2) Ongoing3) Terminal4) ProcessANS: 1 Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately afteran intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the clients health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed atspecific times, but it is not considered a client-centered evaluation.

PTS:1DIF:EasyREF: p. 127 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall 17. Which of the following is the most valid criterion for determining thestatus of a patients anxiety at discharge? The patient 1) Has a relaxed facial expression2) States that he feels more relaxed today3) Shows no physiological signs of anxiety (e.g., pallor)4) Has no further questions about home careANS: 2 A criterion is considered valid when it measures what it is intended to measure.Because anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient says about it. A relaxed facial expression and other physiological signs might or might not show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping or falling asleep. The fact that a patient is not asking questions about his surgery could mean that hehas adequate knowledge about the topic; it would not indicate the presence or absence of anxiety.

All of the options except what the patient states could be measuring something other than anxiety.

PTS: 1 DIF: Difficult REF: p. 127 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 18. The nurse works with the respiratory therapist to administer a patients breathing treatments. He reports the patients breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with thepatient the options for further treatment. This is an example of 1)

Delegation2) Collaboration3) Coordination of care4) Supervision of careANS: 2 Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain the big picture. Supervision is the process of directing, guiding, and influencing the outcome of an individuals performance ofan activity or task.

PTS:1DIF:ModerateREF: pp. 122 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply.

1) 75-year-old patient newly admitted to the hospital with dehydration2) 65-year-old patient hospitalized for a stroke, whose blood pressure is 188/90 mmHg 3) 92-year-old patient with stable vital signs who was admitted with a urinary tractinfection 4) 56-year-old patient with chronic renal failure who has vital signs within hisnormal range ANS: 1, 3, 4 The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires thekeen assessment and critical thinking skills of a registered nurse. The nurse can safely delegate the care of stable clients, such as the client admitted with dehydration, the client admitted with a urinary tract infection, or the client with chronic renal failure. Any client who is very ill or who requires complex decision making should be cared for by a registered nurse.

PTS: 1 DIF: Difficult REF: pp. 122124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Analysis

2. Which commonly accepted practice came out of the Framingham study?Use of 1)Mammography in breast cancer screening 2) Colonoscopy in colon cancer screening 3) Pap testing in cervical cancer screening 4)Digital rectal examination in prostate cancer screening ANS: 1 One commonly accepted practice that came out of the Framingham study is thelink between mammography and breast cancer. Before the Framingham study, mammography was considered an unreliable tool in breast cancer screening.

PTS:1DIF:EasyREF:p. 137 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 3. Which theorist developed the nursing theory known as the science ofhuman caring?

1)Florence Nightingale 2)Patricia Benner 3) Jean Watson 4)Nola Pender ANS: 3 Dr. Jean Watson developed the nursing theory known as the science of humancaring. Her theory describes caring from a nursing perspective. Florence Nightingale developed the theory that stated that a clean environment would improve the health of patients. By changing the care environment, she dramatically reduced the death rate of soldiers. Dr. Patricia Benners theory described the progression of a beginning nurse who learns to be an expert nurse. Nola Penders theory on health promotion became the basis for most health-promotion teaching done by nurses.

PTS: 1 DIF: Easy REF: p. 137 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 3. A patient complains of pain after undergoing surgery. The nurse forms amental image of pain based on her own experiences with pain. This mental image is known as a(n) 1) Phenomenon2) Concept3) Assumption4) DefinitionANS: 2 A concept is a mental image of a phenomenon, an aspect of reality that you canobserve and experience. In the scenario above, the nurse forms a mental imageof pain because of her past experiences with pain. Phenomena are the subject matter of a discipline.

They mark the boundaries of a discipline. An assumption is an idea that is taken for granted. In a theory, the assumption is the idea that the researcher presumes to be true and does not intend to test with research. A definition is a statement of meaning of a term or concept that sets forth the concepts characteristics or indicators.

PTS: 1 DIF: Moderate REF: p. 138

KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 4. Hildegard Peplau was a nursing theorist whose major contribution tonursing was 1) Transcultural nursing2) Health promotion3) Nurse-patient relationship4) Holistic comfortANS: 3 Hildegard Peplau was a psychiatric nurse who showed that developing a relationship with psychiatric patients made their treatment more effective. Fromher work, she developed the theory of interpersonal relations, which focuses on the nurse-patient relationship. This theory is in use every day in nursing.

PTS: 1 DIF: Easy REF: p. 142 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 5. The nurse and other hospital personnel strive to keep the patient carearea clean. This most directly illustrates the ideas of which nursing theorist?

1) Virginia Henderson2) Imogene Rigdon3) Katherine Kolcaba4) Florence NightingaleANS: 4 Florence Nightingale was instrumental in identifying the importance of a cleanpatient care environment. During the Crimean War, Nightingale dramatically reduced the death rate of soldiers by changing the healthcare environment.

Virginia Henderson identified 14 basic needs that are addressed by nursing care. Imogene Rigdon developed a theory about bereavement of older women after noticing that older women handle grief differently than do men and younger women. Katherine Kolcaba developed a theory of holistic comfort in nursing.

PTS: 1 DIF: Moderate REF: p. 141 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 6. A patient who emigrated from India is admitted to the medical step-down unit with a bowel obstruction. A nasogastric (NG) tube is inserted to decompress her stomach. She asks the nurse if her daughter can bring in garlic to administerthrough her NG tube. The nurse tells the patient that she will ask the physician when she makes rounds. This nurse is utilizing the theory developed by which nurse theorist?

1) Betty Neuman2) Dorothea Orem3) Callista Roy4) Madeline LeiningerANS: 4 The nurse is utilizing the theory developed by Madeline Leininger. Leiningers theory focuses on the values of cultural diversity. According to her theory, the nurse must make cultural accommodations for the health benefit of the patient.

PTS:1DIF:ModerateREF:p. 142-143

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 7. According to Maslows hierarchy of needs, which patient need should thenurse address first?

1) Protecting the patient against falls2) Protecting the patient from an abusive spouse3) Promoting rest in the critically ill patient4) Promoting self-esteem after a body image changeANS: 3 According to Maslows hierarchy of needs, basic physiological needs should bemet first.

They include the need for rest, food, air, water, temperature regulation, elimination, sex, and physical activity. Therefore, the nurse shouldaddress the critically ill patients need for rest first.

PTS:1DIF:ModerateREF: p. 144 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 8. A nurse researcher is designing a research project. After identifying andstating the problem, the nurse researcher clarifies the purpose of the study.

Which step in the research process should she complete next?1) Perform a literature review.2) Develop a conceptual framework.3) Formulate the hypothesis.4) Define the study variables.ANS: 1 After identifying and stating the problem, the nurse researcher should clarify thepurpose of the study. Next, the researcher should perform a literature search to find out what is already known about the problem. After the literature search, the researcher should choose a conceptual framework to guide the research, formulate the hypothesis or research question, and define the study variables.

PTS:1DIF:ModerateREF:p. 151-152 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Comprehension 9. The mother of a child participating in a research study that uses high- dose steroids wishes to withdraw her child from the study. Despite reassurancethat adverse reactions to steroids in children are uncommon, the mother still wishes to withdraw. By withdrawing from the study, the mother is exercising which right? The right 1) Not to be harmed2) To self-determination3) To full disclosure4) Of confidentialityANS: 2 The mother is exercising the right to self-determination. This refers to the right of the participant (or parent in the case of a minor) to withdraw from a researchstudy at any time and for any reason. The right to not be harmed outlines the safety protocols of the study. All research participants also have the right to full disclosure. This guarantees the participants answers to questions, such as the purpose of the research study, the risks and benefits, and what happens if the patient feels worse as a result of the study.

Moreover, participants also have theright to confidentiality. Typically that right is preserved by

giving participants anidentification code rather than associating them by name.

PTS:1DIF:ModerateREF:p. 151 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 10. After suffering an acute myocardial infarction, a patient attends cardiac rehabilitation.

This will help to gradually build his exercise tolerance. According to Maslows hierarchy of needs, cardiac rehabilitation most directly addresses which need? 1) Safety and security2) Physiological3) Self-actualization4) Self-esteemANS: 2 Cardiac rehabilitation most directly addresses the patients physiological need for physical activity as well as for health and healing. Indirectly, of course, betterphysical condition might enable the patient to perform activities that would lead to higher self- esteem and even selfactualization.

PTS:1DIF:ModerateREF: p. 144 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Application 11. In his later work, Maslow identified growth needs that must be metbefore reaching self-actualization. These needs include 1) Cognitive and aesthetic needs2) Love and belonging needs 3) Safety and security needs4) Physiological and self-esteem needsANS: 1 In his later work, Maslow identified two growth needs that must be met before reaching selfactualization. They include cognitive (to know, understand, and explore) and aesthetic (for symmetry, order, and beauty) needs. The needs Maslow identified in his earlier work were physiological, safety and security, loveand belonging, esteem, and self-actualization.

PTS:1DIF:EasyREF: p. 144-145 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 12. The PICO question reads, Is TENS effective in the management of chronic lowback pain in adults? Which part of this question comes from the I inPICO? 1) Adults2) Management3) Pain 4) TENS ANS: 4 TENS is the intervention (I) in the PICO system. Adults comes from patient (P). Management comes from the outcome (O). There is no comparison intervention (C) in this PICO question.

PTS:1DIFifficultREF:p. 152 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 13. While reading a journal article, the nurse asks herself these questions:What is this about overall? Is it true in whole or in part? Does it matter to my practice? What is this nurse doing?

1) Reading the article analytically2) Performing a literature review3) Formulating a searchable question4) Determining the soundness of the articleANS: 1 Analytical reading involves questioning the article to be sure you understand itand to determine whether it is applicable to your practice. Such reading asks these questions: What is this about as a whole? Is it true in whole or in part?

Does it matter to my practice? A literature review is performed by searching indexes and databases and reading more than one article. Formulating a searchable question involves creating a PICO-type statement to guide a searchof the literature. The nurse would determine whether the article is a research report by looking for the individual parts of the article to see if they were present in the form of research (e.g., title, problem, hypothesis, purpose, methods, data, data analysis, conclusions).

PTS:1DIF:ModerateREF:p. 153 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application Completion Complete each statement.

1.

1. Nursing research is based on the

method.

ANS: scientific Nursing research is based on the scientific method. It is the process in which the researcher, through use of senses, systematically collects observable, verifiable data to describe, explain, or predict events.

PTS:1DIF:EasyREF:p. 149 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall

2. The unit council in the intensive care unit is designing a research study to seeif they are meeting the spiritual needs of their patients. The study will involve patient interviews after discharge. After the interview process, the staff will examine patient statements for recurring themes. The unit council is conducting research.ANS: qualitative The unit council is conducting qualitative research, which focuses on the lived experiences of people.

PTS:1DIF:ModerateREF:p. 149

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application

3. A 56-year-old patient diagnosed with an acute myocardial infarction (heart attack) makes inappropriate sexual comments to the licensed practical nurse (LPN). The LPN is visibly upset. The registered nurse (RN) assigned to the patientinforms the patient that his behavior is unacceptable and will not be tolerated. Isthe RN demonstrating holistic or mechanistic nursing?

ANS: mechanistic The nurse is demonstrating the mechanistic nursing approach, which focuses ongetting the task done.

PTS:1DIF:ModerateREF:p. 136 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application

4. A 23-year-old athlete decides to donate bone marrow for a child who requiresa bone marrow transplant to fight leukemia. According to Maslows later work, this athlete is fulfilling his need for .

ANS: self-transcendence Self-transcendence is the drive to connect to something beyond oneself and tohelp others recognize their potential. Donating bone marrow to someone to improve his or her life fulfills the need for self-transcendence.

PTS:1DIFifficultREF: p. 145 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application True/False Indicate whether the statement is true or false.

1. Institutional review boards were created to protect the rights of research participants.

ANS: T Every healthcare facility and university that receives federal funding must havean institutional review board to protect the rights of research participants.

PTS:1DIF:EasyREF:p. 151 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Recall 2. A novice nurse is not qualified to identify clinical problems for research.ANS: F Even a novice nurse can identify clinical problems for research.PTS:1DIF:EasyREF:p. 151 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall

Chapter 5. Ethics & Values

Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A 77-year-old woman with an inoperable brain tumor has been hospitalized for the past 5 days. Her daughter comes to visit her. The patient has asked that her daughter not be told her diagnosis. After visiting with her mother, the daughter asks to speak to the nurse. She says, My mother claims she has pneumonia, but I know she is not telling me the truth. The daughter asks the nurse to tell her what is truly wrong with her mother. The nurse shouldtell her that: 1) Her mother has an inoperable brain tumor, but does not wish anyone to know.2) She needs to speak to the physician in charge of her mothers care.3) Her mother has requested that her case not be discussed with anyone, not evenfamily. 4) Her mother is very sick with a serious case of pneumonia that could lead todeath. ANS: 3 The nurses first allegiance is to the patient and her desire for confidentiality. Telling the daughter to speak to the physician would place the physician in the same position as the nurse.

Telling her that her mother has pneumonia would bea lie. The nurse, of course, should inform the physician of the patients wishes so that he will be prepared if the daughter questions him about her mothers health condition.

PTS:1DIF:ModerateREF:p. 1529 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 2. Which of the following terms refers to the ethical questions that arise outof nursing practice?

1) Nursing ethics2) Bioethics3) Ethical dilemma4) Moral distressANS: 1 Nursing ethics refers to ethical questions that arise out of nursing practice. Bioethics is a broader field that refers to the application of ethics to healthcare.An ethical dilemma occurs when a choice must be made between two equally undesirable actions, and there is no clearly right or wrong option. Moral distressoccurs when someone is unable to carry out his or her moral decision.

PTS:1DIF:ModerateREF:V1, p. 1526 1) KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 3. A belief about the worth of something that serves as a principle or astandard that influences decision making is called which of the following?

1)

Morals Attitudes3) Beliefs4) ValuesANS: 4 A value is a belief you have about the worth of something that serves as a principle or a standard that influences decision making. Morals are private, personal, or group standards of right and wrong. Attitudes are mental dispositions or feelings toward a person, object, or idea. A belief is somethingthat one accepts as true.

PTS: 1 DIF: Difficult REF: p. 1530 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 4. A 45-year-old patient is ventilator dependent after a high cervical neckinjury. He is conscious and competent and has decided that he wants to be removed from the ventilator.

His family and the multidisciplinary team agree. The nurse believes the patient intends suicide and would prefer he choose differently but says nothing. The nurse remains at the bedside holding the patients hand. In this instance the nurse is displaying which of the following?

1) Value set2) Value system3) Value neutrality Value awarenessANS: 3 Value neutrality occurs when we put aside our own values regarding an issue in order to provide nonjudgmental care to clients. A value set is your list of values.A value system is your value set with the values ranked on a continuum from most important to least important.

PTS:1DIF:ModerateREF:p. 1532 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 5. A 45-year-old patient is ventilator dependent after a high cervical neck injury. He is alert and oriented and, after giving it much thought, has decided that he wants to be removed from the ventilator. The nurse believes the patientintends suicide but supports his final decision.

When the ventilator is removed, the nurse remains with the patient to support him. The nurses action demonstrates respect for what moral principle?

1) 1) Nonmaleficence2) Autonomy3) Beneficence4) FidelityANS: 2 Autonomy refers to a persons right to choose and his ability to act on thatchoice. In this case, the nurse respects the patients right to choose to die.

Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good. Fidelity is the obligation to keep promises.

PTS:1DIF:ModerateREF:p. 1534 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 6. Which of the following consequentialist theories takes the position thatthe value of an

action is determined by its usefulness?

1) Ethics of care2) Utilitarianism3) Deontology4) Categorical imperativeANS: 2 Utilitarianism is a consequentialist theory that takes the position that the value of an action is determined by its usefulness. An ethics of care is a nursing philosophy that directs attention to the specific situations of individual patients viewed within the context of their life narrative. Deontology considers an actionto be right or wrong independent of its consequences. A categorical imperative is a principle, established by Immanuel Kant, that states that one should act only if the action is based on a principle that is universal.

PTS:1DIF:EasyREF:p. 1532 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 7. The ability of nurses to base their practice on professional standards of ethical conduct and to participate in ethical decision making is known as whichof the following?

1) Ethical agency2) Attitudes3) Belief4) Value neutralityANS: 1 Ethical agency is the ability of nurses to base their practice on professional standards of ethical conduct and to participate in ethical decision making. Attitudes are mental dispositions or feelings toward a person, object, or idea. Abelief is something that one accepts as true. Value neutrality is when we attempt to understand our own values regarding an issue and to know when to put them aside, if necessary, to become 1) nonjudgmental when providing care toclients. PTS: 1 DIF: Moderate REF: p. 1527 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 8. Identify the third step in the MORAL decision-making model.1) Reassess the dilemma2) Resolve the dilemma3) Review the problem4) Recall the history of the problemANS: 2 MORAL is an acronym for the following steps: M, Massage the dilemma; O, Outline the options; R, Resolve the dilemma; A, Act by applying the chosenoption; L, Look back and evaluate.

PTS: 1 DIF: Easy REF: pp. 1540-1541 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 9. A patient has asked the nurse to explain her laboratory results. The nurseinforms the patient that he must first assist another patient to the bathroom andthen he will explain the

results. The nurse assists the other patient to the bathroom and then returns to explain the results to the patient. What moral principle has the nurse displayed?

1) Nonmaleficence2) Autonomy3) Beneficence4) FidelityANS: 4 Fidelity is the obligation to keep promises. Autonomy refers to a persons right tochoose and his ability to act on that choice. Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good.

PTS:1DIF:ModerateREF:p. 1535 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 10. The nurse is a member of the ethics committee. An alert, oriented, andcompetent 87year-old man has asked to have a DNAR order put on his chart.

The patients family does not agree with his decision and requests the ethics committee to intervene on their behalf. The ethics committee would most likelyuse which model in this patients case?

1) Social justice2) Patient benefit3) Autonomy4) DNAR determinationANS: 3 The autonomy model is useful when the patient is competent to decide. This model 1) emphasizes patient autonomy and choice as the highest values. The patient benefit model assists in decision making for the incompetent patient by using substituted judgment. The social justice model focuses more on broad social issues involving the entire institution rather than on a single patient issue.There is no DNAR determination model.

PTS:1DIF:ModerateREF:p. 1542 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Synthesis 11. A 60-year-old patient with a treatable form of breast cancer has decidednot to pursue radiation or chemotherapy. The nurse believes that the patient should be treated. She coerces her into receiving treatment by continuing to remind the patient about her responsibilities for raising her children. What type of behavior has the nurse displayed? 1) Nonmaleficence2) Autonomy3) Paternalism4) BeneficenceANS: 3 Paternalistic behavior occurs when the nurse thinks she knows what is best for a competent patient and coerces the patient to act as she wishes rather than to act as the patient originally desired. Autonomy refers to a persons right to choose and his ability to act on that choice.

Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good.

PTS:1DIF:ModerateREF:p. 1535 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 12. Nursing codes are: Legally binding.2) Not legally binding.3) Legally binding in some circumstances.4) Not admissible in court.ANS: 2 Codes of ethics are open to public scrutiny. The ethical aspects of nursing work,just like the technical aspects, are subject to review by professional groups andlicensure boards, which may use sanctions to punish code violations. However, nursing codes are not legally binding.

PTS:1DIFifficultREF:p. 1536 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 13. An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR order put on his chart. The patients family does not agree with his decision and asks the healthcare team toignore the request. After a great deal of discussion among the physician, nurse, and family, they are no closer to 1) resolution of the conflict. The nurse asks the hospital chaplain to come and help the family and the team understand each others opposing views. Which step of the MORAL model does this illustrate?

1) MMassage the dilemma2) OOutline the options RResolve the dilemma4) LLook back and evaluateANS: 2 This illustrates the Outlining-options step. In Massaging the dilemma, the team would already have identified and defined the issues in the dilemma, and considered the values and options of all the major players. At the Outlining the options step, someone should delineate all of the options to all parties, includingthose that are less realistic and conflicting. In that step, someone often asks a member of the ethics committee or the hospital chaplain to help the parties understand the opposing viewpoints. Resolving the dilemma is the step in which all the options are reviewed and basic moral principles and frameworks are applied to arrive at a decision.

Looking back to evaluate is done after a decision has been made and acted on. At that time, the entire process, including the consequences, is evaluated to determine how well it worked.

PTS: 1 DIF: Difficult REF: pp. 1540-1541 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 14. An alert, oriented, and competent frail older adult man has been told that he is dying, and has asked to have a DNAR order put on his chart. The patients family does not agree with his decision and asks the healthcare team toignore the request. The healthcare team does not comply with the familys wishes, and after several days the family takes the matter to court. The court sides with the family and orders the healthcare team to remove the

DNAR order.This is an example of which of the following?

1) An integrity-producing (good) compromise An ethically sound compromise3) Settlement of an issue by force4) An effort to keep peace on the unitANS: 3 This is clearly an example of settling an issue by force, bringing in a more powerful entity (the court) to force the healthcare team to do what the family wants. It is not a compromiseof any sortbecause neither party backed away from its original position, and the action that was taken was not agreed on by both parties. This was not an effort to keep peace. The familys effort was to settle the disagreement in their favor. If the healthcare teams goal had been to keep peace on the unit, they would have acceded to the familys wishes withoutthe need for court order.

PTS:1DIFifficultREF:p. 1542 1) KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which of the following is an example of whistle-blowing? Choose all thatapply. 1) Reporting fraudulent billing practices2) Reporting patients health status against the patients wishes Reporting unsafe work practices4) Reporting a coworker for working under the influence of drugsANS: 1, 3, 4 Reporting a patients health status against the patients wishes is a breach of patient confidentiality.

Whistle-blowing is identifying incompetent, unethical, orillegal situations or actions of others in the workplace and reporting to someonewho may be in a position to rectify the situation. Fraudulent billing practices areillegal and unethical; unsafe work practices are unethical and illegal; and a coworker under the influence of drugs is a risk to patients, as well acting in an illegal and unethical manner.

PTS: 1 DIF: Moderate REF: p. 1528; requires critical thinking KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis 2. The nurses obligations in ethical decisions include which of the following?

Choose all that apply.

1) Be a patient advocate.2) Involve institutional ethics committees.3) Improve one’s own ethical decision making.4) Respect patient confidentiality.ANS: 1, 2, 3, 4 The nurses obligations in ethical decisions include being a patient advocate, using and participating in institutional ethics committees, and improving ethicaldecision making. Confidentiality is a basic patient right. The nurses role is to uphold that right.

PTS:1DIF:ModerateREF:p. 1542 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Completion Complete each statement.

1.

refer to private, personal, or group standards of right andwrong.

ANS: Morals PTS:1DIF:EasyREF:p. 1526 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Comprehension 1) 2.

refers to the application of ethical principles to healthcare.ANS:

Bioethics PTS:1DIF:ModerateREF:p. 1526 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension3. duty to do or promote good.

ANS: Beneficence PTS:1DIF:EasyREF:p. 1534 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension

is the

Chapter 6. Life Span: Infancy Through Middle Adulthood Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The nurse is providing prenatal counseling for a couple who is trying to become pregnant. The priority for the nurse is to include which of the followingpieces of information?

1) Stages of growth and development of the fetus2) Recommended schedule of visits to her healthcare provider3) Recommended average weight gain during pregnancy4) Healthy eating habits before and during pregnancyANS: 4 Maternal nutrition is vital to the healthy growth of the fetus. Poor maternal nutrition leads to an undergrown placenta. A small, poorly functioning placenta and smaller than normal umbilical cord are the causes for small-for-gestational age (otherwise known as small-fordates) babies. The other options are all things the prospective mother needs to know, but they would not have an immediateimpact on fetal health.

PTS: 1 DIF: Moderate REF: p. 166 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Analysis 2. Which of the following would indicate a 4-year-old child has successfullygone through Eriksons Stage 3 (Initiative Versus Guilt)? The child 1) Refrains from hitting a friend2) Plays cooperatively with friends3) Is able to develop friendships4) Is able to express his feelingsANS: 1 Stage 3 is Initiative Versus Guilt, in which the child becomes responsible for his behavior, develops self-discipline, and is able to manage his impulses.

Cooperation and expressing feelings are tasks for Stage 2. Children developfriendships during the preschool age.

PTS: 1 DIF: Moderate REF: pp. 163-164 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 3. The nurse is preparing to assess a toddler. To make the assessment gosmoothly, before examining the child the nurse should first 1) Talk to the mother before talking to the child Ask the child about his favorite toy3) Get the childs height and weight4) Ask the mother to undress the childANS: 2 Toddlers have a fear of strangers, so it would be important to establish rapport before examining the child. Although talking to the mother before the child priorto a physical

assessment does not lead to distrust, the action simply does not contribute to building a rapport with the child. Undressing the child before a trusting relationship is established often creates anxiety in the child, leading to uncooperativeness, fear, or withdrawal.

Obtaining the childs height and weight would not help the child feel secure. PTS: 1 DIF: Moderate REF: p. 175 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Application 4. According to Erikson, a behavior demonstrating an importantpsychosocial task for a toddler would be for the child to 1) Act defiantly by refusing to hold her mothers hand while crossing the street2) Recognize that it is wrong to take a toy away from someone else3) Be able to understand the concept of time in hours Express to his parents and playmates that he does not like somethingANS: 1 The primary task during Eriksons stage 2, Autonomy Versus Shame and Doubt, is establishing an identity as separate from the parent/caregiver. A child between 18 months and 3 years typically tests the boundaries as part of exercising his will to control his environment. No is a declaration of independence and a bid for increased autonomy. Acts of independence and autonomy (e.g., refusing to hold her mothers hand) are normal during this developmental stage.

The toddler should be able to tolerate time away from herparents, delay gratification, and have elimination control. The other tasks are accomplished during the preschool stage.

PTS: 1 DIF: Moderate REF: p. 163 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 5. A mother comes to the clinic with her infant for a newborn checkup at 1 week of age. The mother tells the nurse, My baby looks yellow to me. The nurses best response is which of the following?

1) What type of detergent are you using to wash the baby clothes?2) Is there a possibility you had hepatitis during your pregnancy?3) The color is from the breakdown of maternal red blood cells.4) There is a cream you can use to reduce the yellowing.

ANS: 3 Jaundice results from the breakdown of the maternal red blood cells that are in the babys system after birth, which elevates the bilirubin in the serum. If detergent caused a reaction, the reaction would commonly present as a rash. Although hepatitis B virus may pass through the placenta to the fetus, the infantdoes not typically show signs at 1 week of life. If treatment becomes necessary, the infant would receive phototherapy; there is no cream to reduce the yellow appearance related to newborn jaundice.

PTS: 1 DIF: Moderate REF: p. 170 KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level:Application 6. A father brings his toddler to the clinic for well-child care. Which of thefollowing would be most important for the nurse to assess?

1)

How successful the child is with potty training2) How the child acts when you enter the room3) Whether the child is using eating utensils4) Whether the home is child-proofedANS: 4 Although all of these areas address important developmental tasks during the toddler period, safety is the highest priority at this age because the child has increased dexterity, mobility, and determination and is becoming more independent. Potty training is typically accomplished between 18 months and 3years of age but is not a safety concern. It would be normal for a child at this age to be afraid of strangers. The child should be using utensils for most foods,but again it is not a safety concern.

PTS: 1 DIF: Moderate REF: pp. 174-175 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Analysis 7. Which comment made by a woman in her early 50s would be a cueindicating the need for further assessment for a problem?

1) My skin is so dry I need to use lotion every day after I bathe.2) I have episodes when I feel really hot even when others are not.3) Its getting harder to lift those big bags of dog food.4) I have to write myself notes because Im getting so forgetful.ANS: 4 Memory in middle adulthood should remain intact. There is a normal decrease inskin moisture and muscle tone in middle adulthood. The perimenopausal period occurs during this time, hallmarked by hot flashes and night sweats.

PTS: 1 DIF: Moderate REF: pp. 189-191 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 8. The nurse has instructed a group of parents on common adolescent behavior.

Which comment by the parent would indicate the most urgent needfor further discussion?

1) I guess my daughter wont be asking my opinion very much. 2) Im really going to watch my daughters eating habits.3) We are really going to have to think about rules we want to enforce after he getshis drivers license.

4) We dont keep alcohol in the house, so thats at least one thing we dont need toworry about.

ANS: 4 Concerns about alcohol intake during adolescence is highest priority, regardless of whether or not it is stored in the home. Alcohol-related injury and death are arisk that should be avoided in every circumstance. Not having alcohol in the house does not guarantee the teenager wont consume it with his friends. Duringthe teen years, the relationships among peers strengthen and strongly influenceadolescent behavior.

Although the parents typically still maintain influence on the core values in the home, teens seek peers opinions for matters about social life or concerns of everyday living. As teens are developmentally concerned withappearance and social relationships, there can be an overemphasis on body image, leading to obesity, as well as eating disorders. Motor vehicle accidents are the leading cause of death for teenagers, typically due to distractibility, inattention, impulsiveness, and inexperience in various driving situations. PTS: 1 DIF: Moderate REF: p. 183 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis 9. Which of the following would be the priority for most adolescents? Being1) A good student2) Sexually active3) Picked to be on the soccer team4) Able to function independentlyANS: 3 The developmental task during adolescence is to establish personal identity. Socially, preteens and teens are driven by a need to belong to a group. School-age children need to receive positive reinforcement for accomplishments and desired behavior, such as being good students. Although a small number of preadolescents are sexually active, it is not the major focus for this age.

Functioning independently is a task for the young adult.PTS: 1 DIF: Moderate REF: p. 182 KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis 10. During adolescence, it would be most important to encourage the teento eat plenty of 1) Grains2) Dairy products3) Vegetables4) Fruit ANS: 2 Both males and females experience a growth spurt during adolescence. Although the childs diet should include adequate amounts of all the food groups,peak bone mass is attained during this stage, so the child needs to consume adequate calcium, vitamin D, iron, and protein. These nutrients are found in dairy products.

PTS: 1 DIF: Easy REF: pp. 181-182 KEY: Nursing process: Implementation | Client need: HPM | Cognitive level:Application 11. According to Erikson, which of the following must a middle-aged adultdo to be prepared for the final stages of life?

1) Accept the fact that she is getting older.2) Reconcile that death is a part of life.3) Feel she has made a contribution to society.4) Have had a meaningful and intimate relationship.ANS: 3 Generativity Versus Stagnation is the stage Erikson describes for the middle adult. During this stage, a mature adult either continues to gain skills, be productive, and pass on his or her knowledge to the next generation or stagnates. During the middle years, many adults are

realistic and insightful about age-related physical and emotional changes. Others experience difficultycoping with passing youth and advancing age.

Accepting death as a part of thecontinuum of life is a task for the older adult. Developing meaningful relationships is a task most influential for the young adult. PTS: 1 DIF: Moderate REF: p. 190 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall 12. The nurse teaches a mother of a preschool-age child about expected development. Which comment by the parent indicates that she understands the information?

1) She understands the monsters in books are not real.2) When I mention that her birthday is in a week, she understands.3) I am saving to buy her the roller skates shes been asking for.4) I cant expect her to understand when a friend doesnt agree with her.ANS: 3 Preschoolers hand-eye coordination develops markedly during this period. They can hop on one foot, skip, and begin to learn to skate. The imagination of a preschool-age child is typically active, whereby they have fears of mythical figures, such as monsters. They have a limited ability to understand the conceptof time or to tell time. A preschooler has the ability to consider simple viewpoints of other people.

PTS: 1 DIF: Moderate REF: p. 176 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application 13. A mother has brought her 8-month-old daughter to the healthcare clinic for a well-child appointment and any needed immunizations. To assess the childsphysical development with age-appropriate norms, which of the following questions should the nurse ask?

Is your child able to walk while holding onto furniture?2) Is your child able to crawl on her hands and knees?3) Is your child able to pick up food with her fingers?4) Is your child able to sit up without support?ANS: 4 At 7 months, most children can sit up by themselves. Cruising usually occurs around 8 to 12 months. At about 7 to 10 months, a child begins to crawl. Infantsdevelop a pincer grasp around 10 months.

PTS: 1 DIF: Moderate REF: p. 171 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 14. A mother comes to the healthcare clinic for a regular health examination for her 5year-old son prior to kindergarten admission. Which comment by the mother would indicate the need for follow-up questions to themother?

1) Hes not a good boy like my other son.2) Ive had to treat him for lice a couple of times.3) He has an imaginary friend he calls Buddy.

Hes so funny when he imitates his dad doing things.ANS: 1 Negative comments or comparisons with another child can be an indicator of or potential for child abuse. The nurse needs to determine whether this is an actual problem. Head lice are a common health problem for children of this age because of close physical contact with play.

The mother seems to have a healthyattitude about the infestations and to be knowledgeable in the treatment.

Imaginary play, magical thinking, and belief in mythical figures are normal atage 5. A child this age will normally imitate the same-sex parent.

PTS: 1 DIF: Difficult REF: p. 177 p. 82 KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis 15. Which behavior by the mother is most likely to help the infant todevelop trust? 1) Talking to the infant2) Breastfeeding instead of bottle-feeding3) Promptly responding to the infants crying4) Having the infant sleep in the same room with the parentANS: 3 Because the infant is totally dependent on the parents, quickly responding to hiscries promotes attachment and trust. Although all options may promote attachment, they are not absolutely necessary for bonding to occur. Mother- infant attachment is complex and involves all sensesnot simply hearing the mother talk to him. There are physical and emotional benefits to breastfeeding, but it is not necessary for mother-infant attachment. Sleeping in the same room may help the parent respond more quickly to the infants needs but is not the basis for attachment.

PTS: 1 DIF: Moderate REF: p. 171 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 16. The nurse is talking to a class of children, ages 9 to 11 years. For thisage group, it would be most important for the nurse to discuss 1) Safe sex practices2) Healthy food choices3) Use of seat belts and safety equipment4) The importance of getting enough sleepANS: 3 All are important topics to discuss with this age, but children of this age are very active, and injuries are common. Motor vehicle accidents are the most common cause of injury. They are just starting puberty, so sexual activity is still not usual.The discussion of appropriate food choices and getting enough sleep should be done throughout the childs developmental stages; it is not peculiar to ages 10 to12 years. The preteen years are particularly important for adequate sleep and rest primarily because of the physical changes, active social lives, andincreasingly complex demands on their lives.

PTS: 1 DIF: Moderate REF: p. 181

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 17. A 38-year-old client comes into the clinic for a health examination. Knowing the psychosocial development tasks and common health problems forthis age group, it would be most important for the nurse to ask 1) If the client has episodes of feeling depressed2) Whether the client practices safe sex3) About the clients exercise habits4) About the health history of the clients parentsANS: 1 Striving to be self-sufficient and successful and to establish a career and family are the tasks for this age. These tasks are demanding and can be emotionally difficult and potentially cause depression. Untreated depression is a leading cause of death among young adults. Sexually transmitted infections are a risk for this age group but are not as severe a threat as depression. Exercise is important to overall health but is not a source of stress. There are genetic healthproblems that can impact the client, but the question is asking about psychosocial development and common health problems.

PTS: 1 DIF: Difficult REF: p. 187-188 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 18. A mother watches the nurse perform an assessment on her newborn and asks the nurse why she is doing things like stroking the bottom of his feet.The nurse should respond in which of the following ways?

1) Im checking the blood flow to your babys feet to make sure its normal.2) Im testing to see if your babys neuromuscular system is fully developed.3) Im checking to see if your baby has the reflex responses we anticipate.4) Im testing to see if your baby has normal sensation in his feet.ANS: 3 The Babinski reflex is elicited by stroking upward of the side of the sole of the foot. This is one of several reflexes that should be present at birth. Stoking thebottom of the foot is not an assessment of circulation to the feet. The neuromuscular system is not fully developed at birth, but reflexes are present.Because an infant is not able to report sensation, which is a subjective finding,this is not the purpose of the nurses action.

PTS: 1 DIF: Moderate REF: p. 168 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 19. The nurse conducts a class on health promotion to a group of youngadults.

Which of the following comments would indicate the teaching was effective?

1) I need to get screened for colon cancer. 2) Ill start doing testicular self-exams.3) I have to have my prostate checked.4) I dont need to do breast self-exams until I am 40.ANS: 2 Men may choose to perform monthly testicular exams until they are 40 years old. Colon cancer screening begins at age 50. Prostate exams are part of an annual health exam for middle

adults. Even young adults should perform breastself-examination (although some practitioners question recommending it routinely). Whatever screening method is chosen, young adults do develop breast cancer; it is not a problem only for those past age 40.

PTS: 1 DIF: Easy REF: p. 186 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application 20. Which of the following is an example of a school-aged childs meeting psychosocial development tasks? The child 1) Wants to show off the latest trick he can do on his bike2) Becomes interested in friendships with the opposite sex3) Starts to see the value of making good decisions4) Wants to buy the same jacket his friend has ANS: 4 Peers are increasingly more important to the school-age child. The child wants tohave what his friends have. Pride in showing off new skills and possessions is normal for all stages of development, particularly during the preschool period.

Friendships are typically between those the same sex at this age. A valuesystem does not start to develop until adolescence.

PTS: 1 DIF: Moderate REF: p. 179 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Analysis 21. Which of the following would be the most important health assessmentfocus for middle adulthood?

1) Cancer screening with the annual health examinations2) Seeking information about consistent use of seat belts3) Screening for eating disorders4) Mental status exam for cognitive changesANS: 1 Chronic diseases, including cancer, are major health problems for adults in the middle years.

Habits for seat belt use should have already been established; although it may be important to reinforce seat belt use, the most important assessment is cancer screening. Eating disorders are more common in adolescence. In general, cognitive changes such as memory loss and dementiado not develop until older adulthood.

PTS: 1 DIF: Difficult REF: p. 190 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Comprehension 22. A mother and father have brought their school-age child to the emergency department with injuries that cause the nurse to suspect child abuse. The nurse wishes to assess further for abuse and neglect. Which of thefollowing should the nurse do?

1) Interview the parents together and the child separately.2) Have one parent in the room to reassure the child during the interview.3) Interview the child and each parent separately.4)

Request that a sexual assault nurse examiner (SANE) interview the familymembers. ANS: 3 Interviewing each family member separately allows the suspected victim more freedom to express concerns. An abused person may be afraid to talk with the abuser present and may even support the abusers version of events. If two adults accompany a child, the situation still does not allow such freedom, because it may be that one of the adults is abusing both the partner and child. The nurse should separate the caregivers and child to be certain they all tell thesame story. A SANE is needed to perform the physical examination only if sexualabuse is suspected from the interview.

PTS: 1 DIF: Difficult REF: p. 180 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Comprehension Matching Match the developmental milestones with the appropriate age group. There maybe more than one answer for each age group.

1) Infant2) Toddler3) Preschool4) School age5) Adolescent 1.Bones have reached maximum strength 2. Puts toys into toy box 3. Ties her tennis shoes 4. Matches colors and shapes 5. Compares balls with blocks 6.Writes sentences using appropriate grammar 7. Understands that characters in cartoons are not real 8. Finds toys that are hidden 9. Applies reason to his thinking 10. Puts a simple jigsaw puzzle together 11. Tells someone his name, age, and address 12. Understands how much a dollar is 13. Understands what no means

1. ANS: 5 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 2. ANS: 1 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 3. ANS: 4 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 4. ANS: 2 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 5. ANS: 3 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 6. ANS: 4 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 7. ANS: 3 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 8. ANS: 2 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 9. ANS: 5 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 10. ANS: 1 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 11. ANS: 3 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 12. ANS: 4 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 13. ANS: 1 PTS: 1 DIF: Moderate REF: pp. 171-187

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application Match the growth and development theory with the appropriate theorist.1) Human behavior and personality development are driven by instincts; there arefour forces and five stages that influence a persons personality.

2)

Cognitive development is progressive and sequential through four stages; theperson must have the basic abilities of assimilation, accommodation, and adaptation.

There are eight stages of personality development with tasks that must be accomplished at each stage; the greater the achievement of the tasks, the moreadjusted the personality. 4) Humans are born with instinctive needs; lower-level needs must be met beforehigher- level needs and the ability to achieve self-actualization is developed.

5) People interact with their social environment in a process of lifelong learning;there are six stages, each with tasks that must be accomplished during that stage.

14. Erikson 15. Freud 16. Havighurst 17. Piaget 14. ANS: 3 PTS: 1 DIF: Moderate REF: pp. 160-165

KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 15. ANS: 1 PTS: 1 DIF: Moderate REF: pp. 160-165

KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 16. ANS: 5 PTS: 1 DIF: Moderate REF: pp. 160-165

KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 17. ANS: 2 PTS: 1 DIF: Moderate REF: pp. 160-165

KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall

Chapter 7. Life Span: Older Adults Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which of the following is the most common major challenge for olderadults? 1) Dealing with the needs of their children2) Chronic health problems leading to the loss of independence3) Loss of the ability to reminisce about the past4) The decline of intellectual abilitiesANS: 2 Older adults have many losses to deal with, including the development of chronic health concerns and loss of independence. During the older adult years, children often provide care for their aging parents. Loss of short-term memory ismore common than recollection of events involving long-term memory. Older adults have vivid memories of past events. Intellectual abilities do not become impaired with age; short-term memory and reaction time decline.

PTS: 1 DIF: Moderate REF: p.205 KEY: Nursing process: N/A | Client need: PHSI/PSI | Cognitive level:Comprehension 2. Which of the following would be the most important health assessmentfocus for older adulthood?

Cancer screening with the annual health examinations2) Seeking information about consistent use of seat belts3) Screening for eating disorders4) A bone scan (DEXA test) for osteoporosisANS: 1 Chronic diseases, including cancer, are major health problems for older adults. In fact, cancer is the second leading cause of deaths for older adults. Older adults should also have an annual physical exam; they should receive cancer screening at that time. Habits for seat belt use should have already been established; although it may be important to reinforce seat belt use, the most important assessment is cancer screening. Eating disorders are more common inadolescence and young adulthood. Although loss of bone density is fairly common in older adults and can be pathological, it does not assume the status as cancer with regard to mortality for older adults.

PTS: 1 DIF: Difficult REF: pp. 211-212 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Comprehension 3. To which age group do most hospitalized patients belong?1) Infants2) Young adults 3) Middle adults4) Older adultsANS: 4 Half of all hospitalized patients are older adults.PTS: 1 DIF: Easy REF: p. 202 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall 4. Which of the following reflects an understanding of the characteristics ofolder

adults?

1) Fewer than 5% of all older adults live in nursing homes.2) Average life expectancy at birth has declined slightly over the past 10 years.3) In general, males tend to live longer than do females.4) Black men have the lowest life expectancy, but the gap decreases as a personages. ANS: 1 Only 3.3% of people 65 and over live in nursing homes; this rises to 15% for those over 85 years. In the United States, life expectancy at birth has risen dramatically in the past century: In 1900, average life expectancy was 49.2 years; in 2005, average life expectancy was 77.8 years. At age 65, white womenled life expectancy with 20 years, followed closely by black women at 18.7 and white men at 17.2 years, whereas black men at age 65 had the lowest life expectancy at 15.2. The disparity in death rates for people of different races isless for older adults than younger ones.

PTS: 1 DIF: Moderate REF: p. 206 KEY: Nursing process: N/A | Client need: HPM

| Cognitive level: Comprehension

5 A 75-year-old white female patient says, Ive heard that women live to an older age than men do. My husband and I are the same age, so I am afraid I will have to spend some years without him. That really worries me. Which response is based on correct information?

1) That is a realistic concern, as women do have a longer life expectancy thanmen. But many things can happen to change that.

2) You need not worry, because both you and your husband are white. Thatstatistic is true only for black men and women.

3) It is true that women have a longer life expectancy at birth. However, life expectancy measured at age 65 is almost the same for both sexes. You are bothwell past 65.

4) That is true only in certain geographical areas, such as those with a highpopulation of newly retired persons.

ANS: 3 For infants born in 2005, the average total life expectancy for females is 80.4years. Life expectancy measured at age 65 was nearly the same for men and women in1900; however, women had a lead of about 3 years over men in 2005, narrowing the gap as men age. So the longer men live, the longer they will live.

The statistics are true for white people as well as black people. The answer saying, That is a realistic concern . . . is only partially true. Women do have a longer life expectancy at birth, but that tends to almost disappear after men reach age 65, and it continues to lessen as they continue to age. In-migration and out-migration have nothing to do with gender differences in life expectancy,although they do affect the population distribution within a state, for example.

PTS: 1 DIF: Difficult REF: p. 202 KEY: Nursing process: Implementation | Client need: HPM | Cognitive level:Application 6 An 86-year-old patient had prostate surgery 2 days ago. Which nursingaction best meets his developmental needs?

1) Perform a spiritual assessment and make referrals as needed.2) Provide a complete bed bath and other hygiene needs.3) Encourage the patient to perform self-care as much as possible.4) Administer pain medications to keep the patient comfortable.ANS: 3 An important nursing goals for all older adults should be to maintain the personsability to function independently for as long as possible. Encouraging self-care will help to achieve that goal. A spiritual assessment is appropriate but is not a need of older adults any more than of other age groups. Providing hygiene needs does not promote independence. Administering analgesics is appropriate but does not encourage functional independence.

PTS: 1 DIF: Moderate REF: Cp. 212 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application 7. A client tells the nurse, I cant see well enough to read anymore. I havenew glasses, but its still hard. What should the nurse advise her to do first?

1) Go back to the eye doctor and have him check your glasses.2) Buy some audio books and listen to those.3) Adapt to reading less and find a new leisure activity.4) Install a bright but glare-free light near where you read.ANS: 4 With aging, there is decreased pupil accommodation, decreased tear production,and thickening of the lens of the eye. All of these contribute to impaired near vision (presbyopia). Decrease in pupil accommodation allows less light into the eye, so in order to read, the person needs a good light. However, there is also increased sensitivity to glare, so the light should have a glare-free bulb. The patient should try this first, since she already has new glasses. If this doesnt help, then perhaps she should have the glasses rechecked. If her vision cannot be improved, then she could think about buying audio books and other ways to adapt to her difficulty reading.

PTS: 1 DIF: Moderate REF: Cp. 214 KEY: Nursing process: Implementation | Client need: HPM | Cognitive level:Application 8. A couple is planning to move to a housing development that has been built to provide elder-friendly dwellings and environments for independent living.The houses are smaller and on a single level. Their purchase includes home maintenance and repair, snow and trash removal, a pool, and a walking track.Only people 60 years and older qualify to buy a house in this community.

Medical and nursing care are not a part of the purchase. How would their livingsituation be described?

1) Naturally occurring retirement community2) Retirement community3)

Continuing care retirement community4) Assisted living facilitiesANS: 2 The scenario describes a retirement community. A naturally occurring retirement community is one in which the person ages in place, living in the same home as always and in a neighborhood where the neighbors have aged together and have provided support for each other through the years. A continuing care retirement community is residential living (e.g., cottages, cluster homes, apartments) into which a person must move. The person pays an entrance fee and monthly fees. In return, the contract provides for assistance with activities of daily living, coordinated social activities, health monitoring, and so on. There is usually a health clinic on site. Assisted living facilities (ALFs) are congregate residential settings that provide or coordinate personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health- related services. State regulations and level of services preclude residents from staying in an ALF when their needs become greater than the resources and services provided.

PTS: 1 DIF: Moderate REF: p. 205 KEY: Nursing process: Implementation | Client need: HPM | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. A client is concerned about the age-related changes of her mother, who is 80 years old.

Which statement(s) made by the client would likely represent a normal change of aging?

1) My mother seems to get cold very easily.2) My mother complains of her mouth being dry.3) Mother goes around the house turning on all the lights.4) Mother complains of leaking urine when she coughs.ANS: 1, 2, 3 Incontinence is not a normal part of aging and should be explored further. The thinning of the layers of the skin causes older adults to feel colda normal part ofaging. With aging, the brown fat layer, which contributes to generating and maintaining body temperature, becomes thinner as well. This is not the same type of fat as adipose, which is a white fat layer.

Additionally, older adults who are sedentary often feel cooler. The elderly normally experience a decrease in saliva production, so although this is also a symptom of dehydration, dry mouth is a normal change of aging. Visual acuity decreases with age, but this, too, is a normal part of aging.

PTS: 1 DIF: Moderate REF: pp. 208-209, 214 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 2. A client lives alone. He is very weak, stays in bed most of the time, andbecomes fatigued after taking only two or three steps with a walker. His personal hygiene is poor. He moves very slowly when doing even small tasks, such as eating a meal. Which of the following are appropriate interventions forthis patient? Choose all that apply; assume all are possible.

1) Arrange for a home aide to assist with activities of daily living.2) Refer the client to a senior center for an adapted physical activity (APA)program. 3)

Assess the patient for symptoms of depression and memory loss.4) Arrange for nutritious meals to be delivered to the patients home.ANS: 1, 3, 4 This client has the characteristics of frailty: low physical activity, muscle weakness, fatigue, and slowed performance. Clearly, the client is not able to perform ADLs adequately; therefore, a home aide is needed. Adapted physicalactivity programs are designed for adults in better physical health, not for frailelders. The client would be unlikely to benefit from an APA and probably couldnot even participate in such a group activity. Depression and impaired mental abilities tend to accompany frailty, so it is important to assess those for this client. Nutrition is essential to slow the progression of frailty, so having meals delivered is both appropriate and important.

PTS: 1 DIF: Difficult REF: pp. 214-216 KEY: Nursing process: Interventions | Client need: PHSI/PSI | Cognitive level: Application 3. When interpreting a population pyramid, which of the following do youneed to know?

1) The youngest age group makes up the base of the pyramid.2) Men are on the left side of the pyramid and women on the right.3) The length of a bar indicates how many people are in that age category.4) Adolescents are the youngest group on the pyramid.ANS: 1, 2 Age distribution of a population is often illustrated in a pyramid, with the youngest age group (04) at the base and the oldest age group (85+) at the peak, and men on the left of the figure and women on the right. The shape of apopulation pyramid changes to rectangle in developed countries with fewer births and increased life expectancy. The length of a bar does not indicate the absolute number of people in a category; it indicates the proportion of the totalpopulation represented by that category.

PTS: 1 DIF: Difficult REF: pp. 203-204 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 4. How can the nurse facilitate communication with an older adult?1) Assess for hearing deficit at the beginning of the interaction.

Speak in a more loudly than normal, and at a slightly higher pitch.3) Pay special attention to cues from body language.4) Speak slowly, allowing time for the patient to word his answers.ANS: 1, 3, 4 The nurse should check for sensory deficits at the beginning of the interaction so he can allow for lip reading, as needed. Because older adults sometimes havedifficulty expressing themselves, body language (e.g., wringing hands, fidgeting)is especially important. Because older adults process information slowly, the nurse should speak slowly, allowing them to formulate their answers. Speakingslowly does not mean the nurse should speak loudly or at a higher pitch. Manyolder adults have high-pitch hearing loss.

PTS: 1 DIF: Moderate REF: p. 214 KEY: Nursing process: Implementation | Client need: HPM | Cognitive level: Comprehension 5. Which older adult is experiencing normal aging changes of the urinarysystem? 1) A man who has difficulty voiding, especially when starting his stream2) A

woman who wakes up to void once during the night3) A man who has difficulty getting a hard erection A man who says he has burning when he urinatesANS: 2, 3 Because of changes in bladder capacity and changes in blood flow to the kidneys, many older adults wake at least once during the night to void. Sexual response changes are also normal; it is common for older adult men to have lessfirm erections. A man who has difficulty starting his urine stream and voiding likely has an enlarged prostate, which is physiologically not normal. Burning on urination is indicative of a bladder infection and is not normal.

PTS: 1 DIF: Moderate REF: p. 214 KEY: Nursing process: Analysis/Diagnosis | Client need: HPM | Cognitive level: Analysis Matching Match the paramount developmental challenge with the appropriate age group.1) Youngold2) Middle-old3) Old-old4) Frail elderly 1. Preventing or slowing the spiral of vulnerability 2. Transitioning to retirement 3. Sensory impairments, oral health, nutritional intake, functional limitations 4. An increasing solitary, sedentary lifestyle Match the descriptions of the theory with the appropriate theory of aging.5) The person should stay as active and engaged as possible to enjoy the most life satisfaction.

6) People age because repeated insults and the accumulation of metabolic wastes eventually cause cells to wear out and cease functioning.

7) The older adult and society gradually and mutually withdraw from each other.

Interaction between a person and his world decreases over time.

8) Ego integrity versus despair is the task for older adults. The person accepts thathis life has had meaning and that death is a part of the continuum of life.

9) People age because cells have a preprogrammed, finite number of cell divisions.Hence, the time of death is determined at birth.

10) A malfunction in the cell causes changes in cellular DNA, leading to problems with cell replication. The cellular malfunction may be the result of free radicalsthat damage cells and

impair their ability to function normally.

5. Disengagement theory 6. Activity theory 7. Psychosocial development theory 8. Wear-and-tear theory 9. Genetic theories 10. Cellular malfunction theory 1. ANS: 4 PTS: 1 DIF: Moderate REF: pp. 206-207

KEY: Nursing process: Planning | Client need: HPM | Cognitive level:Comprehension 2. ANS: 1 PTS: 1 DIF: Moderate REF: pp. 206-207

KEY: Nursing process: Planning | Client need: HPM | Cognitive level:Comprehension 3. ANS: 3 PTS: 1 DIF: Moderate REF: pp. 206-207

KEY: Nursing process: Planning | Client need: HPM | Cognitive level:Comprehension 4. ANS: 2 PTS: 1 DIF: Moderate REF: pp. 206-207

KEY: Nursing process: Planning | Client need: HPM | Cognitive level:Comprehension 5. ANS: 3 PTS: 1 DIF: Moderate REF: p. 209

KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 6. ANS: 1 PTS: 1 DIF: Moderate REF: p. 209

KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 7. ANS: 4 PTS: 1 DIF: Moderate REF: p. 209

KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 8. ANS: 2 PTS: 1 DIF: Moderate REF: p. 206

KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 9. ANS: 5 PTS: 1 DIF: Moderate REF: p. 206

KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 10. ANS: 6 PTS: 1 DIF: Moderate REF: p. 206

KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension

Chapter 8. Promoting Wellness: Health & Illness Multiple Choice Identify the choice that best completes the statement or answers the question.

1. In an effort to promote health, the home health nurse opens the clients bedroom windows to let in fresh air and sunlight, washes her hands often, and teaches the patient and family about the importance of hygiene and cleanliness.This most closely illustrates the ideas of which of the following people?

1) Jean Watson2) Jurgen Moltmann3) Florence Nightingale4) Robert Louis StevensonANS: 3 Florence Nightingale believed that health was prevention of disease through theuse of fresh air, pure water, efficient drainage, cleanliness, and light. Jean Watson believes that health has three elements: a high level of overall physical, mental, and social functioning; a general adaptivemaintenance level of daily functioning; and the absence of illness (or the presence of efforts that lead to itsabsence). Jurgen Moltmann believes that true health is the strength to live, the strength to suffer, and the strength to die. He also stated that health is not a condition of the body; it is the power of the soul to cope with the varying condition of that body. Robert Louis Stevenson wrote that health is not a matterof holding good cards; it is playing a poor hand well.

PTS: 1 DIF: Easy REF: p. 222 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 2. Which of the following is known to be a healthy strategy for coping withstress? 1) Performing meaningful work2) Consuming simple carbohydrates3) Drinking three glasses of red wine each day4) Weight trainingANS: 1 Many individuals find that meaningful work is a healthy way to cope with stressors.

Consuming simple carbohydrates is not a healthy way to cope with stress. Drinking more than one glass of red wine each day is considered unhealthy. Weight training has been shown to increase bone density and reducethe risk of osteoporosis and heart disease but not necessarily to reduce stress.

PTS:1DIF:ModerateREF:p. 225 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application 3. Which family would most likely be helpful in encouraging the client to experience a high level of wellness? A family who Controls feelings to avoid conflict2) Teaches negotiation skills and independence3) Encourages risk taking and adventure4) Views

themselves as helpless victimsANS: 2 Families who promote independence and teach good negotiation skills enable family members to experience a high level of wellness by thinking for themselves. In contrast, families who tend to squelch personal feelings to avoidconflict may not allow a high level of wellness.

Families who emphasize caution in new situations are more beneficial than those who encourage risk-taking.

Families who view themselves as capable and successful are more advantageous than those who view themselves as helpless victims.

PTS:1DIF:EasyREF:p. 225 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 4. The client is a 76-year-old man who is experiencing chronic illness. Hehas a geneticlinked anemia. He says he does not eat a balanced diet, as he prefers sweets to meat and vegetables. Which of the following dimensions ofhealth can the nurse most likely influence by teaching and counseling him?

1) Age-related changes2) Genetic anemia Eating habits4) Gender-related issuesANS: 3 The nurse is most likely to influence the patients eating habits because those are the dimension over which he has the most control and, therefore, has the most potential for changing.

Although people consider biological factors when they describe themselves as well or ill, they are not entirely within our control.Biological factors include age and developmental stage, genetic makeup, and sex.

PTS:1DIF:EasyREF:p. 224 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application 5. What type of loss is most common among patients who are hospitalizedfor complex health conditions?

1) Privacy2) Dignity3) Functional4) IdentityANS: 2 Hospitalized patients commonly experience the loss of dignity. Wearing a hospital gown, having their body exposed, invasive procedures, loss of controlover body functionsall of these contribute to loss of dignity, and all are very common among hospitalized patients.

Healthcare providers have a duty to protect privacy and confidentiality of patients, even though it is certainly threatened by some situations during hospitalization. Some patients lose functioning and identity during hospitalization, but they are not common occurrences.

PTS:1DIF:ModerateREF:p. 227 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level:Comprehension

6. A 62-year-old patient is admitted to the hospital with hypertension. Which question by the nurse is most important when performing the initial assessment interview?

1) What medications do you take at home?2) Do you have any environmental, food, or drug allergies?3) Do you have an advance directive?4) What is the greatest concern you are dealing with today?ANS: 4 It is most important for the nurse to ask the patient about his greatest concern. His concern can then be incorporated into the plan of care, making sure that hisneeds are met. Asking about medications, allergies, and an advance directive is also important but does not take priority over asking about the patients greatestconcern.

PTS:1DIF:ModerateREF:p. 231 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis 7. When developing goals, which guideline should the nurse keep in mind?Goals should be 1) Realistic so that progress is recognized by the patient2) Developed solely by the healthcare team3) Developed without family input, to maintain confidentiality4) Valued by the multidisciplinary care providersANS: 1 Goals should be realistic so that progress is recognized by the patient. They should be valued by both the patient and family. The nurse should develop goalswith input from the patient and his family.

PTS:1DIF:ModerateREF:p. 231 KEY: Nursing process: Planning | Client need: SECE | Cognitive level:Comprehension 8. Which one of the following important nursing actions is a hospitalized patient likely to experience on an emotional level and remember long after thishospitalization has ended?

Administering her medications according to schedule2) Allowing flexible visitation by her family and friends3) Explaining treatment options in terms she can understand4) Providing a healing presence by listening and being attentiveANS: 4 The nurse can contribute meaningfully to the patients hospitalization by providing a healing presence. The nurse can do this by listening to the patient and being attentive. Administering medications according to schedule, allowingflexible visitation, and explaining treatment options are important contributionsthat the nurse can make, but they will not be most meaningful to the patient.

Patients may be impressed, even amazed, by the healthcare technology used to diagnose and treat their illnesses. However, often what they remember, perhapsthrough the rest of their lives, is the people who connected with them in a personal way.

PTS:1DIF:ModerateREF:p. 232 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Comprehension 9. Which statement best describes the health/illness continuum? 1) Health is the absence of disease; illness is the presence of disease.2) Health and illness are along a continuum that cannot be divided.

Health is remission of disease; illness is exacerbation of disease.4) Health is not having illness; illness is not having health.ANS: 2 The health/illness continuum is best described as a graduated spectrum that cannot be divided.

PTS:1DIF:ModerateREF:p. 223 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 10. Which of the following helps the body release growth hormone (growth hormone assists in tissue regeneration, synthesis of bone, and formation of red blood cells)?

1) A healthy diet2) Physical activity3) Restful sleep4) Comfortable room temperatureANS: 3 During sleep, our bodies release the majority of our growth hormone, which assists in tissue regeneration, synthesis of bone, and formation of red blood cells. Consuming healthy foods helps prevent disease. Physical activity reducesthe risk of chronic disease and promotes longevity. Keeping the body at a comfortable temperature helps maintain health but not release of growthhormone.

PTS:1DIF:ModerateREF:p. 224 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 11. A client has been hospitalized for 6 weeks. All of the following interventions are good ones, but which intervention is specifically focused onhelping the patient cope with the emotional responses to prolonged hospitalization?

1) Providing skin care every shift to prevent skin breakdown2) Encouraging the patient to get up in a chair to eat meals3) Assisting the patient to ambulate in the hallway for several minutes each day4) Designating a corner of the patients room to display personal mementosANS: 4 The patients environment can help nourish wellness. Helping the patient designate a corner of the room to display personal mementos can be healing and help the patient cope with the prolonged hospitalization. The other interventions might be helpful to the patient but are not as helpful in specificallydealing with hospitalization as is designating a portion of the room that is uniquely hers.

PTS:1DIF:ModerateREF:p. 226 EY: Nursing process: Implementation | Client need: PSI | Cognitive level:Application 12. Which of the following is particularly valuable in helping a patient with a terminal illness maintain a sense of self?

1) Family relationships2) Spirituality3) Nutrition4) Sleep and restANS: 2 When a patient is faced with a terminal illness, spirituality can help the patientmaintain his sense of self. Family relationships can provide a loving, supportivesource of comfort and

reassurance but can sometimes cause the patient pain and a feeling of loneliness when faced with a terminal illness. Nutrition, sleep, and rest are healing but usually not as helpful to a patient with terminal illnessas is spirituality.

PTS:1DIFifficultREF:p. 226 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall 13. A client with a history of schizophrenia is diagnosed with a urinary tract infection. What is probably the most significant barrier this patient faces?

1) Chronic urinary incontinence2) Stigma associated with mental illness 3) Risk for recurring infections4) Auditory hallucinations (hearing things)ANS: 2 Mental illness is associated with a stigma that is usually a barrier, and even considered a debilitating handicap. Chronic urinary incontinence is not commonly associated with urinary tract infection, and nothing in the scenariosuggests that the patient is incontinent. The patient is at risk for recurring urinary tract infections, but this is not considered a debilitating handicap.

Auditory hallucinations are associated with schizophrenia but have not beendescribed as the most debilitating handicap.

PTS:1DIF:ModerateREF:p. 226 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application 14. A 76-year-old patient is admitted with an acute myocardial infarction (heart attack). The doctor tells the patient that an angioplasty is necessary. Thepatient agrees and signs the informed consent. This patient is experiencing which stage of illness behavior?

1) Sick-role behavior2) Seeking professional care3) Experiencing symptoms4) Dependence on others ANS: 4 This patient is experiencing the dependence-on-others stage of illness behavior;he has accepted the diagnosis and treatment of the healthcare provider. The patient entered the experiencing illness stage when he began having chest painat home. He entered the sick-role behavior phase when he admitted to family that he was experiencing chest pain. When he decided to go to the emergency department for healthcare intervention, he entered the seekingprofessional- care stage of illness.

PTS:1DIF:ModerateREF:pp. 228-229 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis 15. Many health providers define illness as pathology; however, peopleexperience, rather than define, illness. Which of the following is how most people experience illness?

1) Feeling lousy, a true sense of not being all right2) A change in the way they feel or a disruption in their typical life3) Something to be dreaded and avoided if at all possible4) An experience that offers the potential for learning and spiritual growthANS: 2 People typically describe their illness in terms of how it makes them feel or the effect it has on day-to-day life. Feeling lousy is inappropriate as many people do not feel lousy when they are ill. For example, hypertension is an illness that mayhave no symptoms. Similarly, patients may have chronic disease that is well managed and therefore does not make them feel ill.

Something to be dreaded and avoided . . . is also not accurate. If a person has an external locus of control,he may view illness as a consequence of actions taken. From this viewpoint, he may have little control over whether he can avoid illness. Finally, although some people do grow and learn in the face of illness, most people do not hold such a positive view about illnessand the question asks how people experience illness.

PTS:1DIF:ModerateREF:p. 222 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall 16. Dunn believes that an individuals state of health should be evaluated inthe context of the persons environment. This approach illustrates that 1) An unhealthy physical environment, characterized by poor living conditions,always has a negative effect on an individuals health 2) Adequate income, food, and shelter create a healthful environment and always improve physical health status 3) Physical environment, family, and social support may help or hinder the healthstatus of an individual 4) The environment that should always be assessed is the clients immediate surroundings; extended boundaries do not apply in an ill state ANS: 3 The home environment, community, family, friends, and support system all influence health status. The balance among these variables has a net positive ornegative effect on a clients health status. The effect of poor living conditions may be offset by the presence of loving family and friends. Poverty does not always have a negative effect on health.

Similarly, the presence of food, shelterand clothing does not always convey protective health, as loneliness and hopelessness may counteract these positive influences.

When examining the clients environment, extended boundaries must be considered, especially whenproviding community-based care.

PTS:1DIFifficultREF:p. 223 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 17. Some people readily become ill when under stress. Others are able todeal with tremendous stress and remain physically and mentally healthy. This disparity is affected by a persons level of hardiness. How can you apply thisknowledge to your nursing care?

1)

You cannot use this information at all. People are innately hardy or not. This issomething that you must merely recognize.

2) You should encourage all people to develop some level of hardiness in order toget through difficult physical and emotional times.

3) You should assess for your own level of hardiness: If you are hardy, you will be abetter nurse; if you are not, you can learn more about hardiness.

4) You can assess for hardiness in patients; you can encourage hardy patients tolearn about their illness as a means for them to be more comfortable.

ANS: 4 Hardiness is a personality trait that helps many cope with stress and illness. As a personality trait, it is unlikely that you can teach or otherwise encourage this trait. Awareness of your own level of hardiness will help you understand your response to stress, but hardiness does not necessarily make you a better nurse.

PTS:1DIFifficultREF:p. 229 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 18. When preparing a room to receive a newly admitted patient, which ofthe following should the nursing assistive personnel (NAP) do?

1) Mop the floor with an approved disinfecting solution.2) Fold the top bed linens back to open the bed.3) Hook up the suction machine and check to see that it is working.4) Position the bed in its lowest position.ANS: 2 The NAP should create an open bed. The housekeeping department is almost always responsible for cleaning the room between patients. The nurse is responsible for hooking up and checking special equipment such as suction. Thenurse would need to tell the NAP whether the patient is to be admitted ambulatory, by wheelchair, or by stretcher to know whether to position the bed high or low.

PTS:1DIF:ModerateREF:p. 233 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 19. When transferring a patient from a hospital to a long-term care facility,which of the following is most helpful in facilitating the patients planning and emotional adjustment?

1) Notify the patient and family as much in advance of the transfer as possible.2) Send a complete copy of the patients medical records to the new facility.3) Carefully coordinate the transfer with the long-term facility to keep it smooth.4) Help arrange for transportation and accompany the patient to the transportvehicle. ANS: 1 Notifying the patient and family well in advance of the transfer allows them timeto adjust

emotionally and to make any necessary plans. A copy of the records is usually sent, and the nurse does coordinate the transfer with the receiving facility; however, that does very little to assist with the patients emotional status or planning. Someone from the hospital may accompany the patient to the car; or if the transfer is by ambulance, perhaps not. Either way, that will nothelp the patient and family to do the necessary planning for the transfer.

PTS: 1 DIF: Moderate REF: p. 233 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 20. A 36-year-old mother of three small children has had nausea, vomiting,and extreme fatigue for the past 2 days. She calls her mother and tells her she is ill and asks if her mother can care for the children. Which stage of illness behavior is she experiencing? Choose all that apply.

1) Sick-role behavior2) Dependence on others3) Seeking professional care4) Experiencing symptomsANS: 1 The 36-year-old mother is assuming sick-role behavior because she is identifying herself as ill. She is also in the stage of experiencing symptoms; she is experiencing symptoms and realizes that illness is starting, even though she hasnot yet entered the stages of dependence and seeking professional care. By telling her mother of the illness, she is relieved of her normal dutiescaring for her children. Dependence on others occurs when the client accepts a diagnosisand treatment from the healthcare provider. Seeking professional care occurs after the sick-role behavior stage. During this stage, the client makes the decision that she is ill and that professional healthcare is needed.

PTS:1DIF:ModerateREF:p. 228 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application

Chapter 9. Stress & Adaptation Multiple Choice Identify the choice that best completes the statement or answers the question.

1.When released in response to alarm, which of the following substancespromotes a sense of well-being?

1) Aldosterone2) Thyroid-stimulating hormone3) Endorphins4) Adrenocorticotropic hormoneANS:3 Endorphins act like opiates to produce a sense of well-being; they are releasedby the hypothalamus and posterior pituitary gland in response to alarm.

Aldosterone promotes fluid retention by increasing the reabsorption of water byrenal tubules.

Thyroid-stimulating hormone increases the efficiency of cellular metabolism and fat conversion to energy for cell and muscle needs.

Adrenocorticotropic hormone stimulates the adrenal cortex to produce andsecrete glucocorticoids and mineralocorticoids.

PTS:1DIF:ModerateREF:p. 253 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 2.After sustaining injuries in a motor vehicle accident, a patient experiencesa decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing?

1) Alarm 2)Resistance 3)Exhaustion4) RecoveryANS:3 Physiological responses in the exhaustion stage include low blood pressure andhigh respiratory and heart rates. During the alarm stage, heart rate and blood pressure both increase. In the resistance stage, the body tries to maintain homeostasis; blood pressure and heart rate normalize. If adaptation is successful, recovery takes place.

PTS:1DIFifficultREF:p. 254 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 3.You are caring for a patient who suddenly experiences a cardiac arrest. As you respond to this emergency, which substance will your body secrete in large amounts to help prepare you to react in this situation?

1) Epinephrine2) Corticotrophin-releasing hormone3) Aldosterone4)

Antidiuretic hormone ANS:1 During the shock phase of the general adaptation syndrome, large amounts of epinephrine prepare the body to react in an emergency situation. In response tothe epinephrine release, the endocrine system releases corticotrophin-releasing hormone, aldosterone, and antidiuretic hormone.

PTS: 1 DIF: Moderate REF: p. 252 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Application 4.What is the function of antidiuretic hormone when released in the alarmstage of the general adaptation syndrome?

1) Promotes fluid retention by increasing the reabsorption of water by kidneytubules 2)Increases efficiency of cellular metabolism and fat conversion to energy for cellsand muscle 3) Increases the use of fats and proteins for energy and conserves glucose for useby the brain 4) Promotes fluid excretion by causing the kidneys to reabsorb more sodiumANS:1 Antidiuretic hormone promotes fluid retention by increasing the reabsorption ofwater by kidney tubules.

Thyroid-stimulating hormone increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle. Cortisol increases the use of fats and proteins for energy and conserves glucose for useby the brain. Aldosterone promotes fluid retention by causing the kidneys to reabsorb more sodium.

PTS:1DIF:ModerateREF:p. 252 KEY:Nursing process: N/A |Client need: PHSI | Cognitive level: Recall 5.A patient sustains a laceration of the thigh in an industrial accident. Whichstep in the inflammatory process will the patient experience first?

1) Cellular inflammation2) Exudate formation3) Tissue regeneration4) Vascular responseANS:4 Immediately after the injury, the vascular response occurs. Blood vessels at the site constrict to control bleeding. After the injured cells release histamine, the vessels dilate, causing increased blood flow to the area. During the next phase, known as the cellular response phase, white blood cells migrate to the site of injury. In the exudate-formation phase, the fluid and white blood cells move fromcirculation to the site of injury, forming an exudate. Tissue regeneration occurs in the healing phase.

PTS:1DIF:ModerateREF:p. 254 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 6.A patient complains of a vague, uneasy feeling of dread, and his heart rate is elevated. Which of the following nursing diagnoses is most appropriate for this patient?

Anger2) Fear 3) Anxiety4)

HopelessnessANS:3 NANDA-International defines Anxiety as a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. This patient is most likely feeling anxious. Anger is not a nursing diagnosis. Fear, which is also a nursing diagnosis, is an emotion or feeling of apprehension from an identified danger, threat, or pain.

Hopelessness is a nursing diagnosis defined as a state in which the patient sees few or no available alternatives and cannot mobilize energy on his own behalf.

PTS:1DIF:ModerateREF:p. 256 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 7.A patient who has been hospitalized for weeks becomes angry and tellsthe nurse who is caring for him, I hate this place; nobody knows how to take care of me or Id be home by now.

Which response by the nurse is best in this situation?

1) You seem angry; whats going on that makes you hate this place?2) Im sorry that we arent caring for you according to your expectations.

You were very sick; dont be angry; youre lucky to be alive.4) You shouldnt be angry with us; were trying to help you.ANS:1 You seem angry; whats going on . . . encourages the patient to express his feelings and may provide you with more information. The nurse should not takeresponsibility for the patients anger by apologizing (Im sorry . . .). Advising the patient dont be angry or you shouldnt be angry diminishes the patients right tobe angry.

PTS:1DIF:ModerateREF:p. 266 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 8.You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms ofa stomach ulcer to avoid going to work. Which somatoform disorder is this patient most likely experiencing?

1) Hypochondriasis2) Somatization3) Somatoform pain disorder4) MalingeringANS:4 Malingering is a conscious effort to escape unpleasant situations by pretending to have symptoms of a disorder. With hypochondriasis, the patient is preoccupied with the idea that he is or will become seriously ill. In somatization,anxiety and emotional turmoil are expressed in physical symptoms. With somatoform pain disorder, emotional pain manifests physically.

PTS:1DIF:ModerateREF:p. 259 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 9.After a patient has an argument with her husband, she becomes verballyabusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting?

1) Reaction formation2) Displacement3) Denial4) ConversionANS:2 This patient is using displacement. She is transferring the emotions she feels toward her husband to the nurse. When a patient uses the coping mechanism ofreaction formation, the patient is aware of her feelings but acts in an opposite manner to what she is really feeling.

With the coping mechanism of denial, the patient transforms reality by refusing to acknowledge thoughts, feeling, desires, or impulses. With conversion, emotional conflict is changed into physical symptoms that have no physical basis.

PTS:1DIF:ModerateREF:p. 257 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 10.A patient who has been diagnosed with breast cancer decides on atreatment plan and feels positive about her prognosis. Assuming the cancerdiagnosis represents a crisis, this patient is most likely experiencing which phase of crisis?

1) Precrisis2) Impact3) Crisis4) AdaptiveANS:4 When a patient begins to think rationally and problem-solve, she is most likely experiencing the adaptive phase of crisis. During the precrisis phase, the patientfinds success using her previous coping strategies. Anxiety and confusion increase during the impact phase if usual coping strategies are ineffective. The patient may use new coping strategies, such as withdrawal, during the crisis phase.

PTS: 1 DIF: Moderate REF: pp. 259-260 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 11.A nurse identifies the nursing diagnosis Diarrhea related to stress for a patient.

Which nursing intervention should be included in the nursing care planto help the patient relieve the cause of the diarrhea?1) Monitor and record the frequency of stools on the graphic record.2) Administer prescribed antidiarrheal medications as needed.3) Encourage the patient to verbalize about stressors and anxiety.4) Provide oral fluids on a regular schedule.ANS:3 The nurse should encourage the patient to verbalize about stressors and anxietyto help relieve stress, which is the cause of the patients diarrhea. Monitoring stool frequency is an assessment, not a nursing intervention. The other interventions may be necessary to treat diarrhea, but they do not alleviate the cause of the diarrhea.

PTS: 1 DIF: Moderate REF: p. 259 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 12.When counseling a patient about behaviors to reduce stress, which of the

following goals should the nurse put on the care plan?

1) The patient will limit his intake of fat to no more than 15% of the daily calories consumed.

2) The patient will eat three meals per day at approximately the same time eachday. 3) The patient will limit his intake of sugar and salt, as well as sweet and saltyfoods. 4) The patient will consume no more than three alcoholic beverages a day.ANS:3 The nurse should advise the client to limit the intake of sugar and salt; limit theintake of fat to no more than 30% (not 15%) of daily calories; eat smaller, morefrequent meals (not three meals a day); and consume no more than two alcoholic beverages per day but not necessarily every day.

PTS:1DIF:ModerateREF:p. 265 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 13.At the end of a guided imagery session, which physical assessmentfinding would suggest that the relaxation technique was successful?

1) Decreased blood pressure2) Decreased peripheral skin temperature3) Increased heart rate4) Increased respiratory rateANS:1 Reassessment findings that suggest relaxation has been effective include decreased blood pressures, increased peripheral skin temperature, decreasedheart rate, and decreased respiratory rate.

PTS:1DIF:ModerateREF:pp. 266-267 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level:Comprehension 14.The nurse is caring for a patient with unresolved anger. For whichassociated complication should the nurse assess?

1)Depression 2)Hypochondriasis 3)Somatization 4)Malingering ANS:1 Depression is sometimes associated with unresolved anger and may result fromstress. A person with hypochondriasis is preoccupied with feelings that he will become seriously ill. In somatization, anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. Malingering is a conscious effort to avoid unpleasant situations.

Hypochondriasis, somatization, and malingering are not associated with unresolved anger.

PTS:1DIF:EasyREF:p. 256

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level:Comprehension 15.Before entering the room of a patient who is angry and yelling, the nurseremoves her stethoscope from around her neck. The best rationale for doing so is that the stethoscope 1) Could be used by the patient to hurt her2) Might cause the patient not to trust her3) Would distract her from focusing on the patient4) Will function as another stressor for the patientANS:1 When dealing with an angry patient, the nurse must be alert to her own safety needs. A stethoscope, dangling jewelry, or anything else the patient might use as to harm the nurse should be removed before entering the patients room. It isunlikely that a stethoscope would cause the patient not to trust the nurse, nor function as a stressor because stethoscopes are common in the healthcare setting; nearly every caregiver carries a stethoscope. For the same reason, it would not likely distract the nurse. Nurses carry stethoscopes so routinely that they likely dont even notice their presence.

PTS:1DIF:ModerateREF:p. 266 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Analysis 16.A patient is in crisis. After assessing the situation, what should the nursedo first?

Determine the imminent cause of the crisis.2) Intervene to relieve the patients anxiety.3) Decide on the type of help the patient needs.4) Ensure the safety of both the nurse and patient.ANS:4 The first goal of crisis intervention is to assess the situation. Then ensure safetyof self and patient, defuse the situation, decrease the persons anxiety, determine the problem (cause of the crisis), and decide on the type of help needed. Safety is always foremost.

PTS:1DIF:ModerateREF:p. 269 KEY:Nursing process: Implementation | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1.During the alarm stage of the general adaptation syndrome, whichmetabolic change(s) occur(s)? Choose all that apply.

1) Rate of metabolism decreases.2) Liver converts more glycogen to glucose. Use of amino acids decreases.4) Amino acids and fats are more available for energy.ANS:2, 4 The metabolic changes that occur during the alarm stage of the general adaptation syndrome include the following: The rate of metabolism increases, the liver converts more glycogen to glucose, and there is increased use of aminoacids and mobilization of fats for energy.

PTS:1DIF:ModerateREF:pp. 252-253 KEY: Nursing process: N/A | Client need: Physiological integrity | Cognitive level: Comprehension 2.Two days after a patient undergoes abdominal surgery, his surgical incision is red and

slightly edematous; it is oozing a small amount of serosanguineous (pink-tinged serous) fluid.

On the basis of these data, what canyou conclude? Choose all that apply. 1) The wound is most likely infected.2) This is a vascular response to inflammation.3) Damaged cells are being regenerated.4) Exudate formation is occurring.ANS:2, 4 During the vascular response phase of the inflammatory process, blood vessels constrict to control bleeding. Fluid from the capillaries moves into tissues, causing edema. The fluid and white blood cells that move to the site of injury are called exudates; this includes the serosanguineous exudate that commonlyappears at surgical incisions. When a wound becomes infected, yellow, foul- smelling drainage may form at the site; there is no mention of pus in the scenario. Regeneration occurs when identical or similar cells replace damaged cells; although this may be occurring, you cannot prove it with the data given here.

PTS:1DIF:ModerateREF:pp. 254-255 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 3.A 75-year-old patient is tearful, shaky, and withdrawn. She tells you that she is worrying herself to death about losing her aging husband and being all alone. You recognize this reaction as Anxiety rather than Fear because (chooseall that apply) 1) It concerns future or anticipated events2) It concerns anticipation of danger rather than a present danger3) There is no shakiness or tearfulness present4) There is a psychological rather than a physical threatANS:1, 2, 4 Anxiety is an emotional response related to future or anticipated events. Fear isa cognitive response to a present, usually identifiable, source. Anxiety results from psychological conflict, whereas fear can result from either a psychologicalor physical threat. Shakiness and tearfulness may occur in both anxiety and fear, which share several defining characteristics.

PTS:1DIF:ModerateREF:p. 256 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

Chapter 10. Psychosocial Health & Illness

Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which of the following is considered a strength of the nursing profession?1) Biomedical focus2) Psychosocial focus3) Biopsychosocial focus4) Physical focusANS: 3 A strength of the nursing profession is the ability to go beyond the biomedical, psychosocial, or physical focus to care for the entire person. This approach focuses on the overall biopsychosocial well-being of the patient.

PTS:1DIF:EasyREF:p. 273 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 2. A homeless patient is admitted with an infected leg wound. According to Maslows hierarchy of needs, which nursing intervention meets one of his basic physiological needs?

1) Providing the patient with a dinner tray2) Administering antibiotics as prescribed3) Irrigating a wound with normal saline solution4) Encouraging the patient to express his feelingsANS: 1 According to Abraham Maslow and his hierarchy of needs, basic physiological needs, such as food, should be addressed first. After the patients basic needs are met, the nurse can provide wound care, administer antibiotics as prescribed(safety needs), and encourage the patient to express his feelings (love and belonging or self-actualization, depending on what feelings he expresses).

PTS:1DIF:ModerateREF:p. 274 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 3. Which of the following can the nurse assess using Erik Eriksons theory?1) Moral development2) Developmental tasks3) Social identity4) Self-esteemANS: 2 Using Eriksons theory, the nurse can assess for successful completion of developmental tasks.

The theory does not help the nurse assess social identity or self-esteem.

However, these factors are components of developmental tasksthat Eriksons theory explores.

Moral development was addressed in the Kohlbergs theory.

PTS:1DIF:EasyREF:p. 274 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level:Comprehension 4. Which statement best describes self-concept? An individuals1) Understanding of how others perceive him2) Evaluation of himself3) Overall view of himself4) Perspective of his role in societyANS: 3Self-concept is an individuals overall view of himself.

The overall view includeshis evaluation of himself and how he thinks others evaluate him.

PTS:1DIF:EasyREF:p. 274 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 5. A 13-year-old patient is admitted to the hospital. There is no medicalrestriction on visitation. To help maintain the patients social identity while hospitalized, it is most important for the nurse to encourage visits by 1) Peers2) Grandparents3) Siblings4) ParentsANS: 1 Peers are more important than family in maintaining social identity in this agegroup.

PTS:1DIF:ModerateREF:p. 275 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall 6. Which response by the patient demonstrates an internal locus of control?1) My blood sugar wouldnt be out of control if my wife prepared better foods.2) I knew I shouldnt have come to this hospital; Id be better if I hadnt.3) God must be getting even with me for my past behavior.4) Im just glad to be alive; the accident couldve been a lot worse.ANS: 4 People who demonstrate an internal locus of control take responsibility for theirlife experiences and their responses to them. This allows them to interpret unexpected events in a positive light, as the response the accident couldve been a lot worse illustrates. The other options demonstrate an external locus ofcontrol; control of the situation is attributed to external factors.

PTS:1DIF:ModerateREF:p. 275 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 7. The nurse is caring for a group of patients on the medical-surgical unit.Which patient is most likely to experience the most difficulty in adapting to a change in body image? The patient 1) Who suffered a traumatic amputation of the left leg in an industrial accident2) With hypothyroidism who has coarse, dry, thinning hair and weight gain3) Who is obese and who underwent gastric bypass surgery4) With peripheral vascular disease who required a wound graftANS: 1 Theoretically, the patient who suffered a traumatic amputation in an industrialaccident will most likely have more difficulty adjusting to his change in body image because the change occurred abruptly. The patients described in the other options will naturally have some difficulty adjusting to their body image change, but it should not be as great because the physical changes are more gradual, which allows for adaptation over time.

PTS:1DIF:ModerateREF:pp. 275-276 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application

8. Which individual is most likely to have a positive body image?1) Child who has been deaf since birth2) Child who was born with cystic fibrosis3) Adolescent of average appearance who had an appendectomy4) Adult born with a spinal defect and associated paralysis of the lower bodyANS: 3 The adolescent with average appearance who had an appendectomy is likely tohave a positive body image because the adolescent suffered an acute, reversible illness. Those born with physical handicaps are less likely to have a positive body image because many times the handicap leaves them socially isolated. This is, of course, not to imply that no one born with a physical handicap has a positive body image; and, of course, a particular adolescents body image might suffer after an appendectomy. However, the question asks which is most likely based on theoretical knowledge of body image.

PTS:1DIF:ModerateREF:pp. 275-276 97 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis 9. A 35-year-old patient diagnosed with testicular cancer is undergoing chemotherapy, which leaves him unable to help care for his young children. As aresult, his wife misses work whenever the children are ill. She has become increasingly distressed over her situation. Her experience best demonstrates which of the following? 1) Role strain2) Interpersonal role conflict3) Role performance4) Inter-role conflictANS: 4 The patients wife is most likely experiencing inter-role conflict, in which her roleas a mother and worker are making competing demands on her. Role strain is amismatch between role expectations and role performance. Interpersonal role conflict results when another persons idea about how a role should be performed differs from that of the person who is performing the role. Role performance is defined as the actions a person takes and the behaviors he demonstrates in performing a role.

PTS:1DIFifficultREF:p. 276 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 10. Which statement best describes self-esteem?

View of oneself as a unique human being2) Ones mental image of ones physical self3) Ones overall view of oneself4) How well one likes oneselfANS: 4 Personal identity is ones view of oneself as a unique human being. Body image is described as ones mental image of ones physical self. Self-concept is defined as ones overall view of oneself. Self-esteem is a favorable impression of oneself or self-respect.

PTS:1DIF:ModerateREF:pp. 276-277 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall 11. A patient undergoing fertility treatments for the past 9 months learns that despite in

vitro fertilization she still is not pregnant. This patient is at riskfor experiencing a crisis in which component of self-concept?

1) Body image2) Self-esteem3) Personal identity Role performanceANS: 2 Setbacks such as not becoming pregnant after months of fertility treatment cancause the patient to question her self-worth. This might provoke a crisis in self- esteem. The 98 patient is not at risk for experiencing a crisis in body image, personal identity, or role performance.

PTS:1DIFifficultREF:pp. 276-277 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 12. A 17-year-old patient sustained facial fractures and a 6-inch lacerationon the left side of her face in a motor vehicle accident. The patient tells the nurse that she does not want anyone to see her looking this way. Which statement by the nurse is most appropriate?

1) Tell me what you mean by looking this way.2) OK, Ill restrict your visitors until your face heals.3) Your friends and family love you no matter what.4) Youre young; your face will heal quickly.ANS: 1 Tell me what you mean . . . encourages the patient to clarify her statement so that the nurse knows exactly what the patient means. The nurse cannot assumethat the patient is talking about her facial wounds. Ill restrict your visitors . . . assumes that the patient is speaking about her facial wounds when she might not be. The other options are examples of false reassurance and do not addressthe patients concerns.

PTS: 1 DIF: Moderate REF: pp. 288-289; ESG, Chapter 13, Supplemental Materials, Psychosocial Nursing Interventions, V2, p. 116; ESG, SupplementalMaterials, Psychosocial Nursing Interventions KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 13. A patient has recently had a change in a family relationship that is greatly affecting his health. Which nursing diagnosis could you probably makefor this patient? 1) Parental Role Conflict2) Interrupted Family Processes3) Compromised Family Coping4) Ineffective Individual CopingANS: 2 Interrupted Family Processes is defined as a change in a family relationship significantly affecting a patients health. Parental Role Conflict occurs when significant role confusion by a parent results in response to crises. CompromisedFamily Coping occurs when support from a usual family member is compromisedor disabled, causing a significant health challenge.

Ineffective Individual Coping occurs when the patient is unable to comprehend and effectively judge stressors.

PTS:1DIFifficultREF:p. 281 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 14. The nurse is updating a care plan for a patient who has a nursing diagnosis of Anxiety. Which patient behavior might suggest that the problem isresolving?

99 1) Pacing in the hallway at intervals2) Using relaxation techniques3) Speaking rapidly when spoken to4) Avoiding eye contactANS: 2 Using relaxation techniques might suggest that the patients anxiety is resolving.Pacing, speaking rapidly, and avoiding eye contact suggest that anxiety is still aproblem for the patient.

The patients use of relaxation techniques indicates problem solving by the patient.

PTS: 1 DIF: Easy REF: pp. 288-289 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level:Comprehension 15. Which nursing diagnosis is categorized as a psychosocial, rather than aselfconcept, diagnosis?

1) Ineffective Individual Coping2) Situational Low Self-Esteem3) Disturbed Personal Identity4) Disturbed Body ImageANS: 1 Ineffective Individual Coping is considered a psychosocial nursing diagnosis. Itimplies poor life choices, inability to use available resources, and other interactional and relationship symptoms.

The term psychosocial encompassesboth psychological and social factors. The other diagnoses represent primarilyindividual, psychological factors. They are examples of self-concept nursing diagnoses.

PTS:1DIF:ModerateREF:p. 281 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Recall 16. Which statement by the nurse is best when communicating with apatient with clinical depression?

1) Its a beautiful day today; youll feel better if you look out the window.2) Youre having a bad day; Im sure youll feel better soon.3) Life seems overwhelming at times; would you like to discuss how youre feeling?4) You are very lucky to have such a supportive family.ANS: 3 When caring for a patient with depression, the nurse should encourage the patient to discuss his feelings. Its a beautiful day . . . and Youre having a bad day . . . offer false reassurance. It would not be therapeutic to say, You are verylucky . . .; that is offering a judgment.

PTS:1DIF:ModerateREF:p. 293

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 10 17. A patient who lost his job last month has now been told that his wife wants a divorce. He says, I know I dont have much to offer a woman. She wantsmore than what I am, and now Im not even bringing home any money. Whichnursing diagnosis is most appropriate?

1) Chronic Low Self-Esteem2) Situational Low Self-Esteem3) Disturbed Personal Identity4) Disturbed Body ImageANS: 2 Situational Low Self-Esteem occurs when a person exhibits self-disapproval and negative selfevaluations as a specific reaction to loss or change (in this case, ofa job and a marriage).

There are no data to indicate long-standing (Chronic) LowSelf-Esteem. This client has no defining characteristics for Disturbed Personal Identity, which is an inability to determine boundaries between self and others, nor of Disturbed Body Image. He does mention his appearance but does not focus on it in particular; it is only part of his overall dissatisfaction with himself.

PTS:1DIF:ModerateREF:p. 284 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 18. The nurse is updating the care plan of a patient who must undergo a right mastectomy for breast cancer. Which nursing diagnosis should the nurseanticipate in expectation of the body changes associated with the upcoming surgery?

1) Deficient Knowledge2) Impaired Adjustment3) Hopelessness4) GrievingANS: 4 Grieving may occur as a result of body changes associated with mastectomy. Deficient Knowledge, Impaired Adjustment, and Hopelessness are not associatedwith the expected body changes associated with the upcoming surgery, although they could certainly occur.

PTS:1DIF:ModerateREF:p. 285 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 19. A patient admitted with depression has a nursing diagnosis of ChronicLow SelfEsteem. Which NOC outcome is essential for this nursing diagnosis?

1) Decision Making Distorted Thought Content3) 10 Role Performance4)

Depression LevelANS: 4 Depression Level is the appropriate NOC outcome for the patient admitted with depression who has the nursing diagnosis Chronic Low Self-Esteem. Decision Making is associated with the nursing diagnosis Situational Low Self-Esteem, Role Performance with Ineffective Role Performance, and Distorted Thought Content with Disturbed Personal Identity. Although the other options might contribute to the patients low self- esteem, the nurse must write one goal (outcome) that, if achieved, would demonstrate resolution of the nursing diagnosis. Decision Making is the only outcome that does that. PTS: 1 DIF: Moderate REF: p. 293; ESG, Chapter 13, Standardized Language,Table: Self-Concept Diagnoses: Selected Standardized and Individualized Outcomes KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 20. The nursing diagnosis Disturbed Personal Identity is identified for anewly admitted patient. Which of the following is an example of an individualized goal for that patient?

1) Distorted Thought Control2) Anxiety Level Self-Mutilation Restraint4) No Self-Injury, Consistently DemonstratedANS: 4 No Self-Injury, Consistently Demonstrated is an example of using NOC indicators and outcomes to write an individualized goal. The other options are examples of NOC outcomes; they are not written as goals.

PTS:1DIF:ModerateREF:p. 293 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 21. A 73-year-old patient was admitted with a perforated bowel. Followingsurgical repair, he developed complications and required an extensive stay in the hospital. How can the medicalsurgical nurse best promote self-esteem in this patient?

1) Assist the patient to ambulate in the hallway once daily.2) Encourage the patient to participate in self-care.3) Introduce herself to the patient if he does not know her.4) Listen attentively when the patient speaks.ANS: 2 Encouraging the patient to his accomplish own self-care, such as bathing andbrushing his teeth, encourages independence and promotes self-esteem.

Assisting the patient to ambulate in the hallway prevents complications of immobility. Introducing yourself and listening attentively to the patient preventsdepersonalization. PTS:1DIFifficultREF:p.

285 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 22. The nurse is developing a plan of care for a mother of three small children who has been admitted with a serious acute illness, which is likely to continue long term. The nurse writes the following intervention: Facilitate communication between patient and significant other regarding the sharing of responsibilities to accommodate changes brought on by illness.

The purpose ofthis intervention is to help

1) Promote self-esteem2) Promote positive body image3) Facilitate role enhancement4) Prevent depersonalizationANS: 3 Facilitating communication between the patient and significant other regardingsharing of responsibilities to accommodate changes brought on by the illness can help facilitate role enhancement in the patient. The intervention is not designed to promote self-esteem or positive body image or to prevent depersonalization.

PTS:1DIF:ModerateREF:p. 286 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 23. A patient comes to the emergency department complaining of headache, palpitations, nausea, and dizziness. After determining that the patientis anxious, the nurse notes tachycardia and trembling. Which level of anxiety is this patient exhibiting? 1) Mild anxiety2) Moderate anxiety3) Severe anxiety4) Panic anxietyANS: 3 The patient experiencing severe anxiety may experience physical symptoms including headache, palpitations, tachycardia, insomnia, dizziness, nausea, trembling, hyperventilation, urinary frequency, and diarrhea. Symptoms associated with mild anxiety include muscle tension, restlessness, irritability, and a sense of unease. The patient experiencing moderate anxiety might experience a rise in heart rate and respiratory rate, increased perspiration, gastric discomfort, and increased muscle tension. The patient suffering from panic anxiety might believe he has a life-threatening illness. Physical symptomsinclude dilated pupils, labored breathing, severe trembling, sleeplessness, palpitations, diaphoresis, pallor, and uncoordinated muscle movements.

PTS:1DIF:ModerateREF:p. 278 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 24. The nurse is assessing a patient admitted with a newly diagnosed bleeding duodenal ulcer. He is exhibiting physiological signs of anxiety and seems to have difficulty concentrating. During the interview, the patient tells thenurse that he is often short of breath and says, I lie awake nights worrying abouteverything. He has been unable to work or care for his family for the past 6 months. What is the nurses priority after documenting this information in the nurses notes?

1) Provide emotional support for the patient using reflective listening technique.2) Do nothing; people with duodenal ulcers typically cannot work.3) Question the patients family about the information received from the patient.4) Notify the primary care provider and ask for a referral to a mental healthprofessional. ANS: 4 The nurse should involve a mental health professional immediately, because thepatient is exhibiting signs of a disabling anxiety disorder. Although it is important for the nurse to provide emotional support for the patient, a mental health professional is needed for this patient. Doing nothing is neglectful.

Questioning the patients family about the information violates the patients rightto privacy, unless the nurse obtains the patients permission to do so.

PTS: 1 DIF: Difficult REF: p. 291; requires synthesis, answer not given verbatim. KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 25. An adult patient is diagnosed with lung cancer, and surgery to removethe right lung is recommended. The patient is uncertain about whether he should consent to the surgery because of the risks involved. Which nursingdiagnosis is most appropriate for this patient?

1) Decisional Conflict2) Death Anxiety3) Powerlessness4) Ineffective DenialANS: 1 Decisional Conflict is the most appropriate nursing diagnosis for this patient because he is uncertain about whether he should take the surgical risk. Death Anxiety is apprehension, worry, or fear related to death or dying; there is nothing to suggest that this patient is suffering from Death Anxiety at this time. Powerlessness is a perceived lack of control over a current situation; this patientis trying to exert some control over his care. Ineffective Denial is appropriate when the patient consciously or unconsciously rejects knowledge; there is nothing in this scenario to suggest that the patient is rejecting knowledge.

PTS:1DIF:ModerateREF:p. 288 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 26. Which nursing intervention specifically helps reduce a patients anxiety?1) Teaching the importance of adequate nutrition and hydration2) Giving clear fact pertaining to the patients circumstances3) Promoting small-group activities to improve self-esteem4) Monitoring the patient for the risk of suicideANS: 2 Using clear and factual knowledge that is tailored to the patients circumstances helps reduce anxiety. Teaching the importance of adequate hydration, promotingsmall-group activities to improve self-esteem, and monitoring the patient for suicide risk are interventions designed to help the patient with depression.

PTS:1DIF:EasyREF:p. 289 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall 27. The nurse caring for a patient admitted with severe depression identifies a nursing diagnosis of Hopelessness on the care plan. Which outcomeis appropriate for this diagnosis?

1) Displays stabilization and control of mood2) Sleeps 6 to 8 hours per night with report of feeling rested3) Does not engage in risky, self-injurious behavior4) Eats a well-balanced diet to prevent weight changeANS: 1 An outcome for the nursing diagnosis Hopelessness is displays stabilization and control of mood. Sleeps 6 to 8 hours per night and reports feeling rested and eats a well- balanced diet to prevent weight change are example of outcomes forthe diagnosis Depressed Mood. Does not

engage in risky, self-injurious behavior is an outcome for the nursing diagnosis Risk for Suicide.

PTS: 1 DIF: Moderate REF: p. 293 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 28. The nurse is assessing a patient for depression. Which of the followingsets of behavioral symptoms may indicate depression?

1) Preoccupation with loss, self-blame, and ambivalence2) Anger, helplessness, guilt, and sadness3) Anorexia, insomnia, headache, and constipation4) Tearfulness, withdrawal, and present substance abuseANS: 4 Tearfulness, regression, restlessness, agitation, withdrawal, past or present substance abuse, and a past history of suicide attempts are all behavioral symptoms of depression. Denial of feelings, anger, anxiety, guilt, helplessness,hopelessness, and sadness are affective findings associated with depression.

Cognitive findings in depression include preoccupation with loss, self-blame, ambivalence, and blaming others. Physiological findings of depression include anorexia, overeating, insomnia, hypersomnia, headache, backache, chest pain,and constipation.

PTS:1DIF:ModerateREF:p. 289 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level:Comprehension 29. A frail, elderly patient admitted with dehydration to a medical-surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. What is most important for the nurse do?

1) Recognize these symptoms as signs of normal, physiologic aging.2) Obtain a urine specimen before notifying the primary care provider.3) Be sure she is placed in a room occupied with another patient.4) Interview the patient to screen for clinical depression.ANS: 4 Depression is often masked in older adults and expressed as physical and personality changes.

Memory loss and confusion are also common symptoms ofdepression in older adults. Any one of the symptoms might occur as a result of physical illness, but the combination should prompt the nurse to suspect depression and interview and screen for it before exploring physiological causesfor the symptom (as with a urine specimen). Placing the patient with another patient would be indicated for social isolation, which can be associated with depression; however, the nurse needs to screen for depression before looking for causes.

PTS:1DIF:ModerateREF:pp. 291, 295 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level:Application 30. An elderly patient admitted from a skilled nursing residence to a medical- surgical unit is exhibiting confusion, distractibility, memory loss, and irritability. She has a medical diagnosis of dehydration. Which of the followingshould lead the nurse to suspect that dementia, rather than depression or dehydration, is the source of the symptoms? The history and nursing observations indicate that the patient 1) Rambles, speaks incoherently, and answers questions inappropriately2) Speaks slowly with delayed response to questions but responds appropriately3) Awakens

early in the day yet sleeps almost constantly during the day4) Sometimes has difficulty concentrating on details of the present situationANS: 1 In dementia, a patients language is disoriented, rambling, and incoherent and the patient responds to questions inappropriately or with near misses. Speaking slowly and being slow to respond to verbal stimuli are signs of depression, and in depression, the patient usually answers questions appropriately. Awakening early and sleeping constantly during the day are signs of depression; in dementia, sleep is fragmented and the person awakens often during the night. Difficulty concentrating on details is a thinking pattern seen more in depression;in dementia, there is difficulty finding words, difficulty calculating, and decreased judgment.

PTS: 1 DIF: Difficult REF: p. 291 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application Multiple Response 1) Identify one or more choices that best complete the statement or answer thequestion.

1. Which assessment finding(s) might suggest that the patient has low self-esteem and requires more in-depth assessment? Choose all that apply.

1) Infrequent eye contact2) Straight posture3) Overly critical of others4) Careful groomingANS: 1, 3 Assessment findings that suggest low self-esteem include avoiding eye contact and being overly critical of others. You would not need to follow up if the persondisplayed straight posture and careful grooming.

PTS: 1 DIF: Easy REF: pp. 276-277; 282-284 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 2. Which intervention(s) by the nurse might help the patient maintain asense of personhood during hospitalization? Assume that all are culturally appropriate. Choose all that apply.

1) Addressing the patient by his first name2) Making eye contact if it is comfortable for the patient Always offering an explanation before beginning a procedure4) Speaking to others about the patient so that the patient can hear youANS: 2, 3 The nurse can help the patient maintain a sense of personhood by addressing him by his preferred name, which might be his first name or might be his surname with title. Using eye contact, always offering an explanation before beginning a procedure, and not talking about the patient to others in the roomare additional ways for the nurse to offer care that respects patient rights.

PTS:1DIF:ModerateREF:pp. 285-286

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall

Chapter 11. Promoting Family Health Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A 12-year-old patients mother recently married a man who has a 13-year-old daughter. The nurse recognizes that the patient belongs to which type of family?

1) Extended 2) Traditional 3) Blended 4)Nuclear ANS: 3 The patient belongs to a blended family; in which two single parents marry and raise their children together. An extended family may contain grandparents, aunts, uncles, cousins, and other biological relatives. A traditional, or nuclear, family contains a husband, wife, and their children.

PTS:1DIF:EasyREF:p. 301 KEY: Nursing process: N/A | Client need: PSPI | Cognitive level: Application 2. A 65-year-old patient is admitted to the hospital with heart failure. The patients best friend accompanies her on admission. They have been sharing a home since they each were widowed 3 years ago. Both women have grown children who live out of state. Using the family nursing approach, how can the nurse best intervene?

1)Involve the friend and children in the patients care, discharge planning, and home care.

2)Encourage the friend to wait until discharge to provide care for the patient at home.

3)Explain to the friend that for confidentiality reasons she cannot be involved in the patients care.

4)Encourage liberal visiting hours by the friend and the patients’ children.

ANS: 1 The nurse can best intervene by involving the friend and the patient’s children in the patients care, discharge planning, and home care. The friend may or may not be able to care for the patient at home. But if planning to provide home care, the patients friend should be informed of the patients needs while in the hospital and have an opportunity to participate prior to discharge. The nurse caninvolve the friend with the patients consent without infringing on the patients privacy. Her name needs to be listed on the patient privacy (HIPAA) form. The nurse should also encourage liberal visiting hours by the friend and the patients children if it is beneficial for the patients recovery; however, comprehensive involvement in care is more inclusive than simply liberalizing visiting hours and therefore is the best answer.

PTS:1DIF:ModerateREF:pp. 301-302 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 3. A patient and his wife are 2 years from retirement when he is diagnosed with lung cancer. Although with delayed childbearing, developmental stages canvary among families, which typical stage of family development is this couple likely experiencing? 1) 1)

Family launching young adults2) Postparental family3) Family with frail elderly4) Family with teenagers and young adultsANS: 2 This couple is most likely experiencing the postparental stage of family development. During this stage, the parents prepare for retirement and adjust totheir children moving into phases of adulthood. In the stage of family launching young adults, the parents maintain support of young adults as they leave the security of family and the parents rediscover marriage. During the stage of family with teenagers and young adults, open communication is maintained among family members, ethical and moral values are reinforced, and there is a balance established between rules and independence among teens.

PTS: 1 DIF: Moderate REF: p. 303 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 4. A 13-year-old girl is admitted to the adolescent unit with acute leukemia.The patient has a support system that includes her brother, sister, mother, father, and grandmother as well as members of her local community. Which component of her support system is considered a suprasystem?

1) The community2) The parents3) Her mother4) Her sisterANS: 1 Her surrounding community is considered a suprasystem because it is largerthan the family system. Subsystems within the family include the parents, mother, siblings, sister, brother, father, and grandmother; they are smaller components that fit within the family system.

PTS:1DIF:ModerateREF:p. 302 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis 5. The nurse is developing a teaching plan for an older adult patient with Alzheimer disease and her family. Which point should the nurse include in the teaching plan before discharge?

1) Importance of quitting smoking2) Availability of community resources3) Adherence to a low-fat diet4) Importance of physical exerciseANS: 2 When teaching the family of an older adult, the nurse should include informationabout 1) community resources that are available, especially when caring for chronically ill, disabled, or elderly family members. Middle-age adults typically begin experiencing signs and symptoms associated with long-standing, unhealthy behaviors. Therefore, consuming a low-fat diet and limiting the intake of alcohol and tobacco are likely appropriate topics to include in the teaching plan for a middle-aged adult. Physical exercise and activity promote the quality of life. Careful planning is necessary to ensure safety and well-being for the family member with memory loss, confusion, and disorientation.

PTS:1DIF:ModerateREF:p. 306 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 6. Which factor is related to the increased risk of acquiring polio in theUnited States after the disease was thought to be eradicated?

1) Lack of health insurance 2)Bioterrorism 3) Reduced compliance with vaccinations 4) Drug resistance ANS: 3 Reduced compliance with community immunization in the United States increases the risk for diseases, such as polio, that were thought to be eradicated. For vaccines to be effective, the population needs to receive them. Bioterrorism involves the introduction of a highly infectious microbe for which there is no protection to the population. Polio is not such a threat because immunization is available. Vaccinations are available through governmental programs for those who do not have health insurance. Drug resistance has led to the reemergence of tuberculosis, which was previously cured with antibiotics.

PTS:1DIF:EasyREF:p. 306 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension 7. Which question helps the nurse to assess family structure?

1) Where does your family live?

2) How are family decisions made?

3) With which religious affiliation is your family associated?

4) What is your ethnic background?

ANS: 2 Asking how family decisions are made helps the nurse to assess family structure. Asking about religious affiliation, ethnic background, and where the family lives provides identifying data but does not reveal lines of authority andrelationships among family members.

PTS:1DIF:ModerateREF:p. 308 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 1) 8. Which family member is most likely to be disabled? 1)60year-old African American male 2) 65-year-old Asian male 3) 70-year-old Caucasian female 4) 75-year-old Native American female ANS: 4 Slightly more females (15.6%) than males (14.4%) reported a disability. In 2006,the prevalence of disability was lowest for persons ages 16 to 20 (6.9%) and highest for those 75 years and older (52.6%). Disability differs by ethnic group.Asians reported 6.3%, Caucasians 12.7%, African Americans 17.5%, Native Americans 21.7%, and persons of other ethnic

backgrounds reported 11.9% disability. Therefore, the prevalence of disability would be highest in a female Native American who is 75 years or older.

PTS:1DIFifficultREF:p. 307 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which family function(s) is/are outlined in the structural-functional familytheory? Select all that apply.

1) Meeting the emotional needs of family members 2)Reinforcing ethical and moral values 3) Promoting joint decision making among parents and children 4) Being productive members of society ANS: 1, 4 Family functions outlined in the structural-functional family theory include being productive members of society, caring for elderly members, meeting physical and emotional needs of family members, and socialization of children. This model is more focused on the outcomes of family function than the process by which action occurs. Maintaining support for young adults as they leave the security of the family, reinforcing ethical and moral values, and promoting joint decision making among parents and children are examples of tasks outlined infamily development theories.

PTS:1DIF: Moderate REF:P-302 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 2. Which of the following suggest that a family health problem may exist?Select all that apply. Family members 1) Respect each others need for privacy 2) Enact decisions made by the most powerful member 3) Do not consider a conflict resolved until everyone agrees 1) 4) Set boundaries between family members.

ANS: 2, 3 Respect for privacy and clear boundaries between family members are characteristics of a healthy family. Boundaries define the responsibilities of adults that are clear and separate from responsibilities of growing children. In healthy families, there is typically egalitarian distribution of power. In healthy families, it is not always necessary for all members to agree; instead, they havethe ability to compromise and members feel free to disagree.

PTS: 1 DIF: Moderate REF: p. 310 KEY: Nursing process: Analysis/nursing diagnosis | Client need: PSI | Cognitive level: Analysis 3. A family assessment should include the following areas. Choose all thatapply.

1) Coping patterns 2) Health beliefs 3) Medical history 4) Physical exam

ANS: 1, 2 Conducting a family assessment includes identifying the following: data; family composition; family history and developmental stage; environmental data; family structure; family function; health beliefs, values, and behaviors; family stressors and coping; and abuse and violence within the family. The medical history and physical exam of individuals are only relevant to the family assessment if it affects other family members.

PTS: 1 DIF: Moderate REF: pp. 308-311 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level:Comprehension 1)

Chapter 13. Spirituality

True/False Indicate whether the statement is true or false.

1. Religion provides people with instruction and guidance about what to believe and what values are essential.

ANS: T Religion provides instruction and guidance on beliefs, values, and codes of conduct. In contrast, spirituality is a journey that integrates life experiences and understanding.

PTS:1DIF:EasyREF:p. 339 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 2. Spirituality occurs over time and involves the accumulation of life experiences and understanding.

ANS: T Spirituality is like a journey; it occurs over time and involves the accumulation of experiences and understanding, whereas religion provides general instruction and guidance on beliefs, values, and codes of conduct.

PTS:1DIF:EasyREF:pp. 339-340 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which statement best describes theology?1) Discussions and theories related to God and His relation to the world2) Doctrines about the human soul and its relation to eternal life3) A life-long journey involving accumulation of experience and understanding4) Codes of conduct that integrate beliefs and values 1) ANS: 1 Theology is best described as discussions and theories related to God and Hisrelation to the world. Eschatology includes doctrines about the human soul andits relation to death, judgment, and eternal life. Spirituality is considered a lifelong journey. Religion provides codes of conduct that integrate beliefs and values.

PTS:1DIF:ModerateREF:p. 339 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall

2. Which of the following is considered a religious denomination within thetradition of Christianity?

1) Buddhism 2) Jehovahs Witnesses 3)Sikhism 4)Islam ANS: 2 Jehovahs Witnesses is a religious denomination within Christianity. Buddhism, Sikhism, and Islam are all religious traditions outside of Christianity.

PTS:1DIF:EasyREF:pp. 342-343; ESG, Chapter 16, Supplemental Materials, Major Religions: What Should I Know?

KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 3. Which factor is held in common by many of the world religions?

1.) Strict health code, including dietary laws 2.) Belief that one must submit to a god or gods 3.) Rules prohibiting alcohol consumption 4.) Sacred writings that reveal the nature of the Supreme Being ANS: 4 Many of the world religions have sacred writings that are authoritative and reveal the nature of the Supreme Being. Mormons follow a strict health code, which advises healthful living. Islam means submission; therefore people of Islamic faith submit to Allah. Some religions, such as Mormon, Christian Science,Bahai, and Sikhism, prohibit alcohol consumption, but many other religions permit it.

PTS:1DIF:EasyREF:p. 339 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall 4. A female patient tells the charge nurse that she does not want a malenurse caring for her. Which intervention by the charge nurse is best?

1) Explain that hospital policy does not allow nursing assignments based on thegender of the nurse.

2) Explore with the patient her beliefs and determine which might have caused herto make this statement 1) 3) Assure the patient that each nurse is capable of providing professional nursingcare, regardless of their gender.

4) Comply with the patients request and assign a female nurse to care for thepatient. ANS: 2 The charge nurse can best serve the patient and her staff by exploring the patients beliefs that might prevent her from being cared for by a male. There are many reasons the woman may prefer a female nurse: she may be very modest, or she may be prejudiced against male nurses, for example. Hospital policy might state that, to prevent discrimination issues, nursing assignments should not be made based on the gender of the patient or nurse. However, evenif this is so, before explaining this to the patient, the charge nurse should explore the patients beliefs and make special arrangements with hospital administration to uphold the patients

beliefs, if possible. Telling the patient that each nurse is capable of providing care is not sensitive to the patient and her beliefs.

Simply complying with the patients wishes without further investigation may alienate the nursing staff.

PTS: 1 DIF: Moderate REF: pp. 341-343, pp. 351-352 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 5. A patient of Orthodox Jewish faith is admitted to the hospital with heartfailure on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orally for this patient. Based on the patients religious affiliation, which of the following actions should the nurse take?

1) Administer the medication as prescribed.

2.) Hold the medication until after Yom Kippur.

3) Explain the importance of taking the medication despite the holiday.

4) Ask the physician to change the route of administration. ANS: 4 Orthodox Jews require an alternative to the oral route of drug administration on Yom Kippur to comply with their religious beliefs. Therefore, the nurse should ask the physician to change the route of administration. Administering the medication as prescribed breaks the patients religious tradition on the holiest day of the Jewish calendar. Holding the medication until after Yom Kippur delaystreatment and may cause harm to the patient; furthermore, it is not within the scope of nursing practice to hold medications that have been prescribed by a physician. The nurse should explain the importance of the medication in any case; but the nurse should not try to convince the patient to break away from his religious tradition when an alternative route of administration is available.

PTS:1DIF:ModerateREF:p. 341 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 6. The nurse is admitting a Roman Catholic adult patient who is critically ill. Based on her knowledge of the patients religion, for which religious rite should she expect to 1) notify the hospital chaplain?

1)Anointing of the Sick 2)Baptism 3.) Eucharist 4)Sacrament of Reconciliation ANS: 1 In Catholicism, those who are seriously ill might want to receive the sacrament of Anointing the Sick. The Sacrament of Reconciliation, which is performed by a priest, is used to gain forgiveness for past sins. The Eucharist, or communion, can be prepared and administered to a hospitalized patient, but it is not typicallyadministered to someone who is critically ill. Baptism may be offered when infants or children of Christian parents are critically ill.

PTS:1DIF:EasyREF:p. 342 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Comprehension 7. Because of religious beliefs, which of the following patients will mostlikely refuse a blood transfusion? One who is affiliated with 1)

Islam 2) Bahai3) Hinduism4) Jehovahs Witness ANS: 4 Those of Jehovahs Witness faith believe that taking blood into ones body is morally wrong.

Therefore, they will not consent to transfusions of whole blood orits components. Those of Islam, Bahai, and Hindu faith will, as a rule, consent to blood transfusion.

PTS:1DIF:EasyREF:p. 342 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 8. Which special consideration may the nurse need to make when caring fora female Rastafarian patient?

1) Allow the patient to wear her own clothing.2) Provide a diet that is caffeine-free.3) Allow the patient to wear jewelry with religious symbols.4) Provide free-flowing water for bathing.ANS: 1 Wearing secondhand clothes is taboo in the Rastafarian faith; therefore, the nurse should allow the patient to wear her own bedclothes instead of a hospital gown. Rastafarians typically consume tea, but some do not drink milk or coffee. Muslim women may wear a locket containing religious writing around the neck ina small leather bag. These are worn for protection and strength and should not be removed. Hindus prefer washing with free-flowing water for bathing, which should be provided when possible.

1) PTS: 1 DIF: Moderate REF: ESG, Chapter 16, Supplemental Materials, MajorReligions: What Should I Know?

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 9. What is the most effective action by the nurse when delivering spiritualcare to a patient of the same religion as the nurse?

1) Understanding that the patient shares the same beliefs2) Striving to meet the patients spiritual needs independently3) Explaining her own religious beliefs to the patient4) Developing a greater awareness of her own spiritualityANS: 4 The nurse can best deliver spiritual care by developing a greater awareness of her own spirituality. This allows the nurse to be a better listener and provide better care for the patient.

The nurse should avoid assuming that a patient whoshares the same religious affiliation has the same beliefs. Moreover, the nurse should avoid trying to meet the patients spiritual needs independently. A team approach to spirituality provides more comprehensive care. Also, unless asked, the nurse should avoid explaining her own religious beliefs, which might offend the patient.

PTS: 1 DIF: Moderate REF: p. 345 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Comprehension 10. A Muslim client has asked the nurse to pray with her. Which item shouldthe nurse anticipate that the patient may request before praying?

Bathing water2) Rosary beads3) Mala beads4) Prayer clothANS: 1 Muslims may want water to wash the mouth, nostrils, and hands before praying.Roman Catholics may want to hold their rosary beads while praying. Some Buddhists and Hindus meditate with a set of beads, called a mala. Others may use a prayer cloth or other religious items.

PTS:1DIF:ModerateREF:pp. 342-343, 350-351; ESG, Chapter 16, Supplemental Materials, Major Religions: What Should I Know?

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Comprehension 11. When performing a spiritual assessment, who is the preferred source of information?

1) Durable power of attorney2) Next of kin3) Patient Patients clergymanANS: 3 The patient is the preferred source of information. In the event of an emergency admission or when a patient cannot give information, the nurse can consult the next of kin or the durable power of attorney for information about the patients spirituality.

Contacting the clergyman without the patients permission is a breach of patient confidentiality.

PTS:1DIF:ModerateREF:pp. 346-347; high-level question, not answered verbatimin text.

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis 12. Which type of medicine do those of Hindu faith typically practice?1) Ayurvedic medicine2) Western medicine3) Chiropractic medicine4) QigongANS: 1 Those of Hindu faith typically practice Ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Some believe in the medicinal properties of hot and cold foods, which have nothing to do with temperature or degree of spiciness.

People who practice Hinduism do not typically practice Western medicine, chiropractic medicine, or Qigong. Qigong, aform of Chinese martial arts, is used to achieve healing through focus on thebodys energy centers.

PTS:1DIF:ModerateREF:p. 343 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level:Comprehension 13. A patient tells the nurse, I feel that God has abandoned me. I am so angry that I cant even pray. The patient refuses to see his clergyman when hecalls. Which is the most appropriate nursing diagnosis for this patient?

1) Spiritual Distress2) Risk for Spiritual Distress3)

Impaired Religiosity4) Moral DistressANS: 1 This patient exhibits three defining characteristics for Spiritual Distress (feeling abandoned by God, inability to pray, refusing to see a religious leader).

Therefore, the actual problem of Spiritual Distress exists, not the potential problem of Risk for Spiritual Distress. Impaired Religiosity is difficulty in exercising or impaired ability to exercise reliance on beliefs or to participate in rituals of a faith tradition (e.g., going to church). This patient is not unable to seethe clergyman but chooses not to.

Moral Distress occurs when a person makes a moral decision but is prevented from carrying out the chosen action.

PTS:1DIF:ModerateREF:p. 348 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 14. The nurse is asking the patient reflective, clarifying questions to help the patient make a list of what is important and not important in life and the time commitment for each. Which standardized (NIC) nursing intervention doesthis action implement?

1) Spiritual Support2) Self-Esteem Enhancement3) Values Clarification4) Hope InspirationANS: 3 One of the steps of most values-clarification processes is to list values (what is important and not important in ones life) and the time commitment for each. The nurse facilitates this by asking reflective, clarifying questions of the patient.Values clarification does not necessarily directly enhance self-esteem, inspire hope, or provide spiritual support, although it can indirectly contribute to development of spiritual identity.

PTS: 1 DIF: Moderate REF: ESG, Chapter 16, Standardized Language, Table Standardized Language: Using Selected NIC Interventions and Activities to Support Spirituality KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 15. The nurse is a Christian. She is caring for a Jewish patient who has asked her to offer a prayer at the bedside. The nurse feels comfortable doing so.Which of the following actions by the nurse is appropriate?

1)Offer a prayer for healing using the nurses usual words and format.2) Begin the prayer with Jehovah God as she always does while avoiding the nameof Jesus.

3) Avoid saying any name for the Supreme Being while praying and quote an Old Testament Bible scripture as the prayer.

4) Say, What name would you like for me to use to address the Supreme Beingwhen I am praying for you?

ANS: 4 Ask how the patient prefers to address the Divine. Some people prefer the use of parental language in their prayers; for example, Father God or Divine Mother. Some use the names Jehovah, Yahweh, or Allah. Hindus may address one or more of multiple gods, each of whom has several names. So seek direction from the patient in these matters: Most people are honored to be able to explain theirbeliefs and practices to someone who is open to the experience. The nurse should not assume that using the names Jesus and Jehovah God would be supportive to the patient, although they might not offend in any way. The nurse does not need to avoid addressing God by a name, but the most supportive wayto do so is to find out

the name the patient wishes to use.

Furthermore, the nurse should not assume that the patient would find a New Testament Bible verse to be helpful spiritually.

PTS:1DIF:ModerateREF:p. 350 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. A patient has a nursing diagnosis of Noncompliance with medication regimen related to a belief that God will heal her and that it would show a lackof faith to take the medications.

The nurse and a clergyman have spent some time discussing spiritual and treatment issues with the patient. Which of the following would indicate that progress is being made toward achieving compliance with healthcare therapy? (Choose all that apply.) The patient says 1) I will try to pray more often for stronger faith that God will heal me.2) Let me think about it until tomorrow; I may see my way to taking those pillsthen. 3) You know, Ive known some very holy people who were not cured by God.4) There is no confusion in my mind as to the right thing for me to do.ANS: 2, 3 Agreeing to consider treatment (think about it) and recognizing that sometimes faithful people are not cured both suggest that the patient is at least consideringthat it is all right for her to question her beliefs. Praying for stronger faith in Gods healing suggests that she is holding strong in her belief that she will be healed if she only has enough faith.

Having no confusion about the right thing todo would be evidence of problem resolution, provided the right thing to do is to take the medication. However, you need more information to know if that is what the patient means. It could just as easily mean that she is more sure thanever that she should not take the medication.

PTS:1DIFifficultREF:pp. 346-349; answer not stated in text; student must inferanswer from question content KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

Chapter 14. Experiencing Loss Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A 73-year-old patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because she is unable tocare for herself at home. Which type of loss is this patient most likely experiencing?

1) Environmental loss2) Internal loss3) Perceived loss4) Psychological lossANS: 1 This patient is most likely experiencing an environmental loss because she is unable to return to her familiar home setting. Instead, she is being transferred tothe new environment of a nursing home. Internal, perceived, and psychological losses are internal and can only be identified by the person experiencing them.

PTS:1DIF:EasyREF:p. 358 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 2. According to William Worden, which task in the grieving process takeslongest to achieve?

1) Accepting that the loved one is gone2) Experiencing the pain from the loss3) Adjusting to the environment without the deceased4) Investing emotional energyANS: 1 Worden described the tasks a grieving person must achieve. They progress froman initial numbness or denial through experiencing and working through pain and grief and eventually moving on with life. Shock with disbelief is not a Worden task.

PTS:1DIF:EasyREF:p. 359 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall 3. What emotional response is typical during the Randos confrontationphase of the grieving process?

Anger and bargaining2) Shock with disbelief3) Denial4) Emotional upsetANS: 4 During the confrontation phase, the person faces the loss and experiences emotional upset. In the avoidance phase, the person experiences shock, disbelief, denial, anger, and bargaining.

During the accommodation phase, theperson begins to live with the loss, feel better, and resume routine activities.

PTS:1DIF:ModerateREF:p. 359

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall 4. An elderly man lost his wife a year ago to cardiovascular disease. Duringa healthcare visit, he tells the nurse he has begun adjusting to life without his wife.

According to John Bowlby, which stage of grief does this comment most likely indicate?

1) Shock and numbness2) Yearning and searching3) Disorganization and despair ReorganizationANS: 4 According to Bowlby, a person adjusts to life without the deceased during the reorganization phase. During the shock and numbness phase, the person experiences disorientation and a feeling of helplessness. The person wants to bereconnected with the deceased during the yearning and searching phase. The person feels pain and the emotions of grief during the disorganization and despair phase.

PTS:1DIF:ModerateREF:p. 359 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 5. Which patient is at most risk for experiencing difficult grieving?1) The middle-aged woman whose grandmother died of advanced Parkinsonsdisease 2) The young adult with three small children whose wife died suddenly in anaccident 3) The middle-aged person whose spouse suffered a slow, painful death4) The older adult whose spouse died of complications of chronic renal diseaseANS: 2 Although it is impossible to predict with certainty and the grieving process ishighly individual and personal, in general those who suffer a sudden loss typically have more difficult grieving than those who have had the time to prepare for the death. Family and friends of persons with chronic illnesses (e.g.,cancer) have usually had time to emotionally prepare for the death, initiate thefuneral and burial arrangements, and begin the grieving process before the death occurs.

PTS: 1 DIF: Moderate REF: p. 360 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 6. During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits that he drinks at least six bourbon and waters every night before going to bed. Which type of grief doesthis best illustrate?

1) Delayed2) Chronic3) Disenfranchised4) MaskedANS: 4 Masked grief occurs when the person is grieving, but it may look as though something else is occurring; in this case, the person is abusing alcohol. Delayedgrief occurs when grief is put

off until a later time. Chronic grief begins as normal grief but continues long term with little resolution of feelings or ability torejoin normal life.

Disenfranchised grief is experienced when a loss is not socially supported. PTS: 1 DIF: Moderate REF: p. 361 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 7. According to the Uniform Determination of Death Act, which bodilyfunction must be lost to declare death?

1) Consciousness2) Brain stem function3) Cephalic reflexes4) Spontaneous respirationsANS: 2 According to the Uniform Determination of Death Act, death can be declared when there is a loss of brain stem function. Higher-brain death occurs when there is a loss of consciousness, cephalic reflexes, and spontaneous respirations.

PTS:1DIF:ModerateREF:p. 362 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall 8. A patients wife tells the nurse that she wants to be with her husband when he dies. The patients respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns.

Which response by the nurse isbest?

1) Certainly, go ahead; your husband will most likely hold on until you return.2) Your husband could live for days or a few hours; you should do whatever you are comfortable with.

3) You need to take care of yourself; go home and shower, and Ill stay at hisbedside while you are gone.

4) Dont worry. Your husband is in good hands; Ill look out for him.ANS: 2 The patient is exhibiting signs that typically occur days to a few hours before death. The nurse should provide information to the wife so she can make an informed decision about whether to leave her husbands bedside. The nurse should not offer false reassurance by stating that the patient will most likely be fine until the wifes return. The nurse should not offer her opinion by telling the wife that she needs to take care of herself. It is also unrealistic for the nurse to stay with the patient until his wife returns.

The nurse would be minimizing the wifes concern by telling her not to worry because her husband is in good hands. The issue for the family member is not trust in the competency of the healthcareprovider but rather wanting to be present with her spouse at the time of death.

PTS:1DIF:ModerateREF:pp. 367-368 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 9. Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden surge ofactivity may occur 1) Moments before death2) Days to hours before death3) 1

to 2 weeks before death 4) 1 to 3 months before death ANS: 3 Days to hours before death, patients commonly experience a surge of energy that brings mental clarity and a desire to speak with family. One to 3 months before death, the dying person begins to withdraw from the world by sleeping more and eating less. One to 2 weeks before death, the body loses its ability tomaintain itself, and body systems begin to deteriorate. Near the time of death, the dying person does not respond to touch or sound and cannot be awakened.

PTS:1DIF:ModerateREF:p. 367 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 10. Which intervention takes priority for the patient receiving hospice care?1) Turning and repositioning the patient every 2 hours2) Assisting the patient out of bed into a chair twice a day3) Administering pain medication to keep the patient comfortable4) Providing the patient with small frequent, nutritious mealsANS: 3 A priority intervention for the hospice team is administering pain medications to keep the patient comfortable. Turning the patient to prevent skin breakdown andpromote comfort is also important, but it does not take priority over administering pain medications. The patient may not be able to eat meals or getout of bed into the chair and may tolerate only small amounts at a meal. During the dying process, bowel activity reduces and digestion is minimal, which often results in nausea or food intolerance.

Additionally, the bodys need for nutrition and hydration is reduced as the body begins the desiccation process.

PTS:1DIFifficultREF:p. 363 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 11. The nurse has been explaining advance directives to a patient. Whichresponse by the patient would indicate that he has correctly understood the information? An advance directive is a document 1) Specifying your healthcare intentions should you become unable to make selfdirected decisions 2) Identifying the activities considered to be evidence of quality care3) Verifying your understanding of the risks and benefits associated with aprocedure 4)Allowing you the autonomy to leave the hospital when you decide, even if it isagainst medical advice ANS: 1 An advance directive is a group of instructions stating the patients healthcare wishes should he become unable to make decisions. The Patient Care Partnership is a document that helps to ensure that patients receive quality care. An informed consent form verifies the patients understanding of risks and benefits associated with a procedure. An against medical advice form allows thepatient to leave the hospital against medical advice and releases the hospital ofresponsibility for the patient.

PTS:1DIF:ModerateREF:p. 364 KEY: Nursing process: Evaluation | Client need: SECE | Cognitivelevel: Comprehension 12. A patient with a history of chronic obstructive pulmonary disease has aliving will that states he does not want endotracheal intubation and mechanicalventilation as a means of respiratory resuscitation. As the patients condition deteriorates, the patient asks whether he can change his decision. Which response by the nurse is best?

1) Ill call your physician right away so he can discuss this with you.2) You have the right to change your decision about treatment at any time.3) Are you sure you want to change your decision?4) We must follow whatever is written in your living will.ANS: 2 The nurse should inform the patient that he has the right to change his decisionabout treatment at any time. Next, the nurse should notify the physician of the patients decision so that the physician can speak to the patient and revise the treatment plan as needed. Questioning the patients decision is judgmental. Thepatient has the right to change his living will at any time. The medical team should not follow the living will if the patient changes his decision about what isin it.

PTS:1DIF:ModerateREF:p. 364 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 13. Which dysrhythmia confirms death?1) Asystole (absence of heart activity)2) Pulseless electrical activity3) Ventricular fibrillation4) Ventricular tachycardiaANS: 1 Asystole is a dysrhythmia that commonly serves as a confirmation of death. Pulseless electrical activity, ventricular fibrillation, and ventricular tachycardiaare potentially lethal dysrhythmias that may respond to treatment.

PTS:1DIF:EasyREF:p. 365 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 14. A patient dying of heart failure has changed his choice about his end-of-life treatment measures several times. He says, I just cant make up my mind about it. Which nursing diagnosis is most appropriate for this patient?

Deficient Knowledge2) Spiritual Distress3) Decisional Conflict4) Death AnxietyANS: 3 This patient is experiencing Decisional Conflict related to his end-of-life treatment measures.

Deficient Knowledge, Spiritual Distress, or Death Anxietymay be the etiology of his changing decisions, but his indecision about his treatment option clearly identifies his Decisional Conflict.

PTS:1DIF:ModerateREF:pp. 367-368; high-level question, not stated verbatim intext | V2, pp. 168169; high-level question, not stated verbatim in text KEY: Nursing process: Nursing diagnosis | Client need: PSI | Cognitive level:Analysis 15. Which nursing intervention should be included in the plan of care for apatient dying of cancer?

1) Encourage at least one family member to remain at the bedside at all times.2) Follow-up with other healthcare team members during weekly meetings.3) Avoid discussing the dying process with family (to reduce sadness).

Encourage family members to participate in care of the patient when possible.ANS: 4 The plan of care should include encouraging family members to help with the patients care when they are able. Family members should also be encouraged totake care of themselves. They often need to be encouraged to take breaks to eat and rest. Provide them with anticipatory guidance about the stages of death so they know what to expect. Follow up promptly (not weekly) with other healthcare team members to address family concerns.

PTS: 1 DIF: Moderate REF: pp. 369-371 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 16. Which intervention by the nurse is most appropriate when she noticesthat her dying patient has developed a death rattle?

1) Perform nasotracheal suctioning of secretions.2) Turn the patient on his side and raise the head of the bed.3) Insert a nasopharyngeal airway as needed.4) Administer morphine sulfate intravenously.ANS: 2 If a death rattle occurs, turn the patient on his side, and elevate the head of thebed.

Nasotracheal suctioning and inserting a nasopharyngeal airway are ineffective against a death rattle and may cause the patient unnecessary discomfort. The patient may require IV morphine sulfate to treat pain, but it does not help stop a death rattle. This narcotic analgesic can also reduce therespiratory drive, leading to hypoventilation and respiratory depression or arrest.

PTS:1DIF:ModerateREF:p. 376 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 17. Which of the following patient goals is most appropriate when managingthe patient dying of cancer? The patient will 1) Request pain medication when needed2) Report or demonstrate satisfactory pain control3) Use only nonpharmacological measures to control pain4) Verbalize understanding that it may not be possible to control his painANS: 2 The most important goal is that the patient will report or demonstrate satisfactory pain control. The nurse should administer pain medication on a regular schedule to ensure satisfactory pain control; pain may not be controlled if medication is administered on an as needed basis. Nonpharmacologic measures can be a helpful adjunct in controlling pain, but they are not likely to be adequate for pain associated with cancer. Effective pain-control medications are available and can be administered by several routes; it should be possible tocontrol the pain.

PTS: 1 DIF: Moderate REF: p. 369 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 18. When providing postmortem care, the nurse places dentures in the mouth and closes

the eyes and mouth of the patient within 2 to 4 hours afterdeath. Why is the timing of the action so important?

1) To prevent blood from settling in the head, neck, and shoulders2) To perform these actions more easily before rigor mortis develops3) To set the mouth in a natural position for viewing by the family4) To prevent discoloration caused by blood settling in the facial areaANS: 2 Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should placedentures in the mouth and close the patients eyes and mouth before that time. The nurse should place a pillow under the head and shoulders to prevent blood from settling there and causing discoloration.

Closing the patients mouth and tying a strip of soft gauze under the chin and around the head keeps the mouth set in a natural position for a viewing later. Closing the eyes after death creates a peaceful resting appearance when the body is later viewed but has nothing to do with setting the mouth. Placing dentures in the mouth and closing the eyes and mouth do not prevent discoloration in the facial area.

PTS: 1 DIF: Moderate REF: p. 378 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 19. How should the nurse respond to a family immediately after a patientdies?

Ask the family to leave the patients room so postmortem care can beperformed.

2) Leave tubes and IV lines in place until the family has the opportunity to view thebody.

3) Express sympathy to the family (e.g., I am sorry for your loss).4) Tell the family that they will have limited time with their loved one.ANS: 3 The nurse should express sympathy to the family immediately after the patientsdeath. She should give the family as much time as they need with their lovedone and take care to present the body in a restful pose. If family members are not present at the time of death, remove tubes and IV lines before they see the body, unless an autopsy is planned or the death is being investigated by the coroner. The body should not be removed from the patient care area until the family is ready.

PTS:1DIF:ModerateREF:p. 378 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 20. The mother of a preschool child dies suddenly of a ruptured cerebralaneurysm. What recommendation should the nurse make to the family regarding how to most therapeutically care for the child?

1) Take the child to the funeral even if he is frightened.

2.)Notify the physician immediately if the child shows signs of regression.

3) Spend as much time as possible with the child.

4) Provide distraction whenever the child begins to express feelings of sadness.ANS: 3 The nurse should advise the family to spend as much time as possible with the child. If the child is frightened about attending the funeral, he should not be forced to attend.

Signs of regression are a normal reaction to the loss of a lovedone, especially a parent. The child should be encouraged to express his feelingsand fears.

PTS:1DIF:ModerateREF:p. 380 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 21. Which intervention should be included in the plan of care for a patient inthe end- stage death process?

1) Encourage the patient to accept as much help as possible.2) Avoid administering laxatives.3) Wet the lips and mouth frequently.4) Administer pain medication on an as-needed basis.

If the patient is unable to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently. Encourage the patient to be as independent as possible. Administer laxatives if constipation occurs. Administer pain medications on a regular schedule instead of waiting forthe patient to request them.

PTS:1DIF:ModerateREF:p. 375 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 22. Throughout the course of his illness, a patient has denied its seriousness, even though his health professionals have explained prognosis of death very clearly. Physiologic signs now indicate that he will probably die withina short period of time, but he is still firmly in a state of emotional denial. The patient says to the nurse, Tell my wife to stop hovering and go home. Im going to be fine. How should the nurse respond?

1) Your physical signs indicate that you will likely not live more than a few moredays. 2) You seem very sure that you are not going to die. Please tell me more aboutwhat you are feeling.

3) It seems to me you would be feeling some anger and wondering why all this is happening to you.

4) It would be best for your family if you were able to work through this and cometo accept the reality of your situation.

Not all patients go through all the traditional stages of grieving. It is not the nurses responsibility to move patients sequentially through each stage of the dying and grieving process with the goal that everyone ends life accepting death. It is a nursing responsibility to accept and support people where they are and help them to express their feelings. Nurses need to understand patients, notchange them. In this situation, denial may be very important to this patient, as an emotional defense and coping strategy.

You seem sure . . . tell me . . . what you are feeling restates what the patient hassaid (indicating understanding) and encourages expression of feelingsboth are supportive. Even though moving him through stages is not the goal in this situation, support does facilitate that.

Telling the patient that his physical signs indicate that death is imminent is presenting truth and reality; however, the exact time of death is not always predictable. Forecasting the hour of death can have negative impact on the family as they anticipate the event with emotion and exhaustion. Presenting reality is appropriate in certain circumstances earlier in the dying process, butnot in this situation because it has already been tried with no change in the patient. Presenting reality does not support the patients needs at this time.

Saying It seems to me you would be feeling some anger . . . is directed toward moving the patient from denial and suggesting he should feel something he hasnot yet expressed. This is not therapeutic. Saying It would be best for your family . . . presumes that the nurse knows more about what is best for the patients family than the patient himself. This statement is also

judgmental.

PTS: 1 DIF: Difficult REF: pp. 362-363 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 23. A home health patient previously lived with her sister for more than 20years.

Although it has been over a year since her sister died, the patient tells the nurse, Its no worse now, but I never feel any relief from this overwhelming sadness. I still cant sleep a full night. The house is a mess; I feel too tired, even to take a bath.

But, sometimes at night, she comes to me and I can see her plainas can be. The patients clothing is not clean and her hair is not combed. She is apparently not eating adequately. What can the nurse conclude? The patient is probably 1) Grieving longer than usual because of the closeness of the relationship with hersister 2) Experiencing a depressive disorder rather than simply grieving the loss of hersister 3) Feeling guilt and worthlessness because her sister died and she is still alive4) Interpreting the holiday as a trigger event, which is causing her to hallucinateANS: 2 The patient is likely experiencing a depressive disorder. Her symptoms include unrelieved, overwhelming sadness; insomnia; difficulty carrying out ADLs; fatigue; and visual hallucinations. Note that her sadness is pervasive, not created by a trigger event (holiday). Of those symptoms, insomnia is common toboth grief and depression, but the other symptoms are signs of depressive disorder. There is, of course, no correct timeline for what constitutes longer thanusual grieving; however, the patients symptoms are typical of depression, not grief. She has not said she feels guilty or worthless, and there is nothing from which the nurse could infer that. She has specifically said that the holiday has not made her feel any worsethat is, it has not been a trigger event.

PTS: 1 DIF: Difficult REF: pp. 367-368 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which intervention is appropriate for a client receiving palliative care? Choose all that apply.

1) Surgical insertion of a device to decrease the workload of the heart in a patient awaiting heart transplantation 2) Administering IV dopamine to raise blood pressure of a patient with end-stagelung cancer 3) Providing moisturizing eye drops to an unconscious patient whose eyes are dry 4)Administering a medication to relieve the nausea of a patient with end-stageleukemia ANS: 3, 4 Palliative care focuses on relieving symptoms for patients whose disease process no longer responds to treatment. Providing moisturizing eye drops andadministering antinausea medication in a patient with end-stage leukemia are examples of palliative care. Surgical insertion of a device to decrease heart workload and administering dopamine are aggressive treatment measures.

PTS:1DIF:ModerateREF:p. 363 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 2. To be eligible for insurance benefits covering hospice care, a physicianmust certify that which of the following apply to the patient? Choose all that apply.

1) Life expectancy is not more than 6 months.2) Life expectancy is not more than 12 months.3) Condition is expected to improve slightly.4) Condition is not expected to improve.ANS: 1, 4 For a patient to be eligible for hospice care insurance benefits, a physician must certify that the patient is not expected to improve or will most likely die within 6months.

PTS:1DIF:ModerateREF:p. 363 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Recall 3. Which of the following might be a warning sign that a child needsprofessional help after the death of a loved one? Choose all that apply.

1) Interest in his usual activities 2) Extended regression 3)Withdrawal from friends4) Inability to sleep5) Intermittent sadnessANS: 2, 3, 4 The warning signs that may indicate the need for professional help include inability to sleep, extended regression, loss of interest in daily activities, and withdrawal from friends. Interest in usual activities is a sign of coping; intermittent expressions of sadness and anger are to be expected, even over along period of time, so they would not indicate a need for professional help.

PTS:1DIF:EasyREF:p. 380 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

Chapter 15. Communicating & Therapeutic Relationships Multiple Choice Identify the choice that best completes the statement or answers the question.

1.Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment?

1)Small group 2) Interpersonal 3) Group 4) Intrapersonal ANS:2 The nurse uses interpersonal communication when interviewing the patient about his health history during the admission assessment. Small-group communication occurs when a person engages in an exchange of ideas with two or more people at the same time. Group communication is interaction that occurs among several people.

Intrapersonal communication is conscious internaldialogue.

PTS:1DIF:ModerateREF:p. 464 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level:Comprehension 2.During admission to the unit, a patient states, Im not worried about the results of my tests. Im sure Ill be all right. As he observes the patient, the nursenotes that the patient is shaky and tearful and does not make eye contact.

Unfortunately, the nurse is called away to an emergency before he has time to complete this discussion. Which of the following actions is most appropriate for the nurse to establish when returning to the patient? Patient will 1)Explain the reason for his incongruent statements2) Engage in diversional activities to cope with stress3) Express his concerns to his primary care provider4) Discuss his concerns and fears with the nurseANS:4 The nurse has observed a mismatch between verbal and nonverbal communication.

Unfortunately, an emergency has required the nurse to leave the patient. To resolve this mismatch, the nurse will set a goal to have the patient discuss his concerns and fears at their next interaction. It is inappropriate to ask the patient to explain why his verbal message did not match the nonverbal message because this will inhibit further conversation. It may be appropriate to have the patient discuss his concerns with his primary care provider; however, we do not have enough information to suggest this course of action. For example, if the patient is upset about some other matter,this action would not be appropriate. Similarly, it is not appropriate to suggest diversional activities until the reason for the mismatch between his words andbehavior is identified.

PTS: 1 DIF: Moderate REF: p. 476 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 3.The nurse is preparing a patient for a computed tomography (CT) scan ofthe abdomen. Which statement by the nurse is best (all contain correct information)?

1)

You will need to remain NPO for the 4 hours prior to your CT scan.2) You cannot have anything to eat or drink for 4 hours before your test.3) You will need to be NPO and drink this contrast media before your test.4) You may need to void before you go down to the department for your CT scan.ANS:2 Telling the patient that he cannot have anything to eat or drink for a specific time before his test is the best statement. It uses terms that the patient can understand. The other options use medical jargon that many patients may notunderstand.

PTS:1DIF:ModerateREF:p. 465 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 4.The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows she should use touch cautiously, especially whencommunicating with which patient?

1) Middle-aged woman just diagnosed with terminal lung cancer2) Middle-aged man experiencing the acute phase of myocardial infarction3) Older adult with a history of dementia admitted for dehydration4) Young adult in the rehabilitative phase after arthroscopic surgeryANS:3 The nurse should use touch especially cautiously when communicating with a person who suffers from impaired mental health, such as dementia, because thepatient may have difficulty interpreting the meaning of touch. In general, touch can be used with most patients, such as patients with cancer, an acute MI, or general orthopedic surgery, and with all age groups.

However, the nurse should always be conscious of the situation, environment, and receptivity of the patient.

PTS:1DIF:ModerateREF:p. 467 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 5.The nurse manager of the medical intensive care unit formed a group tohelp her staff cope with stress more effectively. Which of the comments by group members will lead the manager to evaluate the group as successful?

1) This was a good idea to form a group; Ive been wanting to get to know some ofthe people working the other shifts.

2) It really helps me to share feelings about how hard it is to see pain and sufferingevery day.

3) I now have a group to help me when I need to work through situations in myown life causing me stress.

4) It feels good to have a chance to get away from the unit and talk on a regularbasis. ANS:2 Work-related social support groups assist members of a profession to cope with the stress associated with their work. The focus of the group is to share feelingsabout the stress of the work environment. Although this may also be an opportunity to meet other staff members, get away from the unit, or share personal and family problems, these are not the primary focus of the group. PTS:1DIF:ModerateREF:p.

473 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 6.A patient who speaks little English is admitted to the hospital after experiencing severe abdominal pain. Which nursing diagnosis is preferred forthis patient?

1)

Impaired Communication2) Readiness for Enhanced Communication3) Impaired Verbal Communication4) Sensory AlterationANS:1 Impaired Communication is the preferred nursing diagnosis when the patient is unfamiliar with the dominant language. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia.

Readiness for Enhanced Communication is appropriate when the patientexpresses willingness to enhance communication. Sensory Alteration is appropriate when there is a change in the characteristics of the patientsincoming stimuli.

PTS:1DIFifficultREF:p. 474 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 7. A young adult with a severe episode of asthma bronchoconstriction comes to the emergency department with signs of respiratory distress. When the nurse performs the admission assessment, she notes that the patient is notable to say where she is or the time.

Which nursing diagnosis is probably most suitable for this patient?

1) Chronic Confusion2) Acute Confusion3) Impaired Verbal Communication4) Readiness for Enhanced CommunicationANS: 2 This patient is experiencing Acute Confusion caused by lack of oxygen related tohis respiratory distress. As a young adult with an acute episode of asthma, this patient would not likely have a history of confusion; therefore, without more data, Chronic Confusion is not an appropriate diagnosis for this patient. ImpairedVerbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia, but not with confusion.

Readiness for Enhanced Communication is appropriate when the patient expresses willingness to enhance communication.

PTS:1DIFifficultREF:p. 474 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 8.A patient experiences expressive aphasia after a stroke. Which expectedoutcome is appropriate for this patient?

1) Uses alternative methods of communication2) Communicates effectively using a translator3) Interprets messages accurately4) Follows commands when askedANS:1 An appropriate outcome for a patient with expressive aphasia is uses alternativemethods of communication. Expressive aphasia means the patient cannot verbalize his intended message, but the patient may be able to understand and to communicate in other ways. Communicates effectively using a translator is an appropriate outcome for a patient who is unfamiliar with the dominant language. Interprets messages accurately and follows commands when asked are appropriate outcomes for the patient with receptive, not expressive,aphasia.

PTS:1DIF:ModerateREF:p. 475

KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 9.Which intervention by the nurse first helps to establish a trusting nurse-patient relationship?

1) Avoiding topics that may provoke emotional responses from the patient2) Listening to the patient while performing care activities3) Performing care interventions quietly and respectfully4) Greeting the patient by name whenever entering the patients roomANS:4 The nurse can establish a trusting nurse-patient relationship by always greetingthe patient by name, listening actively, responding honestly to the patients concerns, providing explanations for care interventions, and providing care competently and consistently.

PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 10.A physician tells a patient that she has cancer and that she should havesurgery as soon as possible. The patient is not certain she wants to pursue thistreatment approach but responds by saying, Ill do whatever you think I should do. Which communication style is this patient using?

Assertive2) Aggressive3) Passive aggressive 2 4) PassiveANS:4 This patient is using a passive communication style to avoid conflict with others while allowing the other person to be in control. An aggressive approach forces others to relinquish control. The goal of the aggressive approach is to win and bein control. With assertive communication, the person expresses beliefs or feelings without infringing on anothers rights.

The passive aggressive approach uses a submissive style of communication but is aggressive in the sense that it manipulates the receiver to help the sender win. This allows the sender to be in control without conflict.

PTS:1DIF:ModerateREF:p. 470 KEY: Nursing process: Analysis | Client need: PSI | Cognitive level: Application 11.Which statement by the nurse manager demonstrates an assertive approach when communicating with the staff nurse about a patient care issue?

1) You must assess and document pain status for every patient.2) Why havent you been assessing and documenting pain for every patient?

Will you please assess and document pain status for every patient?4) Explain why you havent been assessing and documenting pain for every patient. ANS:1 By stating that pain must be assessed and documented for every patient, the nurse manager is using an assertive approach. An assertive approach uses the statement of facts, not

judgments. Asking why the nurse has not been assessingand documenting pain is judgmental and elicits a defensive response by the nurse. Asking the nurse whether she will assess and document pain for every patient invites a negative response and does not use an assertive approach.

Asking the nurse to explain why she has not been assessing and documentingpain is also judgmental.

PTS:1DIF:ModerateREF:pp. 470-471 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 12.A patient comes to the emergency department complaining of severe, substernal chest pain. He is restless and anxious. Which statement by the nurseappropriately offers reassurance?

1) Ill give you some medication to help relieve the pain.2) If you lie still and relax, youll be fine in a little while.3) Please try not to think about the pain as best as you can.4) Dont worry; were going to take good care of you.

ANS:1 By telling the patient that she is going to give him some medication to help relieve his pain, the nurse is offering him realistic reassurance. The other optionsoffer false reassurance and minimize patient concerns.

PTS:1DIF:ModerateREF:p. 479 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 13.Which statement by the nurse indicates that the nurse-patientrelationship is entering the termination phase?

1) Ill be admitting you to our nursing unit as soon as I obtain your health history.2) You seem upset today. Would you like to talk about whatever is bothering you?3) Im leaving for the day. Is there anything I can do for you before I leave?4) Hello. My name is Leslie, and Im going to be your nurse today.ANS:3 When the nurse states, Im leaving for the day. Is there anything I can do for youbefore I leave? the nurse-patient relationship is entering the termination phase. The termination phase is the conclusion of the relationship, which can occur at the end of a nurses shift. The pre-interaction phase occurs before the nurse meets the patient. The statement Ill be admitting you to our floor as soon as I obtain your history demonstrates the pre- interaction phase of the nursepatientrelationship. The nurse introduces herself to the patient during the orientation phase.

During the working phase of the nurse-patient relationship, feelings are explored. This phase is demonstrated by the statement, You seem upset today.Would you like to talk about whatever is bothering you?

PTS:1DIF:ModerateREF:p. 472 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 14.A health center that is interested in purchasing IV infusion pumps organizes a group of nurses to evaluate pumps provided by a variety of vendors.Which type of group has been

organized?

1) Short term2) Ongoing3) Self-help4) Work-related social supportANS:1 The organized group is a short-term group. Short-term groups focus on the taskat hand, which in this case is evaluating infusion pumps. Ongoing groups address issues that are recurrent.

Self-help groups are voluntary organizations composed of people with a common need. Workrelated social support groups assist members of a profession to cope with the stress associated with their work.

PTS:1DIF:ModerateREF:p. 473 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 15.The nurse must insert a nasogastric (NG) tube into a patient with a bowel obstruction.

Before inserting the tube, the nurse must explain the procedure to the patient. Which explanation by the nurse is best, assuming that all provide correct information?

1) Im going to insert an NG tube and connect it to low Gomco to keep yourstomach empty.

2) Im going to insert a tube through your nose into your stomach to prevent youfrom vomiting.

3) Im going to insert an NG tube through your nares to suction your secretions and prevent emesis.

4) Lie still, please; I need to elevate the head of the bed and insert this tube.ANS:2 Because patients are typically confused by medical terminology, the nurse should use language that the patient can understand. NG tube, Gomco, suction secretions, nares, and emesis are all medical jargon that the patient might not understand. Moreover, the nurse should explain all procedures before performing them to help minimize the patients anxiety. Lie still, please . . . offersno explanation of why the NG tube is being inserted, and it conveys that the nurse is impatient.

PTS:1DIF:ModerateREF:p. 465 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 16.A patient had surgery 6 hours ago. When the nurse enters the room to turn him, she notes that he is restless and grimacing. Considering the patientsnonverbal communication, what action should the nurse take first?

1) Administer pain medication to the patient.

2) Turn and reposition the patient.

3) Assess to determine the cause of the grimacing.

4) Leave the patients room so he can rest quietly.

ANS:3 The nurse should assess the patient to determine whether he is having pain. Thenurse should not assume by the patients nonverbal communication that the patient is in pain and administer pain medication; the nurse should validate the message being sent. The nurse should not turn and reposition the patient without assessing him. Leaving the patient without addressing his nonverbal cues is neglectful.

PTS:1DIF:ModerateREF:pp. 466-467

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 17.A patient who speaks only French was admitted to the hospital after a motor vehicle accident. Assuming that the nurse does not speak French, what isthe best way to communicate with this patient?

1) Use sign language for communicating.2) Ask a family member to serve as a translator.3) Request the services of a hospital translator.4) Speak in English, but speak very slowly.ANS:3 The nurse should request the services of a hospital translator to communicate with the patient who does not speak English. A family member should not be used as a translator unless there are no other options because it is often culturally unacceptable to have a family member ask personal questions. Also, considering the patients right to confidentiality, it is not appropriate to share private information about the patient with family members unless permission is obtained.

Using sign language can be an effective strategy for hearing-impairedpersons. Speaking slowly in English is not useful if the patient does not understand the language.

PTS:1DIF:ModerateREF:p. 475 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 18.After a physician discusses cancer treatment options with a patient, thepatient asks the nurse which treatment he should choose. Which response by the nurse is best? 1) If I were you, Id go with chemotherapy.2) What do you think about radiation therapy?3) Why dont you see what your wife thinks.4) Ill give you some information about each option.ANS:4 The nurse should avoid giving a personal opinion; instead offer the patient more information so he can make an informed decision. Responses such as, If I were you, Id go with chemotherapy and Why dont you see what your wife thinks donot respect the patients right to make his own decisions. What do you think about radiation therapy, is leading the patient without exploring the other options.

PTS:1DIF:EasyREF:pp. 478-479 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 19.Which of the following is a nonverbal behavior that enhancescommunication? 1) Keeping a neutral expression on the face2) Maintaining a distance of 6 to 12 inches3) Sitting down to speak with the patient4) Asking mostly open-ended questionsANS:3 Sitting down to speak with the patient enhances communication because it communicates a willingness to listen. A concerned expression, not a neutral one, demonstrates interest and attention. Maintaining a distance of 18 inches to 4 feet, not 6 to 12 inches, while speaking allows most patients to feel comfortable,thereby enhancing communication. When the interpersonal distance is too close, patients might feel uncomfortable. Asking open-ended questions is a verbal communication strategy, not a nonverbal behavior.

PTS:1DIF:ModerateREF:p. 467

KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Comprehension 20.A patient being admitted in hypertensive crisis informs the nurse that hestopped taking his blood pressure medication 3 weeks ago. Which response by the nurse is best?

1) Youre lucky you didnt have a stroke; you really need to take your medication.2) Tell me more about your experience with your high blood pressure medication.3) Why did you stop taking your high blood pressure medication?4) Its very important to take your blood pressure medication.ANS:2 The nurse can gather more information about the patients reasons for stopping his blood pressure medication by asking him to tell her more about his experience with the medication.

Telling the patient he is lucky he did not have astroke suggests criticism.

Asking the patient why he stopped taking his high blood pressure medication may cause the patient to become defensive and haltfurther communication. Telling the patient that it is very important to take his blood pressure medication is patronizing and also suggests criticism; at the veryleast, it fails to elicit more communication from the patient.

PTS:1DIF:ModerateREF:pp. 477-478 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 21.The wife of an elderly patient begins crying after she is informed that hehas a terminal illness. Which intervention by the nurse is best?

1) Sit quietly with the patients wife while she composes her thoughts.2) Inform his wife that a chaplain is available if she would like to speak to him.3) Remind his wife that her husband has lived a long and happy life.4) Tell his wife there are always options and suggest she not give up hope.ANS:1 The nurse can intervene best by sitting quietly with the patients wife, allowingher to compose her thoughts. Silence communicates acceptance. After processing the bad news, the wife can provide the nurse with further information, such as whether she would like to consult with a chaplain. Tellingthe wife there are always options offers false reassurance and would probably discourage her from further communication.

PTS:1DIFifficultREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 22.A patient newly diagnosed with breast cancer tells the nurse, Im worried I wont live to see my children grow up. Which response by the nurse best conveys concern and active listening?

1) There have been many advances in breast cancer treatment; hope for the best.2) Breast cancer is a serious disease; I can understand why youre worried.3) Youre strong and have youth on your side to fight the breast cancer.4) Id be worried, too; Ive seen a lot of patients die from breast cancer.ANS:2 Restating the patients concern by saying, Breast cancer is a serious disease; I can understand why youre worried conveys concern and active listening. Statingthat there have

been many advances in breast cancer treatment minimizes the patients concern. Stating that the patient is young and should have no troublesurviving breast cancer minimizes the patients concern and offers false reassurance. Stating that the nurse has seen a lot of patients die from breast cancer could frighten the patient and cause emotional harm.

PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 23.A nurse has sound, scientific evidence to support changing a procedurethat would reduce catheter-related infections on the unit. The unit manager states, nevertheless, that she is unwilling to make the change because it would be too costly. Which response by the nurse represents assertive communication?

This is a widely used practice. If you read more research, youd probably wonderwhy we arent already doing it.

2) There is extensive evidence to support the new method, but I dont want tocreate an issue.

3) Is the budget more important to the hospital than reducing infections andpatient suffering?

4) Id like to help gather information regarding the cost of new materials versus the savings in treating infections.

ANS:4 The statement pertaining to helping to gather information about of the cost of materials is an assertive response. It does not threaten the authority of the nurse manager and introduce another element preventing change that is unrelated to the procedure itself. It states the nurses position and wishes clearlywith an I statement, and it does not invite negative responses. The statement beginning with This is a widely used practice is aggressive and implies criticism and a judgment that the nurse manager does not read as much as she should. The statement ending with I wouldnt want to create chaos is passive and submissive. The statement beginning with Is the budget more important . . . is aggressive and judgmental.

PTS:1DIF:ModerateREF:pp. 470-471 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level:Application 24.When using the SBAR model to communicate with a physician, what information does the nurse offer first?

Statement of the problem and its probable cause2) Nurses name, patients name, and reason for the communication3) History of information related to and leading up to the situation4) A solution to the problem or what is needed from the physicianANS:2 SBAR is an acronym for Situation, Background, Assessment, and Recommendation. The nurses name, and so forth, are part of the Situation. Statement of the problem and cause are the Assessment. History of the factorsleading up to the current situation make up the Background. What the nurse thinks will correct the problem is categorized under Recommendation.

PTS: 1 DIF: Difficult REF: p. 471 KEY:Nursing process: Implementation | Client need: PSI | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1.Which statement about communication is true? (Choose all that apply.)

Communication is 1) Used to meet physical and psychosocial needs 2) Most basically described as talking and listening 3) The process of sending and receiving information 4) The basis for forming relationshipsANS:1, 3, 4 People use communication to fulfill basic human needs at all levels: physical, psychosocial, emotional, and spiritual needs. Communication is a process of sending and receiving messages. It forms the basis for sharing meaning and building effective relationships among individuals, families, and the healthcare team. Communication involves more than just talking and listening. And simplybecause messages are verbalized does not mean listening and understandingare achieved.

PTS:1DIF:EasyREF:pp. 463-464 KEY:Nursing process: N/A |Client need: PSI | Cognitive level: Recall 2.Which statement by the nurse demonstrates that active listening hasoccurred?

Choose all that apply.

1) I listened to my patient while I was changing his IV site.2) I made eye contact and listened to my patient to find out his concerns.3) I took notes when I listened to my patient describe his symptoms.4) I sat with my patient and his wife to talk about their fears before the surgery.ANS:2, 4 The nurse demonstrates active listening by facing the patient, making eye contact, and listening while he expresses concerns. Arranging time to sit with the patient and his wife to discuss fears about an upcoming surgery also indicates active listening.

Listening to the patient while performing activities, such as hanging an IV infusion or bathing him, distracts the nurse from active listening. Although taking detailed notes can help the nurse to accurately recallthe patients words, this activity while listening to the patient speak can also be a distraction and could reduce eye contact and nonverbal cues of care and concern.

PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 3.A patient tells the nurse, Im having a lot of pain in my hip. Which response by the nurse is openended and would stimulate the patient to provide the most complete data? Choose all that are correct.

1) Is your pain severe?2) Tell me about your pain.3) When did you first notice this pain?4) How would you describe your pain?ANS:2, 4 The responses Tell me about your pain and How would you describe your pain? are openended responses that stimulate conversation. Although it is importantinformation, the question Is your pain severe? prompts a yes or no response.

When did you first notice this pain?also important informationis likely to stimulate a brief, factual answer. Such questions allow the nurse to control thepatients response.

Limiting the response might lead to an incomplete assessment.

PTS:1DIF:ModerateREF:p. 476; includes cross-reference to Chapter 3 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application

Chapter 16. Patient Education Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which teaching technique is best for teaching a nursing assistant how toperform fingerstick glucose testing?

1) Provide a manufacturers pamphlet with detailed instruction.2) Explain the best technique for performing glucose testing.3) Demonstrate the procedure; then ask for a return demonstration.4) Suggest that the assistant watch a DVD showing the procedure.ANS: 3 The best way to teach a psychomotor skill is to demonstrate the procedure and then ask for a return demonstration. Supplementary written information or DVDcan also be supplied to the patient to reinforce learning. However, they are not the best method for teaching a psychomotor skill; enacting the procedure is more effective.

PTS: 1 DIF: Moderate REF: pp. 871, 873 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 2. A patient with a diabetic foot ulcer will need to perform dressing changesafter discharge. When should the nurse schedule the teaching session(s)?

1) Within 10 minutes after his next dose of oral pain medication2) After the patient wakes up from a restful nap3) Before the surgeon dbrides the wound4) Before the patient undergoes flow studies of his affected legANS: 2 For learning to be most effective, teaching must occur when the patient is mostready. A patients capacity to take in new information is reduced when he is anxious, in this example about testing or treatment, or is tired, or is experiencing pain. Therefore, the best time to teach this patient is when he is rested, such as after a restful nap. Ten minutes is not enough time for oral medication to take effect and relieve pain.

PTS: 1 DIF: Difficult REF: pp. 857-858 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 3. Which intervention by the nurse would be best to motivate a patient newly diagnosed with hypertension to learn about the prescribed treatment plan?

1) Explain that when left untreated, hypertension may lead to stroke.2) Ask the patient to let you know when he is ready to learn.3) Encourage the patient to learn about various treatment options.4) Reassure the patient that adhering to the treatment produces a good outcome.ANS:1 A patient newly diagnosed with hypertension may not be motivated to learn because he most likely has not experienced physical symptoms or other outward complications.

Therefore, the nurse should motivate the patient by pointing out serious risks to the quality of

life if the blood pressure control is notachieved. Although readiness to learn is an important consideration, treatment might be delayed too long if the patient does not appropriately perceive the immediacy of the health risk. Simply encouraging a patient to learn about bloodpressure and treatment options might not be suitable motivation to engage in active learning and to comply with prescribed treatment. Reassuring the patientand promising a good outcome by complying with medical treatment is not appropriate. Adhering to medical therapy reduces the risk for stroke and other complications; however, this cannot be guaranteed.

PTS:1DIF:ModerateREF:pp. 856-857 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 4. Assume all of the following written instructions about digoxin providecorrect information for patient care. Which one is best worded for patient understanding?

1) Obtain your radial pulse every morning before taking your digoxin dose.2) Return to your healthcare provider for monthly laboratory studies of your digoxinlevels. 3) Call your provider if you notice that objects look yellow or green.4) Always take the same brand of medication because certain brands may not be interchangeable.

ANS: 3 The nurse should provide written instructions that contain short sentences and easy-to- read words. If instructions are written at too high a reading level, the patient may not understand and make a harmful error in dosing. Calling the provider when objects look yellow or green is the clearest statement for patientteaching because the instruction is short, concrete, and written with easy-to- understand words. Patient instructions must not contain words that require a higher level of reading or medical jargon. The instruction pertaining to being consistent with brand use is too wordy, especially for patients who are ill or for whom English is not a primary language.

PTS:1DIFifficultREF:p. 873 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 5. Which teaching strategy is typically most effective for presentinginformation to large groups?

1) Distributing printed materials2) Lecturing using audiovisual format3) Providing online sources of information4) Role modelingANS: 2 Lecturing using audiovisual materials appeals to learners who best process information by hearing and seeing. From a practical point of view, a lecture format (traditional classroom or webinar) is efficient and effective with large groups. Although printed materials can help to reinforce information taught during a lecture, this can be problematic for auditory learners or those whose primary spoken language is not English. Online sources of information are idealfor learners who learn best by doing (kinesthetic learners). Role modeling is most effective for individuals or small groups of learners, especially when the relationship between the instructor and learner is meaningful.

PTS:1DIF:EasyREF:p. 872 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall 6. A patient with attention deficit disorder is admitted to the hospital with type 1 diabetes.

Which nursing diagnosis is commonly yet inappropriately used but should be avoided for this type of patient? Assume there are data to supportall the diagnoses.

1) Deficient Knowledge (disease process)2) Impaired ability to learn related to fear and anxiety3) Difficulty learning related to cognitive developmental level4) Lack of motivation to learn related to feelings of powerlessnessANS: 1 Patients who have a learning disability should not have an identified nursing diagnosis of Deficient Knowledge; instead, they should have a diagnosis that accurately identifies their problem, such as Impaired Ability to Learn related to Fear and Anxiety; Difficulty Learning related to Delayed Cognitive Development;or Lack of Motivation to Learn related to Feelings of Powerlessness. Note that these are not NANDA-I diagnoses.

PTS:1DIF:ModerateREF:pp. 864-865 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level:Comprehension 7. Which phrase is stated as a teaching goal (as compared with an objective) for a patient who had bowel resection with creation of a colostomy?The patient 1) empties the colostomy appliance when half filled.2) performs skin care around the stoma site.3) will perform ostomy self-care within 3 days after surgery.4) applies a new ostomy appliance, making sure it adheres properly.ANS: 3 Performing ostomy self-care is an appropriate goal for a patient who needs tolearn colostomy self-care after surgery. Emptying the colostomy appliance demonstrates a behavioral learning objective, not a broad teaching goal.

Performing skin care is also a desired skill stated by a learning objective.Applying an ostomy device is another observable learning objective.

PTS:1DIFifficultREF:p. 866 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Analysis 8. During advanced cardiac life support (ACLS) training, a nurse performs defibrillation using a mannequin. Which teaching strategy is being employed? 1) One-to-one instruction2) Computer-assisted instruction3) Role modeling4) SimulationANS: 4 ACLS training utilizes this strategy by creating a scenario using resuscitation mannequins and teaching healthcare workers to respond appropriately to life- threatening cardiopulmonary events. The nurse is demonstrating the skill of defibrillation. ACLS certification requires learners to perform the skill back to the examiner. With one-to-one instruction, one instructor

orally presents informationto one student. With ACLS training, the healthcare team is involved and not just individual nurses. In role modeling, the teacher teaches by example, demonstrating the behaviors (not skills) that need to be acquired by learners.

PTS:1DIF:ModerateREF:p. 872 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 9. During family therapy, to improve communication skills the nurse teaches family members to rehearse responses to situations involving interpersonal conflict. What is the primary drawback of using this teachingstrategy?

1) Some people might have difficulty with an interactive approach when there isconflict among participants.

2) Nurses might rehearse responses that are not effective for resolvinginterpersonal conflict.

3) Nurses do not use the rehearsal technique because it is an inefficient use oftime for participants.

4) This type of interactive teaching strategy is not as effective as dispersinginformation verbally or in print.

ANS: 1 The teaching strategy described is role-playing. Role-playing may cause participants to feel selfconscious; to be effective, participants must be willing toparticipate as an observer or role player, particularly in a situation where there is conflict among those involved in the exercise.

With role-playing, the participant may be unaware that teaching is occurring. The strategy can therefore be a productive use of time while modeling effective responses and desired behavior.

Rehearsing real-life situations common to family dynamics is typically more effective for conflict resolution than reading about the topic or discussing approaches for effective communication.

PTS:1DIF:ModerateREF:ESG, Chapter 24, General Teaching Strategies: RolePlaying KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Analysis 10. An older adult patient who underwent bowel resection is recovering from surgery without complication. He ambulates in the hallway and requireslittle analgesia for pain.

During the healthcare teams morning rounds, the surgeon informs the patient that the lesion removed was cancerous. Which factor will likely be the patients most significant obstacle for learning?

1) The patients baseline physical condition2) A negative environmental influence3) Anxiety associated with the new diagnosis4) Reduced ability to understand the diagnosisANS: 3 Anxiety associated with the new diagnosis of cancer will most likely be a barrier to learning in this patient. Fear of the unknown, fear of pain, fear of physical discomfort with treatment options, fear of altered role in home or work life, andmany other fears accompany the anxiety patients often experience when potentially life-threatening diagnoses are communicated. The patient has been ambulating and requiring minimal amount of pain medication; therefore, his physical condition is probably not the most significant barrier to learning. Simplybecause the patient is an older adult does not suggest he has reduced capacity to learn.

PTS: 1 DIF: Difficult REF: pp. 857-858 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Analysis

11. How can the nurse best provide teaching for a patient whose primaryspoken language is not the same as hers?

1) Provide written materials in the patient’s primary language.

2) Make arrangements to teach using an interpreter.

3) Provide a demonstration and request a return demonstration.

4) Use visual teaching aids to convey information.

ANS: 2 The nurse can best provide teaching for the patient whose primary spoken language is not the same as her own by requesting the aid of an interpreter. An interpreter can help the nurse to communicate clearly and accurately when assessing learning needs; dispersing the information; providing feedback to learners; and determining if teaching is effective. An interpreter also allows the patient to ask questions when necessary and the healthcare provider to respondwith meaningful information. Written materials in the patients primary language can help reinforce teaching. Demonstrating and requesting a return demonstration may be difficult if the patient does not understand the spoken language of the nurse. Visual aids may also be helpful for some learners, but they should not be the primary method for teaching because they do not offer an opportunity for the exchange of information through questions, demonstration, or discussion.

PTS: 1 DIF: Moderate REF: p. 862 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Comprehension 12. A preschool-age child is scheduled for a tonsillectomy. Which strategymight help lessen the childs anxiety before surgery?

1) Show the child a short, animated video (DVD) about the hospital visit andprocedure. 2) Give the child a tour of the hospital a week before the surgery is scheduled.3) Allow the child to use computer-assisted instruction to teach him about theprocedure. 4) Provide one-to-one instruction about the care he will need after surgery.ANS: 1 To reduce anxiety in a preschool-age child requiring surgery, show a short, animated video showing the area of the hospital where the child will be. The video should include a simple explanation of what is going to happen while he isin the hospital and afterward in a manner that is upbeat and friendly. A tour of the hospital with the sights and smells of sicker people might be more frightening to the young child. It is best to avoid exposure to pathogens before surgery, such as what could be acquired when touring the building. One-to-one instruction is a teaching strategy that is effective with adults and older children.

PTS:1DIF:Moderate REF: p. 860 [Preoperational Stage]; answer not directly stated in text.

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Comprehension 13. The nurse manager is devising a teaching schedule for the staff who areabout to begin using a new type of patient bed in the ICU. Implementation is planned in 6 weeks. When is the best time for the manager to schedule theteaching sessions?

1)

Immediately2) One week before implementation3) Two weeks before implementation4) Four weeks before implementationANS: 2 People retain information better when they have the opportunity to use it soon after it is presented. Therefore, the nurse manager should schedule teaching sessions 1 week before implementation of the equipment. If classes are scheduled too early, the nurses might forget how to use the equipment before itis implemented. If the teaching is offered immediately prior to use with patients,there would not be an adequate opportunity to practice skills and ask appropriate questions regarding use of the new device.

PTS:1DIF:ModerateREF:p. 858 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 14. For which patient is the nursing diagnosis Deficient Knowledge most appropriate?

1) Adolescent with Down syndrome and newly diagnosed with cardiac problem Young adult admitted with acute renal failure who requires hemodialysis3) Middle-aged woman with breast cancer receiving the last round ofchemotherapy 4) Older adult with a long-standing history of type 1 diabetes admitted with a footulcer ANS: 2 The young adult patient admitted with acute renal failure who needs hemodialysis will probably have Deficient Knowledge related to his treatment regimen. Patients with chronic illness, such as diabetes or cancer, are most likelyto be knowledgeable about the disease and course of treatment; therefore, the nursing diagnosis Deficient Knowledge is less relevant than it is to a patient whois newly diagnosed. The adolescent patient with Down syndrome would have anursing diagnosis of Impaired Ability to Learn.

PTS:1DIFifficultREF:pp. 864-865 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application 15. Prior to discharge, a patient with diabetes needs to learn how to check afinger- stick blood sugar before taking insulin. Which action will best help the patient remember proper technique?

1) Encouraging the patient to check the blood sugar each time the nurse givesinsulin 2) Providing feedback after the patient takes his blood sugar for the first time Verbally instructing the patient about how to obtain a finger-stick blood sugar4) Offering a brochure that describes the technique for checking blood sugarANS: 1 Having the patient check the finger-stick with the nurse each time insulin is administered is the best way to practice the correct technique and gain confidence prior to discharge.

Repetition increases the likelihood that the patientwill retain information and incorporate it into the daily management of his diabetes care. Although feedback is important, the patient might need it on more than one occasion. Verbal instructions for performing a new skill are most useful when the patient has an opportunity to perform the technique. A brochureis informative

and useful for later reference; however, information about performing a new skill is best offered when the patient can see it demonstrated and has the opportunity to practice it with feedback from the nurse.

PTS:1DIF:ModerateREF:p. 858 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 16. It is a busy day on the medical-surgical floor, and the nurse must teacha patient ready for discharge about his medications. How can the nurse most efficiently utilize her time and provide this education?

1) Write down instructions so the patient can read them at home.2) Discuss the information while assisting the patient with his bath.3) Educate the patient about his medications as each one is given.4) Follow up with the patient after discharge with a phone call.ANS: 3 Teaching does not have to be performed in a formal session but is often most effective at a teachable moment when the information is perceived as most relevant, such as at the time the medication is given to the patient. Additionally,the information is more memorable when the patient can see the actual dose and identify it with the information presented. A teaching session about wound care would be appropriate during bathing but not medication teaching.

Providingthe patient written instructions without discussing the information does not allow the patient an opportunity to ask questions or the nurse to verify the patient understands the instruction. The patient should not be discharged without education about his prescribed medications, including what they are for,how to take them, instructions regarding dosing, what side effects can occur, and when to stop taking the medications.

PTS:1DIF:ModerateREF:p. 859 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application Completion Complete each statement.

1. The physician prescribes a new drug with which the nurse is unfamiliar. She consults the hospital formulary to learn about the drug. Which learning domainis the nurse utilizing?

ANS: Cognitive Learning through the use of reading materials uses the cognitive domain of learning.

Learning a skill through mental and physical activity uses the psychomotor domain. The affective domain involves changing feelings, beliefs,attitudes, and values.

PTS:1DIF:ModerateREF:pp. 856-857 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application

Chapter 17. Interprofessional Partnerships: Documenting & Reporting Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The clients condition is getting worse; he is cyanotic(turning blue) with periods of labored breathing. What action should the nurse take first?

1) Study the discharge plan.

Check the graphic data for vital signs.3) Examine the history and physical.4) Look for an advance directive.ANS: 4 The advance directive, which should be located in a special section of the patients medical record, should be examined first because the patients symptoms indicate that he may need to be resuscitated. The advanced directivecontains information about the patients wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data are to record assessment done frequently, such as vital signs. The history and physical provide a detailed summary of the patients current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.

PTS:1DIF:EasyREF:p. 386 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Application 2. A hospital uses a source-oriented medical record. What is a majordisadvantage of this charting system?

1) It involves a cooperative effort among various disciplines.2) The system requires diligence in maintaining a current problem list.

Data may be fragmented and scattered throughout the chart.4) It allows the nurse to provide information in an unorganized manner.ANS: 3 A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medicalrecord requires a cooperative effort among disciplines and diligence in maintaining a current problem list.

Narrative charting allows the nurse to provide information in a disorganized manner.

PTS:1DIF:ModerateREF:p. 387 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 3. The patients medical record contains the following documentation: 06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge IV catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.Ann. Davids, RN Which type of charting has the nurse used?1)

Narrative2) Focus3) SOAP PIE ANS: 1 The nurse used narrative charting when documenting the condition of this newly admitted patient. This format is free text description of the patient status and nursing care. Focus charting highlights the patients concerns, problems, and strengths in a three- column format.

SOAP is an acronym for subjective data, objective data, assessment, and plan. This charting format is used to address single problems or to write summative notes. PIE is an acronym for problem, interventions, and evaluation. This charting method also addresses problems.

PTS:1DIF:EasyREF:p. 392 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 4. The department of nursing at a local hospital is considering changing tocharting by exception (CBE). Which statement provides a rationale to support making this change? CBE 1) Reduces the time nurses spend charting2) Addresses the patients concerns holistically3) Establishes an ongoing care plan from admission4) Is most useful when constructing a timeline of eventsANS: 1 An advantage of CBE is that it reduces the amount of time that nurses must spend documenting. CBE assumes that unless a separate entry is made, all standards have been met with a normal response. Focus charting addresses the patients concerns holistically. PIE charting establishes an ongoing care plan fromadmission. Narrative charting is especially useful when attempting to construct timelines of events.

PTS:1DIF:ModerateREF:p. 387 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 5. A patient is admitted to the emergency department with a stroke. After being stabilized, the patients needs are best met if the nurse documents a careplan that provides for 1) Acute interventions2) Patient teaching3) Discharge needs4) Family health dataANS: 3 The patients potential discharge needs should be evaluated when the patient first enters the healthcare facility. After the patient is admitted, discharge needsshould be continually reevaluated and documented throughout the patients hospitalization.

PTS:1DIF:ModerateREF:p. 395 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 6. The patients health record contains the following providers order: furosemide 40 mg intravenously STAT. If the nurse later needed to know whenthe medication had been given and the patients response to the medication, where would he look?

1) Progress

notes2)

Graphic record3) Narrative notes4) MAR ANS: 3 The nursing narrative note will contain documentation about the time the medication was administered and the patients response to the medicine. In contrast, the MAR will only contain documentation about when the medication was given, not the patients response. The physicians progress note contains documentation about why the furosemide was ordered. The graphic record will not contain charting about the medication but will contain information about thepatients output.

PTS: 1 DIF: Easy REF: pp. 386-387; 396; 401 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 7. A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour PRN pain. When should thenurse administer the medication?

Every hour around-the-clock2) Immediately after taking off the order3) As needed, but not more than once per hour4) 1 hour after the last administered doseANS: 3 PRN is the abbreviation for as needed. The nurse should administer the medication after assessing that the patient needs the medication or the patient requests it and at least 1 hour has elapsed since the last dose. STAT medicationsmust be administered immediately.

PTS:1DIF:ModerateREF:p. 399 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 8. The nurse administers heparin 5000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse document?

1) Injection site2) Previous site of administration3) Patient response to medication Heart rate prior to administrationANS: 1 After administering an injection, the nurse must document the injection site toprevent the patient from receiving repeated injections in the same location.

Heparin 5000 units subQ was prescribed for the patient. The previous route of administration is already documented on the MAR from the previous dose and would not be noted in the entry for the current dose. The patients response to medication is recorded in the nurses narrative note in the traditional paper for the electronic health record. When the nurse signs out that the drug was given in the medication administration record, she is validating that she administeredthe drug according to the physicians order. Heparin does not affect heart rate.

PTS:1DIF:ModerateREF:p. 399 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application

9. A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer. Which integrated plan of care (IPOC)would be most appropriate for the nurse to implement?

1) Hypertension2) Rheumatoid arthritis3) Postoperative colon resection4) Follow all three plans ANS: 3 The postoperative colon resection integrated plan of care should be followed; however, modifications should be made to meet the patients other health needs. Therefore, portions of the hypertension and rheumatoid arthritis integrated plan of care may be added to the postoperative colon resection planof care.

PTS: 1 DIF: Difficult REF: p. 400; ESG, Chapter 18, Tables, Boxes, Figures, ESGFigure 18-3, An Example of an Integrated Plan of Care (IPOC) KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitivelevel: Application 10. The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order?

1) 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews,RN 2) 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN 3) 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay Andrews, RN 4) 09/02/13 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RNANS: 2 Correct documentation of a telephone order is as follows: 09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews,RN (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescribers name and title, nurses name and title.) The other options demonstrate incomplete documentation of a telephone order.

PTS:1DIF:ModerateREF:pp. 403-404 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 11. A patient refuses a dose of medication. How should the nurse documentthe event?

1) Patient is uncooperative and refuses the prescribed dose of digoxin.2) Patient refuses the 0900 dose of digoxin.3) Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin.4) 0900 dose of digoxin not given.ANS: 2 Patient refuses the 0900 dose of digoxin objectively describes the event in whichthe patient refuses to take his 0900 dose of digoxin. 0900 dose of digoxin not given provides no explanation as to why the medication was not given. The other two options offer judgmental information, which should be avoided when charting.

PTS:1DIF:ModerateREF:p. 399 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application

12. The nurse makes a mistake while documenting in the patients healthrecord.

Which action should the nurse take?

1) Use an opaque white fluid to cover the documentation error.2) Completely cover the documentation error with black ink.3) Draw a line through the error and initial the change.4) Use correction tape to make the documentation correct.ANS: 3 The nurse should draw a single line through the documentation error and placeher initials next to the change. In some institutions, the nurse must also write the words error or mistaken entry above the error. The nurse should never use opaque cover-up liquid or correction tape. It is not acceptable to alter the patients health record as though the error was not made. Making note of the correction in documentation makes it clear to others what happened.

PTS:1DIF:ModerateREF:p. 407 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 13. At 1000 on 11/14/10, the nurse takes a telephone order for metoprolol 5 mg intravenously now. What is the latest date and time the nurse will expect the prescriber to countersign the order?

11/14/13 at 1200 2) 11/14/13 at 2200 3) 11/15/13 at 1000 4) 11/16/13 at 1000 ANS: 3 The prescriber must countersign all verbal and telephone orders within 24hours.

PTS:1DIF:ModerateREF:p. 404 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 14. The nurse takes a telephone order from a primary care provider for 40mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order?

1) Repeat the order to the prescriber even if she believes she understood the order correctly.

2) Immediately notify the pharmacy of the order and verify it with a pharmacist.3) Ask the unit secretary to listen to the prescriber on the phone to verify the order.

Transcribe the order onto note paper and verify the dosage in a drug handbook.ANS: 1 The nurse should repeat the order to the prescriber even if she believes she understood it entirely. If possible, she should have a second nurse (not the unitsecretary) listen to the order to verify accuracy. Only the prescribing provider, not the pharmacist, can verify the order. The nurse should transcribe the orderdirectly on the patients chart.

Transcribing it on a piece of paper and then copying it again introduces one more chance of error.

PTS:1DIF:ModerateREF:p. 404 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 15. A resident in a long-term care facility receiving Medicare funds requirescare for a stage 2 pressure ulcer. How often must the nurse document this patients care?

1) Every 2 weeks 2) Every shift3) 3. Every week4) 4. Every 3 months ANS: 2 When a patient requires Medicare-reimbursed services, such as wound care, documentation is required every shift. Those who require assistance with medications, nutrition, and activities of daily living must have a summary 2) written by a registered nurse or licensed practical nurse every 2 weeks. A summary must also be recorded on a weekly basis for those who require woundcare. The Minimum Data Set must be updated every 3 months.

PTS:1DIF:ModerateREF:p. 401 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 16. What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility?

1) 14 days 2) 3 days 3) 2 days 4) 24 hours ANS: 1 Federal regulations require that a resident be evaluated using the Minimum DataSet within 14 days of admission to a long-term care facility.

PTS:1DIF:EasyREF:p. 401 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 17. A client is admitted to a long-term care facility. The nurse knows thatfederal law requires the use of 1) The Minimum Data Set (MDS) for assessment Situation-background-assessment-recommendation (SBAR) for reporting3) Healthcare Financing Administration guidelines prior to surgery4) Joint Commission guidelines for discharge planningANS: 1 Federal regulations require that a resident be evaluated using the Minimum DataSet (MDS) within 14 days of admission to a long-term care facility. SBAR is a technique used for communicating and organizing a hand-off report. HCFA guidelines govern home healthcare documentation. Joint Commission guidelines do apply to long-term care facilities, but only the MDS assessment is mandated by federal law.

PTS:1DIF:EasyREF:p. 401 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 18. The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The orderstates: OOB in AM. Which action

indicates that the nurse is following the surgeons order? The nurse 1) Performs oral care2) Assists the patient out of bed3) Assists the patient with bathing Changes the patients operative dressingsANS: 2 OOB is the abbreviation for out of bed. The nurse is following the physicians order when she assists the patient out of bed in the morning. OOB does not indicate that the nurse should perform oral care, assist with bathing, or changethe patients postoperative dressings.

PTS:1DIF:EasyREF:p. 391 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 19. What is the purpose of completing an occurrence report?1) Provide a legal defense should the patient seek legal action after an unusualoccurrence 2) Track problems and identify areas for quality improvement3) Report errors to the Food and Drug Administration4) Report medical errors to the Joint CommissionANS: 2 Occurrence reports are used to track problems and identify areas for quality improvement.

Occurrence reports are not used to provide legal defense should apatient seek legal action or to report errors to the FDA or Joint Commission.

PTS:1DIF:ModerateREF:p. 400 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 20. The nursing instructor is teaching the student about occurrence reports.Which statement by the student indicates an understanding of the purpose of occurrence reports?

1) Occurrence reports track problems and identify areas for quality improvement.

2)Occurrence reports are required by the Food and Drug Administration to reportdrug errors.

3) The Joint Commission requires occurrence reports for all client falls.

4) Occurrence reports provide legal information should the patient seek legalaction after an unusual occurrence.

ANS: 1 Occurrence reports are used to track problems and identify areas for quality improvement.

Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to theFDA or Joint Commission.

PTS:1DIF:ModerateREF:p. 400 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 21. Which of the following is a disadvantage of paper health records?1) Assist collaboration2) 2) Provide cautionary reminders3) Are sometimes illegible4) Serve

as a resourceANS: 3 A disadvantage of paper documentation systems is that they are sometimes illegible. This increases the risk for medication administration and other errors,as well as taking nurses time to decipher handwriting and call providers.

PTS:1DIF:ModerateREF:p. 390 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 22. The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and providescare.

Identify the correct documentation of the fall.

1) Patient found on floor in pain after falling out of bed.2) Patient found on floor after falling out of bed; found by NAP Smith.3) Patient fell out of bed but is currently in bed.4) Patient reminded to not climb OOB after falling.ANS: 2 Charting must be accurate and succinct. Only chart what you observe. Do notchart what others have observed as your own observation. Avoid judging patients; instead, chart objectively.

PTS: 1 DIF: Moderate REF: p. 400 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 23. Which set of topics makes up a hand-off report given in a recommended format?

1) Data-action-response2) Subjective-objective-assessment-plan3) Situation-background-assessment-recommendation 4) Patient-diagnosis-medications-activityANS: 3 The SBAR (situation-background-assessment-recommendation) technique is used as a mechanism to give a hand-off report by enabling a focused communication between healthcare team members. DAR is used in Focus Charting, and SOAP is a method for documenting nursing care. The nursing admission assessment is completed and documented at the time of admission.

PTS: 1 DIF: Easy REF: p. 402 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which statement by the student nurse indicates an understanding of thenursing Kardex? Choose all correct answers.

1) 2) The Kardex pulls data from multiple areas of the patients chart.2) The Kardex is usually kept at the patients bedside.3) The Kardex is used to document patient response to interventions.4) The Kardex summarizes the plan of care and guides nursing care.ANS: 1, 4 The Kardex is a tool that pulls data from multiple areas of the patients health record and helps

guide nursing care. Responses to interventions are documented on flow sheets and in nurses notes. Kardexes are paper forms that are kept together in a portable file at the nurses station to allow all team members access to the summary information. The file is portable, so it could becarried to the bedside briefly; however, it is not stored there, as a general rule.

PTS:1DIF:ModerateREF:p. 400 KEY: Nursing process: N/A | Client need: Safe-care environment | Cognitive level: Application 2. Which action by the nurse breaches patient confidentiality? Select all thatapply. 1) Leaving patient data displayed on a computer screen where others may view it Remaining logged on to the computer system after documenting patient care3) Faxing a patient report to the nurses station where the patient is beingtransferred 4) Informing the nurse manager of a change in the patients conditionANS: 1, 2 Leaving patient data displayed on a computer screen where others may view them breaches patient confidentiality. The nurse should log off the computer immediately after use.

Faxing a report to the nurses station receiving a patient does not breach patient confidentiality because it is located at the nurses station out of others view. Anyone directly involved in the patients care has theright to know about the patients condition without breaching patient confidentiality.

PTS:1DIF:ModerateREF:p. 408 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 3. Which statement by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply.

1) I can wait until the end of the shift to document my care.2) Charting every 2 hours is the most appropriate way to document nursing care.3) I find it easier to chart before I go to lunch and then after my shift report.

I should chart as soon as possible after nursing care is given.ANS: 1, 2, 3 Documentation should be performed as soon as possible after the nurse makes an assessment or provides care.

The longer the nurse waits, the less accurate the documentation will be. Leaving documentation until the end of the shift maycause important details to be omitted or mistaken. It is not necessary to complete documentation on a strict schedule, such as every 2 to 4 hours. Even waiting until lunch or reporting after the shift is over is too long of a period of time for accurate documentation. In addition, the objectivity of documentation might be influenced by the discussion that occurs during report.

PTS: 1 DIF: Moderate REF: p. 405-406 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 4. The nurse who understands the electronic health record (EHR) can dowhich of the following? Select all that apply.

1) Facilitate evidence-based nursing practice2) Promote efficient use of the nurses documentation time3) Reduce the opportunity for interdisciplinary collaboration4)

Ensure improved client safety and outcomesANS: 1, 2, 4 Electronic health records (EHR) have many advantages, including the facilitationof evidence-based nursing practice, efficient use of the nurses documentation time, and improved client safety and outcomes. The EHR does not impair interdisciplinary collaboration; rather, the EHR fosters communication and collaboration among healthcare team members.

PTS:1DIF:EasyREF:p. 388 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 5. In performing a hand-off report, the nurse should communicateinformation on which of the following? Select all that apply.

1) Teaching performed2) Any change in client status3) Treatments administered4) Hygiene measures performedANS: 1, 2, 3 Hand-off reports include any client teaching done, therapies and treatments administered, and changes in the clients status. Hygiene care is routinely donein inpatient settings and is usually recorded on a flow sheet. Hand-off reports should be succinct and not contain routine information.

PTS: 1 DIF: Easy REF: p. 402 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall True/False Indicate whether the statement is true or false.

1. The nursing Kardex is part of the patients permanent health record.ANS: F The Kardex is not part of the patients permanent medical record. It is a tool thathelps guide nursing care. It changes as different care is required.

PTS:1DIF:EasyREF:p. 400 KEY: Nursing process: N/A | Client need: Safe-care environment | Cognitive level:Recall

Chapter 18. Measuring Vital Signs Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A clients vital signs at the beginning of the shift are as follows: oral temperature 99.3F (37C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later the clients oral temperature is 102.2F (39C). Based on the temperature change, the nurse should anticipate the clients heart rate would be how many beats/min?

1)62 2) 82 3) 102 4) 122 ANS: 3 Heart rate increases about 10 beats per minute for each degree of temperatureto meet increased metabolic needs and compensate for peripheral dilation.

PTS:1DIF:ModerateREF:p. 426 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 2. The nurse is assessing vital signs for a client after surgical procedure onthe left leg.

IV fluids are infusing. It would be most important for the nurse to 1) Compare the left pedal pulse with the right pedal pulse2) Count the clients respiratory rate for 1 full minute3) Take the blood pressure in the arm without an IV4) Take an oral temperature with an electronic thermometerANS: 1 For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This canbe done only by comparing one leg with the other. The nurse would, of course, count the respiratory rate for 1 full minute and take the BP in the arm without the IV. Oral temperatures are commonly obtained using electronic thermometers.

PTS:1DIF:ModerateREF:p. 449-450 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 3. The nurse hears rhonchi when auscultating a clients lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?

1) Have the client take several deep breaths.2) Request the client take a deep breath and cough.3) Take the clients blood pressure and apical pulse.4) Count the clients respiratory rate for 1 minute.ANS: 2 Rhonchi are caused by secretions in the large airways and may clear with coughing.

This is how you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to clear rhonchi. Taking the blood pressureand apical pulse and counting the respiratory rate are not effective for clearing rhonchi and would not be sufficient for the nurse

to identify whether the soundswere, indeed, rhonchi.

PTS:1DIF:ModerateREF:p. 431 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 4. Which of the following sets of vital signs are all within normal limits forpatients at rest?

1) Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54 Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/683) Adult: T 99.6F (oral), HR 48, RR 22, BP 130/844) Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95ANS:2 All of the adolescents vital signs are within normal parameters for the age. The infants temperature is below normal for a rectal reading because the core temperature is approximately 1 degree higher than readings from other sites. The heart rate (HR) for an infant is high, the respiratory rate (RR) is low, and theblood pressure (BP) is high for the age. For the typical adult, the temperature is high, the HR is low, the RR is high, and the BP is elevated for the age.

For the older adult, the temperature is high-end normal, the HR is high, the RR is high, and the BP is high for the age.

PTS:1DIFifficultREF:p. 414; for adult vital signs ESG Table 19-1, Comparison of Normal Vital Signs for Various Ages KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 5. The nurse assesses the following changes in a clients vital signs. Whichclient situation should be reported to the primary care provider?

1) Decreased blood pressure (BP) after standing up2) Decreased temperature after a period of diaphoresis3) Increased heart rate after walking down the hall Increased respiratory rate when the heart rate increasesANS: 1 A drop in the clients blood pressure when standing indicates orthostatic hypotension, and the cause should be investigated. The changes in vital signsindicated in the other options are normal changes for the situations.

PTS:1DIF:ModerateREF:p. 439 for hypotension information but should readcontent about all of the vital signs KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 6. The clients temperature is 101.1F. Which is the correct conversion tocentigrade?

1)38.0C 2) 38.4C 3) 38.8C 4) 39.2C ANS:2 To convert Fahrenheit to centigrade, subtract 32 from the temperature, andmultiply by 5/9.

PTS:1DIFifficultREF:p. 419 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 7. The client has had a fever, ranging from 99.8F orally to 103F orally, overthe last 24 hours. The clients fever would be classified as

Constant2) Intermittent3) Relapsing4) RemittentANS: 4 Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay above normal with only slight fluctuations. Intermittent fevers alternate betweennormal or subnormal temperatures with periods of fever. Relapsing fevers alternate between periods of fever and periods of normal temperature, each phase lasting 1 to 2 days. PTS:1DIF:ModerateREF:p.

418 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 8. A clients vital signs 4 hours ago were temperature (oral) 101.4F (38.6C),heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4F (37.4C). Based only on the expected relationship between temperature and respiratory rate, the nurse might best anticipate the clients respiratory rate to be 1)16 2)18 3)20 4)22 ANS:2 For every degree Fahrenheit (0.6C) the temperature falls, the respiratory rate may decrease up to 4 breaths per minute. The clients temperature has fallen 2 degrees; multiplied by 4, this is 8.

It was 26 breaths/min: 26 8 = 18 breaths/min. Keep in mind, this is an estimate and would vary depending on the patients baseline health, current condition, age, and other factors.

PTS:1DIF:EasyREF:p. 430 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 9. Which one of the following clients would probably have a higher thannormal respiratory rate? A client who has 1) Had surgery and is receiving a narcotic analgesic2) Had surgery and lost a unit of blood intraoperatively3) Lived at a high altitude and then moved to sea level4) Been exposed to the cold and is now hypothermicANS: 2 A reduction in hemoglobin from blood loss would increase the respiratory rate.

Narcotics and hypothermia slow the respiratory rate. Going from lower altitudesto higher altitudes inhibits oxygen binding, so going to a lower altitude would decrease the respiratory rate or have no effect. Hypothermia decreases the metabolic rate, so the respiratory rate would likely decrease.

PTS:1DIF:ModerateREF:p. 430 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 10. For which of the following adult clients should the nurse make follow-up observations and monitor the vital signs closely? A client whose 1)

Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mmHg 2) Oral temperature is 97.9F in the morning and 99.8F in the evening3) Heart rate was 76 beats/min before eating and 88 beats/min after eating 4) Respiratory rate is 16 breaths/min when standing and 18 when lying down ANS: 1 Both the blood pressures would be classified as prehypertension according tothe JNC 7 Express guidelines. Body temperature normally increases during the course of a day. Heart rate increases for several hours after eating. Respiratorydepth decreases when lying down, so it would be normal for the rate would increase; both rates are within normal limits.

PTS:1DIF:ModerateREF:p. 440 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 11. A client who has been hospitalized for an infection states, The nursingassistant told me my vital signs are all within normal limits; that means Im cured. The nurses best response would be which of the following?

1) Your vital signs confirm that your infection is resolved; how do you feel?2) Ill let your healthcare provider know so you can be discharged.3) Your vital signs are stable, but there are other things to assess.4) We still need to keep monitoring your temperature for a while.ANS: 3 Vital signs are one indicator of a clients physiological status, but they are not an absolute indicator of well-being from every aspect. It may be inaccurate to statethat the vital signs indicate the infection is resolved; vital signs could stabilize even if the infection remains active. The healthcare providers decision regardingthe clients readiness for discharge is not based exclusively on the vital signs butrather is based on a compilation of other sources of information, primarily the clients clinical status, but also cultures, complete blood counts, and various other laboratory and possibly radiologic evidence. Although the nurse will need to continue monitoring the temperature, other clinical signs must also be monitored; therefore, the statement We still need to keep monitoring your temperature . . . is incomplete and less useful than the statement that begins Your vital signs are stable, but . . .

PTS:1DIFifficultREF:p. 414 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 12. The nursing instructor asks students how they would assess the fifthvital sign. Which student would be correct?

1) I would have the client rate her pain on a scale of 0 to 10.2) I would ask the client when she had her last bowel movement.3) I would take the clients pulse oximetry reading.4) I would interview the client about history of tobacco use.ANS: 1 Pain is considered to be the fifth vital sign.PTS:1DIF:EasyREF:p. 414 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 13. A clients axillary temperature is 100.8F. The nurse realizes this is outside normal range for this client and that axillary temperatures do not reflectcore temperature. What should the nurse do to obtain a good estimate of the core temperature?

1)

Add 1F to 100.8F to obtain an oral equivalent.2) Add 2F to 100.8F to obtain a rectal equivalent.3) Obtain a rectal temperature reading.4) Obtain a tympanic membrane reading.ANS: 3 Body temperatures, from lowest to highest, are axillary, oral, rectal, and tympanic. For oral, axillary, and rectal temperatures, there is a 1F degree difference between each site and the next higher one. However, mathematical conversions between sites are not reliable and should be used only when a rough estimate is neededfor instance, to decide whether a reading needs to be validated by another site or another thermometer. Rectal temperatures are mostreliable and most accurately reflect the core temperature.

Tympanic membrane readings are considered by most to be the least accurate and least reliable.

PTS:1DIF:ModerateREF:pp. 415, 421-422 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 14. In caring for a client who has a fever, it would be important for thenurse to monitor for increased 1) Urine output2) Sensitivity to pain3) Blood pressure4) Respiratory rateANS: 4 The metabolic rate increases with a fever, increasing a persons respiratory rate.Urine output would more likely decrease, rather than increase, because of increased insensible loss and possible loss of intake because of loss of appetite. Change in pain sensation is not a symptom of a fever. Blood pressure is more likely to decrease with a fever because of peripheral vasodilation.

PTS:1DIF:ModerateREF:p. 430 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 15. The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home. It would be most important forthe nurse to 1) Ask the client to demonstrate the use of the blood pressure device2) Explain the importance of frequent calibration of the device3) Give the client a chart to record his blood pressure readings4) Provide written instructions of the information taughtANS: 1 All are important things to include in client education, but self-monitoring ofblood pressure is of little value unless it is done using proper technique.

Requesting that the client demonstrate the procedure would allow the nurse toevaluate the clients technique.

PTS: 1 DIF: Difficult REF: p. 437; not stated directly KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 16. At last measurement, the clients vital signs were as follows: oral temperature 98F (36.7C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2F (38.5C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurses first intervention at this time?

1) Ask the client if he has had a warm drink in the last 30 minutes.2) Notify the primary care provider of the clients temperature.3) Ask the client if he is feeling chilled.4) Take the temperature by a different route.ANS: 1 With a fever, the heart rate and respiratory rate are usually elevated. In this case, they are within normal limits, so the nurse should wonder about the accuracy of the temperature reading and validate it in some way. Because having a hot drink is a common cause of false readings, the nurse should determine whether that has occurred before retaking or otherwise validating thereading.

PTS: 1 DIF: Moderate REF: p. 421; should know norms for all vital signs, p. 414,to answer question KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 17. A clients average normal temperature is 98F. Which of the following temperatures would be expected during the night in this healthy young adult client who does not have a fever, inflammatory process, or underlying healthproblems? 1)97.2F 2) 98.0F 3) 98.6F 4) 99.2F ANS: 1 The lowest temperature occurs during sleep (usually at night) when the metabolic rate is lowest.

Temperature normally increases throughout the dayuntil it peaks in the early evening.

PTS:1DIF:EasyREF:p. 417 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 18. The nurse is instructing a client how to appropriately dress an infant incold weather.

Which of the following instructions would be most important for the nurse to include?

1) Be sure to put mittens on the baby.

2) Layer the infants clothing.

3) Place a cap on the infant’s head.

4) Put warm booties on the baby.

ANS: 3 All interventions are correct, but because of the many blood vessels close to theskin surface in the head, infants lose approximately one third of their body heat through the head. Therefore, to prevent heat loss, it is most important to cover the head.

PTS:1DIF:ModerateREF:p. 417 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 19. In evaluating a clients blood pressure for hypertension, it wouldbe most important to 1) Use the same type of manometer each time 2)Auscultate all five Korotkoff sounds 3) Measure the blood pressure in both arms 4) Monitor the blood pressure for a pattern

ANS: 4 Blood pressure fluctuates a great deal during the day and is influenced by age, sex, activity, and many other factors. Any determination of hypertension must be done after two or more BP readings taken on separate occasions. The type of manometer does not greatly influence the reliability of BP readings, although the mercury manometer is more accurate. Only the first and last Korotkoff sounds are necessary to determine a BP reading. The first time BP is assessed for a patient, the nurse should compare the reading in the left and right arm; however, this is not specific to evaluating for hypertension.

PTS:1DIF:ModerateREF:p. 434 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 20. Which of the following pieces of information in the clients health historymight indicate a risk for primary hypertension?

1) Consumes a high-protein diet2) Drinks three to four beers every day3) Has a family history of kidney disease4) Does not engage in physical exerciseANS: 2 Heavy alcohol consumption, age, race, high-sodium diet, tobacco use, familyhistory of hypertension, and high cholesterol levels put a client at risk for primary hypertension. Kidney disease is a cause of secondary hypertension.

PTS:1DIF:ModerateREF:pp. 434-435 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 21. The nurse provides client education regarding hypertension preventionand management. Which of these statements indicates that the client understands the instructions?

1) I don’t have to worry if my blood pressure is high once in a while.

2) I guess I will have to make sure I don’t drink too much water.

3) I can lose some weight to help lower my blood pressure.

4) I will need to reduce the amount milk and other dairy products I use.

ANS: 3 A single lifestyle change, such as weight loss, can lower blood pressure (BP). Whenever the client has an elevated BP, the reading should be monitored even when it occurs just occasionally. Drinking too much alcohol is associated with hypertension, but water consumption is not unless accompanied by high sodiumintake. A diet high in calcium is recommended to prevent and manage hypertension; therefore, it is not advisable to limit the intake of dietary calcium found in dairy products.

PTS:1DIF:ModerateREF:pp. 434-435 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 22. For which of the following patients would it be most important to obtainan apicalradial pulse and calculate the pulse deficit? A patient who 1)

Had abdominal surgery 2 hours ago 2) Suffered a fractured hip yesterday 3) Is dehydrated from vomiting 4) Has a heart or lung disease ANS: 4 Conditions that require assessment of pulse deficit include digitalis therapy andblood loss, cardiac or respiratory disease, and other conditions that affect oxygenation status.

PTS:1DIF:ModerateREF:p. 427 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 23. Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count?

1) Counting the rate for 1 full minute 2) Exposing only the left side of the chest 3) Determining why assessment of apical pulse is indicated 4) Using your ring finger to palpate the intercostal spacesANS: 1 Apical pulse is generally indicated for patients with cardiac conditions or who aretaking cardiac medications. Often they have irregular heartbeats or slow rates. Amore accurate count is obtained when such heartbeats are counted for a full minute. Exposing the chest is, of course, necessary; exposing only the left side protects the patients privacy but does not improve the accuracy. The nurse should know why an apical pulse is indicated, but this would not affect the accuracy of the count. Which finger the nurse uses to palpate depends on whichhand is used.

Even if the nurse failed to use the index or ring finger, this would be unlikely to affect the accuracy of the counting.

PTS:1DIF:ModerateREF:p. 452 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 24. Which assessment data best support a report of severe pain in an adultclient whose baseline vital signs are within an average normal range?

1) Oral temperature 100F (37.8C) 2)Respiratory rate 26 breaths/min and shallow 3) Apical heart rate 56 beats/min 4) Blood pressure 124/82 mm Hg ANS: 2 Respiratory rate 26 breaths/min and shallow. Acute pain causes an increase in respiratory rate but a decrease in depth. Elevated temperature does not indicatepain. The apical pulse is lower than normal, but because the pulse increases with pain, a rate of 56 beats/min does not indicate pain. A blood pressure of 124/82 mm Hg is within normal limits. Blood pressure usually elevates temporarily with acute pain; it may decrease over time with unremitting chronic pain.

PTS:1DIF:EasyREF:p. 430 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 25. During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse toimplement?

1) Ask the client when in the day dizziness occurs.

2) Help the client to assume a recumbent position.

3) Measure both heart rate and blood pressure with the client standing.

4) Measure vital signs with the client supine, sitting, and standing.

ANS: 4 Dizziness upon standing is a symptom of orthostatic hypotension. The nurse should obtain orthostatic vital signs (measure pulse and blood pressure with the patient supine, sitting, and standing) to assess for orthostatic hypotension. The time of day is irrelevant to the diagnosis. If the nurse observes the patient become dizzy upon standing, the first action would be to help the client lie downand then obtain orthostatic vital signs; but this is not necessary when the symptom is not present. The nurse needs to measure both the heart rate and the blood pressure but not only in the standing position.

PTS:1DIF:ModerateREF:p. 439 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which blood pressure has a pulse pressure within normal limits? Chooseall that apply.

1) 104/50 mm Hg2) 120/62 mm Hg3) 120/80 mm Hg4) 130/86 mm HgANS: 3, 4 The pulse pressure is the systolic blood pressure (BP) minus the diastolic BP. Thepulse pressure is usually approximately one third of the systolic pressure. (12080 = 40; 40 = 1/3 of 120) (130 86 = 44; 1/3 of 130 = 43.3) PTS:1DIF:ModerateREF:p. 433 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 2. Which of the following interventions would be appropriate for a clientwho has a fever?

Choose all that apply.

1) Put an ice pack on the client’s neck and axillae.

2) Provide the client a blanket when he is shivering.

3) Offer the client fluids to drink every 1 to 2 hours.

4) Take the temperature using a tympanic thermometer.

ANS: 1, 3 If ice packs are used, they are applied to the groin, neck, or axillae. A fever increases metabolic needs, so fluids are necessary to prevent dehydration. Ablanket would help with heat retention.

A tympanic thermometer is not appropriate when an accurate temperature is needed, as when a client has afever.

PTS:1DIF:EasyREF:p. 423 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 3. Comparing the changes in vital signs as a person ages, which statementis correct? Select all that apply.

1) Blood pressure decreases less than heart rate and respiratory rate.

2)Respiratory rate remains fairly stable throughout a persons life.

3) Blood pressure increases; heart rate and respiratory rate decline.

4) Men have higher blood pressure than women until after menopause.

ANS: 3, 4 Heart rate and respiratory rate tend to decrease as people age, whereas the blood pressure increases because of increased vascular resistance. Men’s blood pressure tends to be higher than women’s until after menopause, when women’s blood pressure typically increases.

PTS: 1 DIF: Moderate REF: pp. 430, 434 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis 4. Which of these steps in taking a blood pressure is correct? Choose allthat apply.

1) Use a bladder that encircles 40% of the arm.

2) Wrap the cuff snugly around the clients arm.

3) Ask the client to hold the arm at heart level.

4) Have the client sit with feet flat on the floor.

ANS: 2, 4 The cuff should be wrapped snugly around the clients arm. Crossed legs or dangling legs can increase blood pressure, so feet should be flat on the floor. The bladder should encircle 80% of the arm. Holding the arm out can cause an erroneously higher blood pressure measurement; the arm should be supported.

PTS: 1 DIF: Moderate REF: pp. 457-460 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension 5. When assessing the quality of a clients pedal pulses, what is the nurseassessing?

Choose all that apply.

1) Rhythm of the pulses 2) Strength of the pulses 3)Bilateral equality of pulses 4)Rate compared with apical pulse ANS: 2, 3 The quality of a pulse refers to the pulse volume (strength) and bilateral equalityof the pulses.

PTS:1DIF:EasyREF:pp. 427-428 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 6. All of the following clinical signs may be present with hypoxia. However,only two are specific indicators of hypoxia (that is, if they are present, it meansthat the patient is probably hypoxic). Which ones are specific indicators of hypoxia? Choose all that apply.

1) Feelings of anxiety 2) Crackles in the lung bases 3)Increased heart rate 4)Improved breathing in upright position

ANS: 1, 3 Apprehension, confusion, dizziness, and an increased heart rate are all specific manifestations of hypoxia. Although they are not listed in this question, cyanosisof the tongue and oral mucosa are also good indicators of hypoxia because those areas are not affected by cold or reduced circulation as are the nails, lips, and skin. Crackles and orthopnea are abnormal respiratory findings, but they do not necessarily indicate poor oxygenation.

PTS:1DIFifficultREF:p. 432 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis Matching Match the breath sound with the appropriate description.1) Highpitched sound heard on inspiration in infants2) High-pitched, continuous musical sound3) High-pitched popping or low-pitched bubbling sounds4) Lowpitched continuous sounds that clear with coughing5) Labored, snoring sound 1. Crackles 2. Rhonchi 3. Stridor 4. Wheezes 5. Stertor 1. ANS: 3 PTS: 1 DIF: Moderate REF: pp. 431-432; descriptions of the variousbreath sounds are as stated

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 2. ANS: 4 PTS: 1 DIF: Moderate REF: pp. 431-432; descriptions of the variousbreath sounds are as stated

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 3. ANS: 1 PTS: 1 DIF: Moderate REF: V1, pp. pp. 431-432; descriptions of thevarious breath sounds are as stated

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 4. ANS: 2 PTS: 1 DIF: Moderate REF: V1, pp. pp. 431-432; descriptions of thevarious breath sounds are as stated

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 5. ANS: 5 PTS: 1 DIF: Moderate REF: V1, pp. pp. 431-432; descriptions of thevarious breath sounds are as stated

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application Other

1. How will each of the errors affect a clients blood pressure reading?

A. B. C. D. E. F. G.

Blood pressure cuff too narrow Blood pressure cuff too wide Assessing immediately after smoking Assessing immediately after eating Assessing when the client is in mild-to-moderate pain Assessing when the client experiences severe pain Assessing immediately after exercise

ANS: A: erroneously high; B: erroneously low; C: temporarily high; D: temporarily high;E: temporarily high; F: temporarily low; G: temporarily high.

Improper cuff size causes errors in blood pressure (BP) readings: Too narrow a cuff increases the BP reading, while too wide a cuff decreases it. Tobacco use, eating, mild/moderate pain, and exercise all stimulate and increase BP. Severe pain can lower BP, whereas mild to moderate pain can increase blood pressure.

PTS: 1 DIF: Moderate REF: pp. 434-435| p. 436; for cuff size implications KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall Essay

Describe where to auscultate the apical pulse for an average-size adult.

ANS: Auscultate at approximately 3 inches to the left of adult sternum at thefourth, fifth, or sixth intercostal spaces in the midclavicular line.

Apical pulse is heard at the apex of the heart. The position of the apex of theheart is different for a child than an adult.

PTS:1DIF:EasyREF:p. 427 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

Chapter 19. Health Assessment Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A mother brings her 6-month-old infant to the clinic for a well-babycheckup. How should the nurse proceed when weighing the patient?

1) Have the mother remain outside the room.2) Ask the mother to remove the infants clothing and diaper.3) Weigh the infant wearing only the diaper.4) Place the infant supine on the scale with his knees extended.ANS: 2 The nurse should ask the mother to remove the infants clothing and diaper before weighing and measuring the infant. An older child can be examined in hisunderwear; infants should be undressed. Infants are typically more comfortable with the parent close by, so the mother should remain in the room. The infant should be supine with knees extended on the examination table when being measured, not when being weighed.

PTS: 1 DIF: Moderate REF: p. 517 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 2. Where should the nurse assess skin color changes in the dark-skinnedpatient? 1) Nailbeds2) Any exposed area3) Oral mucosa4) Palms of the handsANS: 3 In dark-skinned patients, look for color changes in the conjunctiva or oral mucosa. They should be pink and moist. In dark-skinned patients, skin colorchanges may not be apparent in nailbeds, palms of the hands, and other exposed areas.

PTS: 1 DIF: Easy REF: pp. 497-498, 519 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 3. While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborns back and asks,Whats that? Is something wrong with my baby? Which response by the nurse isbest?

1) Ill ask the physician to look at the spot.2) Those spots are quite common and typically fade with time.3) You may want a plastic surgeon to look at that.4) That spot is benign so its nothing you need to worry about.ANS: 2 The best response by the nurse is to explain that Mongolian spots are common in darkskinned newborns and typically fade over time. The nurse should reportthe finding in the patient health record, but there is no need to notify the physician immediately. It is inappropriate for the nurse to recommend that the mother take her newborn to a plastic surgeon; Mongolian spots do not require treatment. Although it contains correct information, nothing you need to worry about is condescending.

PTS: 1 DIF: Moderate REF: p. 497 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application 4. An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains nohair on the clients lower legs. Which condition does this finding suggest?

1) Venous insufficiency2) Hyperthyroidism3) Arterial insufficiency4) DehydrationANS: 3 Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little or no hair. Venous insufficiency leads to thick, rough skin that is commonly hyperpigmented.

Hyperthyroidism is associated with abnormally warm skin.

Decreased turgor would be seen in dehydration.PTS: 1 DIF: Moderate REF: p. 498 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 5. Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with travelersdiarrhea?

1) Edema2) Hyperhidrosis3) Pallor4) TentingANS: 4 Tenting, skin that takes several seconds to return to normal after lifting up a fold, may be a sign of dehydration. Edema, an excessive amount of fluid in the tissues, may be a sign of heart failure, kidney disease, peripheral vascular disease, or low albumin levels. Hyperhidrosis is a term for excessive sweating, which may be a sign of thyrotoxicosis. Pallor, abnormal loss of skin color, may bea sign of anemia or blood loss.

PTS:1DIF:ModerateREF:p. 498 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 6. A female patient has excessive facial hair. The nurse should documentthis finding as: 1) Alopecia.2) Albinism.3) Hirsutism.

4) Lanugo.ANS: 3 The nurse should document this finding as hirsutism, excess facial or trunk hair. Hair loss should be documented as alopecia. Albinism is a condition caused bylack of pigment in which the patient has white hair and very pale skin. Lanugo isthe fine, downy growth of hair that covers the body of a newborn.

PTS: 1 DIF: Moderate REF: p. 499

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 7. The nurse should assess skin temperature by using the:1) Dorsum of the hand.2) Pad of the fingertip.

3) Palm of the hand. 4) Dorsum of the wrist.ANS: 1 The dorsum of the hand should be used to assess skin temperature. The nurse should compare the temperature of the hands with that of the feet and comparethe right side of the body with the left.

PTS: 1 DIF: Easy REF: p. 497 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 8. While assessing an older adult patient, the nurse notes clubbing of thefingers. This finding is a sign of: 1) Fungal infection.2) Poor circulation.3) Iron deficiency.4) Long-term hypoxia.ANS: 4 Clubbing (when the nail plate angle is 180 or more) is associated with long-term hypoxic states such as chronic lung disease. A thick nail with yellowing indicates a fungal infection. Spoon-shaped nails may result from iron-deficiency anemia.

Brittle nails are commonly seen with malnutrition and hyperthyroidism. PTS: 1 DIF: Moderate REF: p. 500 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 9. A 6-week-old infant is brought to the pediatricians office for a well-baby checkup. The nurse notes a flattening of the skull. Flattening of the skull in the infant might suggest: 1) The baby has been lying in the same position for several hours a day.2) A disorder associated with excessive growth hormone.3) An accumulation of excessive cerebrospinal fluid.4) Temporomandibular joint syndrome.ANS: 1 Abnormal flattening of the skull in infants may result from placing the baby in the same position for several hours every day. A large head in an adolescent or adult may be associated with acromegaly, a disorder associated with excess growth hormone.

In infants and children, a head that is growing disproportionately faster than the body may be a sign of hydrocephalus, which isfluid collection in the cavity within the brain. Irregular jaw movement and cracking of the jaw in adults may indicate temporomandibular joint (TMJ) syndrome.

PTS: 1 DIF: Moderate REF: p. 500 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

10. The nurse notes ptosis in a patient who just arrived in the emergency department.

The nurse quickly triages the patient because she knows that thisfinding, along with other symptoms, might suggest: 1) Hyperthyroidism.2) Stroke.3) Glaucoma.4) Macular degeneration.ANS: 2 Ptosis, or drooping of the eyelid, may be seen in a patient who experienced Bellspalsy or a stroke. Exophthalmos is associated with hyperthyroidism. Mydriasis may be seen with glaucoma.

Macular degeneration has no outward signs.

PTS: 1 DIF: Moderate REF: p. 500 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 11. Small hemorrhages are noted under the nailbed of a patient with ahistory of intravenous drug abuse. This finding is associated with: 1) Low albumin levels.2) Zinc deficiency.3) Renal disease.4) Bacterial endocarditis.ANS: 4 Small hemorrhages under the nailbed, known as splinter hemorrhages, are associated with bacterial endocarditis, a complication of IV drug abuse. A distal band of reddish- pink covering 20% to 60% of the nail (half and half nails) is seenin patients with low albumin levels and renal disease. White spots may indicate zinc deficiency.

PTS: 1 DIF: Difficult REF: p. 499 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 12. A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which finding might the nurse expect when assessing the patients nails?

1) Soft, boggy nails2) Brittle nails 3)Thickened nails4) Thick nails with yellowingANS: 1 Soft, boggy nails are seen with poor oxygenation. Brittle nails are seen with hypothyroidism, malnutrition, calcium, and iron deficiency. Thickened nails mayresult from poor circulation. A thick nail with yellowing is an indication of fungalinfection known as onychomycosis.

PTS: 1 DIF: Moderate REF: p. 500 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 13. A patients ankles appear swollen. When the nurse assesses the edema, the skin depresses 6 mm, and the depression lasts 2 minutes. The nurse should document this finding as: 1) Trace edema.

2) +1 edema.

3) +2 edema.

4) +3 edema.

ANS: 4 To assess edema, the nurse presses firmly with her fingertip for 5 seconds over abony area.

Trace appears as a minimal depression; +1 appears as a 2-mm depression with a rapid return of skin to position; +2 reveals a 4-mm depression,which disappears in 10 to 15 seconds; +3 displays a 6-mm depression that lasts1 to 2 minutes; and +4 demonstrates an 8-mm depression that persists for 2 to3 minutes. The area is grossly edematous.

PTS: 1 DIF: Moderate REF: p. 521 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 14. Which abnormal laboratory value is associated with icteric sclerae?1) Bleeding time2) Bilirubin3) Hemoglobin4) GlucoseANS: 2 Icteric sclerae are associated with elevated bilirubin levels. Low hemoglobin would indicate anemia. High hemoglobin is polycythemia, which is like thick blood. Low glucose is hypoglycemia, and high sugar is hyperglycemia.

PTS: 1 DIF: Easy REF: p. 500 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Recall 15. The left pupil of a patient fails to accommodate. This finding may reflectan abnormality in which cranial nerve?

4) CN III2) CN V3) CN VIII4) CN X ANS: 1 CN III, the oculomotor nerve, is responsible for accommodation. Failure of a pupilto accommodate reflects an abnormality in this cranial nerve. CN V, the trigeminal nerve, controls the corneal reflex, chewing, and biting. CN VIII, the acoustic nerve, plays a role in hearing and the sense of balance. CN X, the vagus nerve, affects heart rate, peristalsis, swallowing, and the gag reflex.

PTS: 1 DIF: Moderate REF: p. 501 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 16. When testing near vision, the nurse should position printed text howmany inches away from the patient?

1)20 2)18 3)16 4.)14 ANS: 4

Test near vision by having the client read text from a distance of 14 inches.PTS: 1 DIF: Easy REF: p. 501 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 17. A 48-year-old patient comes to the physicians office complaining ofdiminished near vision, which the nurse confirms with testing. She should document this finding as: 1) Myopia.2) Diplopia.3) Presbyopia.4) Mydriasis.ANS: 3 Diminished near vision in a patient over age 40 or so years is known as presbyopia.

Diminished distant vision is known as myopia. Double vision isknown as diplopia.

Mydriasis or enlarged pupils may be seen with glaucoma.

PTS: 1 DIF: Moderate REF: p. 501 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 18. Which portion of the ear is responsible for maintaining equilibrium?

External ear2) Inner ear3) Middle ear4) OssiclesANS: 2 The inner ear is responsible for hearing and equilibrium. The middle ear, whichcontains the ossicles (auditory structures), conducts sound waves to the inner ear. The external ear collects and conveys sound waves to the middle ear.

PTS: 1 DIF: Easy REF: p. 502 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 19. Which statement best describes the procedure used to assess capillaryrefill?

1) Briefly press the tip of the nail with firm, steady pressure, then release andobserve for changes in color.

2) Press firmly with your fingertip for 5 seconds over a bony area, release pressure,and observe the skin for the reaction.

3) Tap on the skin with short strokes from your fingers.

4.) Lift a fold of skin, and allow it to return to its normal position.

ANS: 1 To assess capillary refill, the nurse should briefly press the tip of the nail with firm, steady pressure, then release, and observe for changes in skin color. Tap on the skin . . . describes the procedure for performing percussion. Lift a fold of skin . . . demonstrates the procedure for assessing for tenting. The nurse shouldpress firmly with her fingertip for 5 seconds over a bony area, then release her finger, and observe the skin for the reaction to grade edema.

PTS: 1 DIF: Moderate REF: p. 528 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

20. Which of the following is an abnormal capillary refill finding that thenurse should report?

1) 1 second 2) 2 seconds 3) 3 seconds 4) 4 seconds ANS: 4 Normal capillary refill is less than 3 seconds; therefore, the nurse should report a capillary refill of 4 seconds.

PTS: 1 DIF: Easy REF: p. 528 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 21. Which of the following is a correct developmental outcome for aninfant? The infants anterior fontanel (soft spot) typically fuses: 1) At about 8 weeks.2) At about 14 months.3) By 6 months of age.4) Before 1 year of age.ANS: 2 The large soft spot on the top of the head, known as the anterior fontanel, typically fuses at about 12 to 18 months. The infant should be able to hold up his head by age 6 months. The posterior fontanel fuses at about 8 weeks of age.

PTS: 1 DIF: Moderate REF: p. 529 KEY: Nursing process: Planning | Client need: HPM | Cognitive level:Comprehension 22. The nurse assesses a 4-year-old childs vision as 20/40. This finding is considered: 1) Myopia.

2) Hyperopia.

3) Normal.

4) Presbyopia.ANS: 3 Children typically do not have 20/20 vision until the ages of 6 or 7 years. A finding of 20/60 in a 4-year-old child is considered normal, so of course 20/40 isnormal as well. Myopia is diminished distant vision, which is associated with Snellen chart reading of 20/100. Hyperopia is diminished near vision and is represented by a large fraction, such as 20/15; when found in people over age 45 it is known as presbyopia.

PTS: 1 DIF: Moderate REF: p. 531 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis 23. Which test should the patient undergo when the Weber test is positive?1)

Romberg test2) Rinne test3) Pure tone audiometry4) TympanometryANS: 2 If the Weber test is positive, the patient should undergo the Rinne test to assess the type of hearing loss. The Romberg test is performed to test equilibrium. Pure tone audiometry uses a machine to hear sounds at different volumes while thepatient wears a headset. Tympanometry assesses pressure in the ear; it does not assess hearing.

PTS: 1 DIF: Moderate REF: p. 502 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 24. The nurse is performing an otoscopic examination on an adult patient. She has the patient tilt his head to the side not being examined and looks into the ear canal to make sure a foreign body is not present. Which step should sheperform next?

1) Straighten the ear canal by pulling the helix up and back.

2) Insert the speculum into the ear canal slowly 3) Test the mobility of the tympanic membrane.

4) Straighten the ear canal by pulling the helix down and back.

ANS: 1 Next, the nurse should straighten the ear canal by pulling the helix up and back.In a preschool child, the nurse should straighten the ear canal by pulling the helix down and back. After straightening the ear canal, the nurse should slowly insert the speculum and observe the ear canal.

PTS: 1 DIF: Moderate REF: p. 538 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 25. An 85-year-old patient is brought to the emergency department with lethargy and hypotension. When the nurse assesses the patients tongue, she notes that it appears dry and furry.

This finding suggests: 1) Fungal infection.

2) Dehydration.

3) Allergy.

4) Iron deficiency.

ANS: 2 A dry, furry tongue is associated with dehydration. A black, hairy tongue is characteristic of a fungal infection. Absence of papillae, reddened mucosa, and ulcerations may indicate allergy. Patients who have a deficiency of iron may have a smooth, red tongue.

PTS: 1 DIF: Moderate REF: p. 503 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 26. Which assessment should the nurse perform if she notes a palpablethyroid gland?

1) Illuminate the thyroid gland for the presence of fluid.

2)Auscultate the thyroid gland for bruits.

3) Percuss the thyroid gland for mass size.

4) Measure the thyroid gland to assess change.

ANS: 2 Normally, the thyroid gland is smooth, firm, and nontender. It is often nonpalpable. If the thyroid gland is palpable, the nurse should auscultate it for bruits. It is not necessary to measure or illuminate the thyroid gland. The thyroidgland should not be percussed.

PTS: 1 DIF: Moderate REF: p. 548 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 27. While palpating the anterior chest, the nurse notes crackling in the skinaround the patients chest tube insertion site. The nurse recognizes this finding is: 1) Tactile fremitus.

2)Egophony.

3)Bronchophony.

4)Crepitus.

ANS: 4 The nurse should document this finding as crepitus, crackling skin caused by airleaking into the subcutaneous tissues. Tactile fremitus involves palpating for vibrations as the client says 99, which indicates the presence of fluid in thechest. Bronchophony is present if the words 1, 2, 3 are clearly heard over the lungs as the nurse listens while the patient says those words.

Egophony is present if the sound heard is ay when the nurse listens over the lung fields asthe patient says eee.

PTS: 1 DIF: Easy REF: pp. 554-555 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 28. Bronchovesicular breath sounds are best heard over which area?

1) Midline over the trachea just below the larynx 2) Fourth intercostal space, in the midclavicular line 3) First and second intercostal spaces next to the sternum 4) At the base of the lungs near the diaphragm ANS: 3 Bronchovesicular breath sounds are best heard over the first and secondintercostal spaces adjacent to the sternum on the anterior chest.

PTS: 1 DIF: Moderate REF: p. 557 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 29. High-pitched breath sounds produced by airway narrowing are knownas:

1.) Rales.

2.) Crackles.

3.) Rhonchi.

4.) Wheezing.

ANS: 4

Wheezing is a high-pitched sound produced by narrowing of an airway. Rales and crackles are crackling sounds that indicate atelectasis, pulmonary edema,or pneumonia. Rhonchi are lowpitched snoring or rumbling sounds that result from mucous secretions in the large airways.

PTS: 1 DIF: Easy REF: ESG, Chapter 21, Supplemental Materials, Abnormal Vocal Sounds, and Sound Files: Breath Soundson DavisPlus KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 30. The nurse notes a small pulsation at the fifth intercostal spacemidclavicular line. This should be documented as a: 1) Thrill.

2)Murmur.

3)Normal finding.

4.) Heave.

ANS: 3 A small pulsation at the fifth intercostal space midclavicular line is known as thepoint of maximal impulse (PMI) and is considered a normal finding. A thrill is a vibration or pulsation palpated in any area except the PMI. A murmur occurs when structural defects in the hearts chambers or valves cause turbulent blood flow. A heave, which is a visible palpation, is associated with an enlarged ventricle.

PTS: 1 DIF: Moderate REF: p. 507 KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level:Application 31. The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the physician of the finding, which most likely suggests: 1) Heart failure.2) Coronary artery disease.3) Hypertension.4) Pulmonic stenosis.ANS: 1 A third heart sound, commonly referred to as S3, is heard with heart failure or volume overload. S4 heart sound may be auscultated with coronary artery disease, hypertension, and pulmonic stenosis.

PTS: 1 DIF: Difficult REF: p. 507 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 32. The admission assessment form indicates that the patient has pedalpulses that are rated 1 in amplitude. This documentation indicates that the patients pulses are: 1)Bounding.

2) Normal.

3)Full.

4)Diminished.

ANS: 4 Pulses documented as 1 are diminished and barely palpable; 2 are normal; 3 arefull and increased; and 4 are bounding.

PTS: 1 DIF: Moderate REF: p. 563

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 33. A patients jugular venous pressure measures 5 cm. This findingindicates: 1) A normal finding.

2)Hypovolemia.

3) Heart failure.

4) Dehydration.

ANS: 3 Normal jugular venous pressure is less than 3 cm. A jugular venous pressure of 5cm is elevated and suggests heart failure.

PTS: 1 DIF: Moderate REF: p. 559 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level:Comprehension 34. The nurse is caring for a patient who underwent abdominal surgery 24hours ago and has a nasogastric tube to intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient?

1) Avoid palpating the patients abdomen.

2) Turn off the suction before auscultating bowel sounds.

3) Listen for bowel sounds for 2 minutes in each quadrant.

4) Percuss the abdomen before auscultating bowel sounds.

ANS: 2 The sound of suction attached to a nasogastric tube can be mistaken for bowelsounds; therefore, the nurse should discontinue the suction or clamp off the tube while auscultating bowel sounds. Light palpation can be performed in the postoperative patient. The nurse should listen for bowel sounds for at least 5 minutes before determining that they are absent.

Auscultation should be performed before percussion in examining the abdomen.

PTS: 1 DIF: Moderate REF: p. 509 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 35. Abdominal palpation should be avoided in a child who has whichdisorder?

1)Appendicitis 2) Wilms tumor 3) Crohns disease 4) Small bowel obstruction ANS: 2 Abdominal palpation should be avoided in the child who has Wilms tumor, largediffuse pulsation, or a history of organ transplant. Abdominal palpation can be performed with appendicitis, Crohns disease, and small bowel obstruction. PTS: 1 DIF: Moderate REF: p. 568 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 36. A father brings his 18-month-old child to the pediatric clinic for a well- baby checkup. The father tells the nurse that he is concerned because his childslegs are bowed.

Which response by the nurse is appropriate?

1) Your child will most likely require physical therapy.

2) You should consider having your child seen by an orthopedic surgeon.

3) This is a normal finding in children for 1 year after they begin walking.

4) Your child is walking fine, so you dont need to worry.

ANS: 3 Genu varum, or bowlegs, is a normal finding in children for 1 year after they begin walking and the bones of the legs become more ossified with development and weight- bearing.

However, assessment over time is important to be sure the gait and positioning develop normally. The nurse should allay thefathers concerns by providing him with this information.

The child shows no signs, in the scenario above, that physical therapy is needed. It is not appropriate for the nurse to recommend an orthopedic surgeon; physician referrals are given by the physician or advanced practice nurse when appropriate. Your child is walking fine . . . is condescending and does not appropriately address the fathers concerns.

PTS: 1 DIF: Moderate REF: p. 571 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application 37. The nurse asks the patient to spread his fingers and then bring them together again.

Which of the following is the nurse testing when asking to bringhis fingers together?

1) Abduction2) Adduction3) Flexion4) ExtensionANS: 2 Asking the patient to spread his fingers tests abduction; asking him to bringthem together assesses adduction. Asking the patient to make a fist tests flexion, whereas asking him to extend the hand tests extension.

PTS: 1 DIF: Moderate REF: p. 576 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 38. An adult admitted to the hospital after a stroke does not respond toverbal stimuli. What should the nurse do next to try to provoke a response?

1) Apply pressure to the mandible at the jaw.2) Rub the patients sternum.3)Squeeze the trapezius muscle.4) Gently shake the patients shoulder.ANS: 4 If the patient does not respond to verbal stimuli, the nurse should try tactile stimuli by gently shaking the patients shoulder. If the patient does not respond to tactile stimuli, the nurse should try painful stimuli by squeezing the trapezius muscle, rubbing the sternum, applying pressure on the mandible at the angle of the jaw, or applying pressure over the moon of the nail. But do not start out withpainful stimulation before you are sure the patient is not going to react to a less invasive approach.

PTS: 1 DIF: Moderate REF: p. 579 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 39. Which assessment question helps assess immediate memory?1) How

did you get to the hospital today?2) Can you repeat the numbers 2, 7, 9 for me?3) Do you recall the three items I mentioned earlier?4) What was your birth date including the year?ANS: 2 The nurse can assess immediate memory by asking the patient to repeat a series of three numbers and gradually increasing the length of the series until the patient cannot repeat the series correctly. The nurse can assess recent memory by asking the patient how he got to the hospital or by asking the patient to repeat three items that the nurse mentioned earlier in the examination. The nurse can assess remote memory by asking the patient hisbirth date or the date of a significant historical event. PTS: 1 DIF: Moderate REF: p.

580 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 40. Assuming that all are accurate, which documentation about a patientslevel of consciousness is best?

1) Patient is lethargic and slept when undisturbed.2) Patient responds to tactile stimulation; falls back to sleep immediately aftertactile and verbal stimulation are stopped.

3) Patient slept throughout the day, missing his meals and bath.4) Patient appears to be tired as he slept throughout the day except when bathed.ANS: 2 The option that includes the most detailed information provides the most accurate description of the patients level of consciousness. The other documentation provides little information about the level of consciousness. Fromthose descriptions, the patient might have a decreased level of consciousness orcould simply be exhausted.

PTS: 1 DIF: Moderate REF: p. 510; High-level question; answer not statedverbatim KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level:Analysis 41. Based on developmental stage, how should the nurse modify thecomprehensive physical examination of an older adult?

1) Work rapidly to finish as quickly as possible.2) Sequence the exam to limit position changes.3) Demonstrate equipment before using it.4) Omit portions of the exam that may be tiring.ANS: 2 Because older adults may tire easily and because they may have stiff muscles and arthritic joints, the nurse should arrange the sequence of the exam to limit position changes. The nurse should work efficiently; however, speed is not the goal, and the nurse should observe the patients energy level and stop for periods of rest as needed. It is appropriate to demonstrate equipment for school-age children but is not usually necessary for older adults, who have probably experienced other physical examinations.

Because this is a comprehensive exam, it is not appropriate to omit portions of the exam because they may be tiring. As discussed, the patient should rest and then thenurse should return to the examination.

PTS: 1 DIF: Moderate REF: p. 515

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 42. The nurse applies resistance to the top of the clients foot and asks him to pull his toes toward his knee. The nurse observes active motion against some,but not against full, resistance.

How should the nurse document this finding?

1) 5: Normal 2) 4: Slight weakness 3) 3: Weakness 4) 2: Poor ROM ANS: 2 The nurse should document 4: Slight weakness. The following is the musclestrength rating scale: Rating Criteria Classification 5Active motion against full resistanceNormal 4Active motion against some resistanceSlight weakness 3Active motion against gravityWeakness 2Passive ROMPoor ROM 1Slight flicker of contractionSevere weakness 0No muscular contractionParalysis PTS: 1 DIF: Difficult REF: pp. 577-578 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which finding(s) require(s) further assessment? Select all thatapply.

1) Blood pressure 110/64 mm Hg2) Pulse rate 118 beats/minute 3) Respiratory rate 35 breaths/minute 4)Oral temperature 98.6F (37C)ANS: 2, 3 The pulse rate of 118 beats/minute and the respiratory rate of 35 breaths/minute are abnormally elevated and require further assessment. Blood pressure 110/64 mm Hg and oral temperature 98.6F (37C) are considered normal and do not require further assessment.

PTS: 1 DIF: Easy REF: p. 517 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 2. Which disorder(s) might limit a patients visual field? Select all that apply.1) Diabetes2) Advanced glaucoma3) Peripheral vascular disease4) Cataracts ANS: 1, 2, 4 Poorly controlled diabetes, cataracts, macular degeneration, and advancedglaucoma may limit

the visual field. Peripheral vascular disease may be associated with diabetes, but it occurs in the extremities, not the eyes.

PTS: 1 DIF: Moderate REF: p. 501 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

Chapter 20. Promoting Asepsis & Preventing Infection Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which of the following behaviors indicates the highest potential forspreading infections among clients? The nurse: 1) disinfects dirty hands with antibacterial soap.2) allows alcohol-based rub to dry for 10 seconds.3) washes hands only when leaving each room.4) uses cold water for medical asepsis.ANS: 3 Patients acquire infection by contact with other patients, family members, and healthcare equipment. But most infection among patients is spread through the hands of healthcare workers. Hand washing interrupts the transmission and should be done before and after all contact with patients, regardless of the diagnosis. When the hands are soiled, healthcare staff should use antibacterial soap with warm water to remove dirt and debris from the skin surface.

When no visible dirt is present, an alcohol-based rub should be applied and allowed to dryfor 10 to 15 seconds.

PTS:1DIF:EasyREF:p. 618 KEY:Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension 2. What is the most frequent cause of the spread of infection amonginstitutionalized patients?

1) Airborne microbes from other patients2) Contact with contaminated equipment3) Hands of healthcare workers4) Exposure from family membersANS: 3 Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other patients, family members, and contaminated healthcare equipment. Some of these are pathogenic (cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing infection among patients are spread by direct contact on the hands of healthcare workers.

PTS:1DIF:EasyREF:p. 609 KEY:Nursing process: Implementation | Client need: SECE | Cognitive level:Recall 3. Which of the following nursing activities is of highest priority formaintaining medical asepsis?

1) Washing hands2) Donning gloves3) Applying sterile drapes4) Wearing a gownANS: 1 Scrupulous hand washing is the most important part of medical asepsis. Donning gloves,

applying sterile drapes before procedures, and wearing aprotective gown may be needed to ensure asepsis, but they are not the most important aspect because microbes causing most healthcare-relatedinfections are transmitted by lack of or ineffective hand washing.

PTS: 1 DIF: Easy REF: p. 617 KEY: Nursing process: Interventions | Client need: Safe Care Environment |Cognitive level: Comprehension 4. A patient infected with a virus but who does not have any outward sign ofthe disease is considered a: 1) pathogen.2) fomite.3) vector.4) carrier.ANS: 4 Some people might harbor a pathogenic organism, such as the human immunodeficiency virus, within their bodies and yet do not acquire the disease/infection. These individuals, called carriers, have no outward sign of active disease, yet they can pass the infection to others. A pathogen is an organism capable of causing disease. A fomite is a contaminated object that transfers a pathogen, such as pens, stethoscopes, and contaminated needles. Avector is an organism that carries a pathogen to a susceptible host through a portal for entry into the body.

An example of a vector is a mosquito or tick that bites or stings.

PTS:1DIF:ModerateREF:p. 607 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application 5. A patient is admitted to the hospital with tuberculosis. Which precautionsmust the nurse institute when caring for this patient?

1) Droplet transmission2) Airborne transmission3) Direct contact4) Indirect contactANS: 2 The organisms responsible for measles and tuberculosis, as well as many fungal infections, are spread through airborne transmission. Neisseria meningitidis, the organism that causes meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as Clostridium difficile, are spread by directcontact. The common cold can be spread by indirect contact or droplet transmission.

PTS:1DIF:ModerateREF:p. 608 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 6. A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed?

1) Endogenous nosocomial2)

Exogenous nosocomial3) Latent4) PrimaryANS: 1 Thrush in this patient is an example of an endogenous nosocomial infection. Thistype of infection arises from suppression of the patients normal floras as a result of some form of treatment, such as antibiotics. Normal floras usually keep yeast from growing in the mouth. In exogenous nosocomial infection, the pathogen arises from the healthcare environment. A latent infection causes no symptoms for long periods. An example of a latent infection is human immunodeficiency virus infection. A primary infection is the first infection that occurs in a patient.

PTS: 1 DIF: Difficult REF: p. 608 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 7. A patient admitted to the hospital with pneumonia has been receivingantibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal.

Which stage of infection is the patient most likely experiencing? 1) Incubation2) Prodromal3) Decline4) ConvalescenceANS: 3 The stage of decline occurs when the patients immune defenses, along with anymedical therapies (in this case antibiotics), are successfully reducing the number of pathogenic microbes. As a result, the signs and symptoms of infection begin to fade. Incubation is the stage between the invasion by the organism and the onset of symptoms. During the incubation stage, the patient does not know he is infected and is capable of infecting others. The prodromal stage is characterized by the first appearance of vague symptoms. Convalescence is characterized by tissue repair and a return to healing as theorganisms disappear.

PTS:1DIF:ModerateREF:p. 609 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 8. The nurse assists a surgeon with central venous catheter insertion. Whichaction is necessary to help maintain sterile technique?

1) Closing the patients door to limit room traffic while preparing the sterile field2) Using clean procedure gloves to handle sterile equipment3) Placing the nonsterile syringes containing flush solution on the sterile field4) Remaining 6 inches away from the sterile field during the procedureANS: 1 To maintain sterile technique, the nurse should close the patients door and limitthe number of persons entering and exiting the room because air currents can carry dust and microorganisms. Sterile gloves, not clean gloves, should be usedto handle sterile equipment.

Placing nonsterile syringes on the sterile field contaminates the field. One foot, not 6 inches, is required between people and the sterile field to prevent contamination.

PTS: 1 DIF: Moderate REF: p. 629 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 9. A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection?

1)

Phagocytosis2) Complement cascade3) Inflammation4) ImmunityANS: 3 The classic signs of inflammation, a secondary defense against infection, are erythema (redness) and localized heat. The secondary defenses phagocytosis (process by which white blood cells engulf and destroy pathogens) and the complement cascade (process by which blood proteins trigger the release of chemicals that attack the cell membranes of pathogens) do not produce visiblefindings. Immunity is a tertiary defense that protects the body from future infection.

PTS:1DIFifficultREF:p. 610 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 10. The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which antibody would most likely be found in a test of immunoglobin levels?

1) IgA2) IgE3) IgG4) IgM ANS: 4 IgM are the first antibodies made in response to infection. IgE is the antibody primarily responsible for this allergic response. IgA antibodies protect the bodyin fighting viral and bacterial infections, and appear later. IgG antibodies also appear laterperhaps up to 10 days later.

PTS:1DIF:ModerateREF:p. 612 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 11. What type of immunity is provided by intravenous (IV) administration of immunoglobulin G? 1) Cell-mediated2) Passive3) Humoral4) ActiveANS: 2 Intravenous administration of immunoglobulin G provides the patient with passive immunity. Immunoglobulin G does not provide cell-mediated, humoral,or active immunity.

Passive immunity occurs when antibodies are transferred from an immune host, such as from a placenta to a fetus. Passive immunity is short lived. Active immunity is longer lived and comes from the host. Humoral immunity occurs by secreted antibodies binding to antigens.

Cell-mediated immunity does not involve antibodies but rather is a fight of infection frommacrophages that kill pathogens.

PTS:1DIF:ModerateREF:ESG, Chapter 22, Supplemental Materials, HumoralImmunity KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall

12. A patient asks the nurse why there is no vaccine available for thecommon cold. Which response by the nurse is correct?

1) The virus mutates too rapidly to develop a vaccine.2) Vaccines are developed only for very serious illnesses.3) Researchers are focusing efforts on an HIV vaccine.4) The virus for the common cold has not been identified.ANS: 1 More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly to develop a vaccine. Although some researchers are focusing efforts on a vaccine for HIV infection, others continue to research thecommon cold.

PTS:1DIF:ModerateREF:p. 616 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 13. A patient who has a temperature of 101F (38.3C) most likely requires: acetaminophen (Tylenol).2) increased fluids.3) bedrest.4) tepid bath.ANS: 2 Fever, a common defense against infection, increases water loss; therefore, additional fluid is needed to supplement this loss. Acetaminophen and a tepidbath are not necessary for this low-grade fever because fever is beneficial in fighting infection.

Adequate rest, not necessarily bedrest, is necessary with a fever.

PTS:1DIF:ModerateREF:p. 616 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 14. Why is a lotion without petroleum preferred over a petroleum-basedproduct as a skin protectant?

1) It prevents microorganisms from adhering to the skin.2) It facilitates the absorption of latex proteins through the skin.3) It decreases the risk of latex allergies.

4) It prevents the skin from drying and chaffing.ANS: 3 Non-petroleum-based lotion is preferred because it prevents the absorption of latex proteins through the skin, which can cause latex allergy. Both types of lotion help prevent the skin from drying and becoming chafed. Neither preventsmicroorganisms from adhering to the skin.

PTS: 1 DIF: Moderate REF: p. 634[answer not directly given in the text. Answermust be inferred from the content.]

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 15. For which range of time must a nurse wash her hands before working inthe operating room?

1) 1 to 2 minutes 2)

2 to 4 minutes 3) 2 to 6 minutes 4) 6 to 10 minutes ANS: 3 In a surgical setting, hands should be washed for 2 to 6 minutes, depending onthe type of soap used.

PTS:1DIF:EasyREF:p. 639 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 16. How should the nurse dispose of the breakfast tray of a patient whorequires airborne isolation?

1) Place the tray in a specially marked trash can inside the patients room.

2) Place the tray in a special isolation bag held by a second healthcare worker atthe patients door.

3) Return the tray with a note to dietary services so it can be cleaned and reusedfor the next meal.

4) Carry the tray to an isolation trash receptacle located in the dirty utility roomand dispose of it there.

ANS: 2 Patients who require airborne isolation are served meals on disposable dishes and trays. To dispose of the tray, the nurse inside the room must wear protectivegarb and place the tray and its contents inside a special isolation bag that is held by a second healthcare worker at the patients door. The items must be placed on the inside of the bag without touching the outside of the bag.

PTS:1DIF:ModerateREF:p. 625 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 17. As a general rule, how much liquid soap should the nurse use foreffective hand washing? At least: 1) 2 mL 2) 3 mL 3) 6 mL 4) 7 mL ANS: 2 APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effectivehand washing.

PTS:1DIF:EasyREF:p. 633 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

18. To assure effectiveness, when should the nurse stop rubbing antiseptichand solution over all surfaces of the hands?

1) When fingers feel sticky 2) After 5 to 10 seconds 3) When leaving the clients room 4) Once fingers and hands feel dryANS: 4 The nurse should rub the antiseptic hand solution over all surfaces of the handsuntil the solution dries, usually 10 to 15 seconds, to ensure effectiveness.

PTS: 1 DIF: Easy REF: p. 634 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 19. A patient is admitted to the hospital for chemotherapy and has a low white blood cell count. Which precaution should the staff take with this patient?

1) Contact 2)Protective 3)Droplet 4)AirborneANS: 2 Protective isolation is used to protect those patients who are unusually vulnerable to organisms brought in by healthcare workers. Such patients includethose with low white blood cell counts, with burns, and undergoing chemotherapy. Some hospital units, such as neonatal intensive care units and labor and delivery suites, also use forms of protective isolation.

PTS:1DIF:ModerateREF:p. 625 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 20. While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is over 1 inch away from the glovesand only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point?

1) Continue using the gloves inside the package because the package is intact.2) Remove gloves from the sterile field and use a new pair of sterile gloves.3) Throw all supplies away that were to be used and begin again.4) Use the gloves and make sure the yellow edges of the package do not touch theclient. ANS: 2 The gloves should be discarded because the gloves are likely to be contaminated from an outside source. The supplies do not have to be thrownaway because they have not been contaminated.

PTS:1DIF:ModerateREF:pp. 629, 646 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 21. The nurse is removing personal protective equipment (PPE). Which itemshould be removed first?

1) Gown2) Gloves3) Face shield4)

Hair coveringANS: 2 The gloves are removed first because they are usually the most contaminatedPPE and must be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed second, then the mask or faceshield, and finally, the hair covering.

PTS:1DIF:ModerateREF:pp. 637-638 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Prioritizing Prioritize the nurses actions, listing the most important one first.

1. A nurse is splashed in the face by body fluid during a procedure. Prioritizethe nurses actions, listing the most important one first.

1. Contact employee health 2. Complete an incident report 3. Wash the exposed area 4. Report to another nurse that she is leaving the immediate area.

1)-1, 2, 3, 4 2)-2, 3, 4, 1 3)-3, 4, 1, 2 4)-4, 1, 2, 3 ANS: 3 If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse she is leaving the area, contact the infection control or employeehealth nurse immediately, and complete an incident report. It is most importantto remove the source of contamination (body fluid) as soon as possible after exposure to help prevent the nurse from becoming infected. The other activitiescan wait until that is done.

PTS:1DIF:ModerateREF:p. 630 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. In which situation would using standard precautions be adequate? Selectall that apply.

1) While interviewing a client with a productive cough2) While helping a client to perform his own hygiene care3) While aiding a client to ambulate after surgery4) While inserting a peripheral intravenous catheterANS: 3, 4 Standard precautions should be instituted with all clients whenever there is apossibility of coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a client, if the disease is not spreadby air or droplets, there is no likelihood of the nurses encountering body fluids. Ifthe disease is spread by air or

droplets, then droplet or airborne precautions would be needed in addition to standard precautions. If giving a complete bed bath or performing oral hygiene, the nurse would need to use standard precautions (gloves); if merely assisting a client to perform those ADLs, it is not necessary. No exposure to body fluids is likely when helping a client to ambulate after surgery.

PTS: 1 DIF: Easy REF: pp. 619-624 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 2. Which of the following protect(s) the body against infection? Select allthat apply. 1) Eating a healthy, well-balanced diet2) Being an older adult or an infant3) Leisure activities three times a week4) Exercising for 30 minutes 5 days a weekANS: 1, 3, 4 Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect thebody against infection. Illness, injury, medical treatment, infancy or old age, frequent public contact, and various lifestyle factors can make the body more susceptible to infection.

PTS:1DIF:EasyREF:pp. 612, 616 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 3. The nurse is teaching a group of newly hired nursing assistive personnel(NAP) about proper hand washing. The nurse will know that the teaching was effective if the NAP demonstrate what? Select all that apply. The NAP: 1) Uses a paper towel to turn off the faucet.

2) Holds fingertips above the wrists while rinsing off the soap.

3) Removes all rings and watch before washing hands.

4) Cleans underneath each fingernail.

ANS: 1, 3, 4 Hand washing requires at least 15 seconds of washing, which includes latheringall surfaces of the hands and fingers to be effective. The fingers should be held lower than the wrists.

PTS: 1 DIF: Moderate REF: pp. 633-634 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall 4. Alcohol-based solutions for hand hygiene can be used to combat whichtypes of organisms? Select all that apply.

1) Virus 2)Bacterial spores 3)Yeast 4)Mold ANS: 1, 3, 4 If there is potential for contact with bacterial spores, hands must be washed withsoap and water; alcohol-based solutions are ineffective against bacterial spores.

PTS:1DIF:ModerateREF:p. 618 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

5. A patient with tuberculosis is scheduled for computed tomography (CT).How should the nurse proceed? Select all that apply.

1) Question the order because the patient must remain in isolation.

2) Place an N-95 respirator mask on the patient and transport him to the test.

3) Place a surgical mask on the patient and transport him to CT lab.

4) Notify the computed tomography department about precautions prior totransport. ANS: 3, 4 Transporting a patient who requires airborne precautions should be limited; however, when necessary the patient should wear a surgical mask (an N-95 respirator mask is not required) that covers the mouth and nose to prevent the spread of infection. Moreover, the department where the patient is beingtransported should be notified about the precautions before transport.

PTS: 1 DIF: Difficult REF: pp. 623-624 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension True/False Indicate whether the statement is true or false.

1. Bacteria are necessary for human health and well-being.ANS: T Organisms that normally inhabit the body, called normal floras, are essential forhuman health and well-being. They keep pathogens in check. In the intestine, these floras function to aid digestion and promote the release of vitamin K, vitamin B12, thiamine, and riboflavin.

PTS:1DIF:EasyREF:p. 606 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall

Chapter 21. Promoting Safety Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Physiological changes associated with aging place the older adultespecially at risk for which nursing diagnosis?

1) Risk for Falls 2) Risk for Ineffective Airway Clearance (choking) 3) Risk for Poisoning 4) Risk for Suffocation (drowning) ANS: 1 Loss of muscle strength and joint mobility place older adults at risk for falls.Choking, drowning, and ingesting poisons are primary safety concerns for infants and toddlers.

PTS:1DIF:ModerateREF:p. 653 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall 2. A 78-year-old patient is being seen in the emergency department. Thenurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next?

1) Perform the Get Up and Go Test.2) Ask the patient if he has fallen in the past year.3) Refer the patient for a comprehensive fall evaluation.4) Administer the Timed Up and Go Test.ANS: 2 If a patients gait or balance is unsteady, the nurse should question the patientfor a history of falls. If the patient reports a single fall, the nurse should do the Get Up and Go Test. If the patient has difficulty with that test, or is unsteadywith it, the nurse should perform a follow-up assessment of gait and balance by having the person close the eyes for a few seconds wile standing in place; standwith eyes closed while the nurse pushes gently on the sternum; walk, stop, turn around, return to the chair, and sit in the chair without using his arms for support. Physicians and advanced practitioners perform the Timed Up and Go Test; it is recommended annually for patients 65 years or older.

PTS:1DIFifficultREF:p. 661 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Application 3. The nurse notes that the electrical cord on an IV infusion pump iscracked. Which action by the nurse is best?

1) Continue to monitor the pump to see if the crack worsens.

2) Place the pump back on the utility room shelf.

3) A small crack poses no danger so continue using the pump.

4) Clearly label the pump and send it for repair.ANS: 4 Whenever an electrical safety hazard is suspected or visible, the nurse shouldlabel the malfunctioning equipment and send it for repair or inspection.

Continuing to use the IV infusion pump or any other equipment places thepatient at risk for

injury. Placing the pump back on the shelf places other healthcare team members at risk for electrical injury if they attempt to use theequipment.

PTS:1DIF:EasyREF:p. 673 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 4. A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action shouldthe nurse take first?

1) Apply a cloth vest restraint.

2) Encourage a family member to stay with the patient.

3)Administer lorazepam (an antianxiety medication).

4)Keep the patients bed side rails up.

ANS: 2 The nurse should use one-to-one supervision with this patient to maintain the patients safety.

One way to accomplish this is by encouraging a family member to stay with the patient.

Restraints should be used only when all other less- restrictive measures have failed and are absolutely necessary to prevent injury to the patient. Restraints have been shown to jeopardize patient safety. It is not appropriate to administer sedation for the purpose of keeping the patient in bed;this is a form of restraint. Keeping the side rails up is also a form of restraint andincreases the risk for falling.

PTS: 1 DIF: Moderate REF: p. 673 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 5. Despite less-restrictive interventions, a patients behavior escalates, requiring emergency application of restraints. Which of the following must thenurse do in this situation?

1) Obtain a physician’s order before applying restraints.

2) Monitor the patient’s status every 4 hours while restrained.

3) Release the restraints and check circulation every hour.

4)Continually reevaluate the patients need for restraint.

ANS: 4 The patient must be continually monitored, and the need for restraint must be continually reevaluated. As a rule, a medical order should be obtained before applying restraints. However, in an emergency, the nurse is permitted to apply restraints for behavior management, but a physician or advanced practice nursemust then evaluate the patient within 1 hour of restraint application. The order for restraint must be renewed daily. The restraints must be released at least every 2 hours, and circulation must be checked.

PTS: 1 DIF: Difficult REF: pp. 679-681 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 6. A patient has received a radiation implant. The patient is weak and needs help even to turn in bed. Which action should the nurse take when caring for this patient?

1.) Avoid giving the patient a complete bed bath.

2.) Limit the amount of time spent with the patient.

3.) Allow extra time for the patient to express feelings.

4.) Do not allow anyone to visit the patient.

ANS: 2 When caring for a patient with a radiation implant, the nurse should organize nursing care to limit the amount of time with the patient to limit radiation exposure. The nurse must meet the patient’s personal hygiene needs by bathingthe patient, if necessary. The nurse should encourage the patient to express herfeelings; however, she should limit her contact with the patient. Pregnant women should not visit the patient; however, others may visit as long as they uphold the principles of time, distance, and shielding.

PTS: 1 DIF: Moderate REF: p. 660 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 7. A child is brought to the emergency department after swallowing liquidcleanser. He is awake and alert and able to swallow. Which action should the nurse take first?

1)Administer a dose of syrup of ipecac.

2)Administer activated charcoal immediately.

3.) Give water to the child immediately.

4) Call the nearest poison control center.

ANS: 3 If the child is awake and able to swallow, and the child has swallowed a household chemical, give one-half glassful of water immediately. After giving thewater, call the poison control center. The American Academy of Pediatrics does not advise giving syrup of ipecac.

Emergency departments have stopped using ipecac in favor of activated charcoal, which binds to poison in the stomach and prevents it from entering the bloodstream. Continued vomiting caused by syrup of ipecac may later result in the child being unable to tolerate activated charcoalor other poison treatments. No one can tell how much a child vomits, and therefore, no one would know if all the poison was eliminated from the stomach. There is also potential for misuse by bulimics. The poison control center may recommend activated charcoal, depending upon the agent ingested. PTS: 1 DIF: Difficult REF: ESG, Chapter 23, Table 23-2, Sources and Medical Treatment for Commonly Ingested Poisons KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Analysis 8. A nurse is teaching a group of mothers about first aid. Should poisoncome in contact with their childs clothing and skin, which action should the nurse instruct the mothers to take first?

1) Remove the contaminated clothing immediately.2) Flood the contaminated area with lukewarm water.3) Wash the contaminated area with soap and water and rinse.4) Call the nearest poison control center immediately.ANS: 1 The nurse should tell the mother to first remove the contaminated clothing as quickly as possible. Then, flood the contaminated area with lukewarm water. Next, gently wash the area with soap and water and rinse. Have someone call the poison control center. It does not need to be a local poison control center. Additionally, it is most important to remove contact between the skin and poisonbefore doing anything.

PTS: 1 DIF: Moderate REF: ESG, Chapter 23, Box 23-2, Home Care: If Poisoning Occurs at Home KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis

9. Which of the following instructions is most important for the nurse toinclude when teaching a mother of a 3-year-old about protecting her child against accidental poisoning?

1) Store medications on countertops out of the childs reach.2) Purchase medication in child-resistant containers3) Take medications in front of the child, and explain that they are for adults only.4) Never leave the child unattended around medications or cleaning solutions.ANS: 4 The nurse should instruct the mother to avoid leaving her child unattended around medications or cleaners even for a moment. Medications should neverbe stored on kitchen counters or bathroom surfaces because children love to explore and climb and can get into them. The nurse should explain that medications should not be taken in front of the child because children imitate adult behavior. The nurse should reinforce that although child-resistant containers are a deterrent, they are not foolproof because many toddlers and preschoolers can open them.

PTS:1DIF:ModerateREF:p. 665 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 10. A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associatedwith mercury inhalation?

1) Chest pain, pneumonitis, and inflammation of the mouth 2)Intestinal obstruction and numbness of the hands 3)Hypotension, oliguria, and tingling of the feet 4)Tachycardia, hematuria, and diaphoresis ANS: 1 Acute adverse effects of mercury inhalation include chest pain, inflammation ofmouth, pneumonitis, respiratory damage, wakefulness, muscle weakness, anorexia, headache, and ringing in the ears, Chronic effects include numbnessor tingling of the hands, lips, and feet, and personality changes. Intestinal obstruction is an acute effect of mercury ingestion. Hypotension, oliguria,hematuria, and diaphoresis are not acute effects of mercury inhalation.

PTS: 1 DIF: Difficult REF: p. 659 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 11. Which aspect of restraint use can the nurse delegate to the nursingassistive personnel?

1) Assessing the patients status 2)Determining the need for restraint 3) Evaluating the patients response to restraints 4) Applying and removing the restraintsANS: 4 The nurse can delegate applying and removing the restraints, skin care, and checking for skin breakdown. The nurse responsible for care of the patient must assess the patients need for restraint and the patients status and must evaluatethe patients response to restraints.

PTS: 1 DIF: Moderate REF: p. 675 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

12. The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first?

1) Encourage the child to continue coughing.

2) Deliver upward abdominal thrusts with a fisted hand.

3) Deliver five rapid back blows between the shoulder blades.

4) Perform a blind finger sweep of the childs mouth.

ANS: 1 If the nurse suspects aspiration in a child who is coughing vigorously, the nurseshould encourage the child to continue coughing. If coughing weakens, the nurse should perform the choking maneuver by administering five rapid back blows alternated with five upward thrusts to the upper abdomen with a fisted hand, just below the rib cage. A blind finger sweep should never be performed because it could push the foreign object into the airway.

PTS:1DIF:Moderate REF: ESG, Box 23-5, Rescue Maneuver for Choking: Adult or Child Over Age 12 Months KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 13. Which is the most commonly reported incident in hospitals?

1)Equipment malfunction 2) Patient falls 3) Laboratory specimen errors 4)Treatment delays ANS: 2 Patient falls are by far the most common incident reported in hospitals and long-term care facilities. Although equipment (e.g., infusion pump) malfunctions, missed or incorrectly identified laboratory specimen collection, and treatment delays sometimes occur, they do not occur as frequently as patient falls.

PTS:1DIF:EasyREF:p. 657 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 14. The Joint Commissions national Speak Up campaign encourages patients to become active and informed participants on the healthcare team.The goal is to: 1) Prevent healthcare errors.

2) Help control the cost of healthcare.

3) Reduce the number of automobile accidents.

4) Provide a forum for people without health insurance.ANS: 1 The Joint Commission, with the Centers for Medicare and Medicaid Services, urges patients to take a role in preventing healthcare errors by becoming active,involved, and informed participants on the healthcare team. A reduction in healthcare errors could indirectly reduce healthcare costs, but this is not the intent of the campaign. The campaign has nothing to do with automobile accidents, as might be deduced from the fact that the Joint Commission and Medicare/Medicaid regulate healthcare agencies. The campaign has little relationship to insurance, other than to encourage clients to speak up, askquestions, and know their rights.

PTS:1DIFifficultREF:p. 664 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension

15. A patient in the emergency department is angry, yelling, cursing, andwaving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse is(are) advisable?

1) Reassure the patient by entering the room alone.2) Ask the patient if he is carrying any weapons.3) Stay between the patient and the door; keep the door open.4) Make eye contact while stating firmly I will not tolerate cursing and threats.ANS: 3 The nurse should keep the door open and position herself so that the patient cannot block her exit from the room (stay between the patient and the door). The nurse should not enter a room alone with an angry patient. The progressionto physical violence is first anxiety, then verbal aggression, and finally physical aggression. The nurses first priority in this situation is her own safety and the safety of others in the environment. The object is to relieve the patients anxietyand not respond to anger with anger.

Questioning about weapons, or being firm and defending against verbal aggression will likely provoke even more anger from the patient. The nurse must be calm and reassuring.

PTS:1DIFifficultREF:p. 674 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which point(s) should the nurse include when teaching safetyprecautions to a mother of a toddler? Select all that apply.

1) Make sure the child sleeps on his back at night.2) Keep the telephone number of the poison control center accessible.3) Use a front-facing car seat placed in the back seat of the car.4) Keep syrup of ipecac on hand in case of accidental poisoning.ANS: 2, 3 The nurse should teach the mother of a toddler to keep the telephone number ofthe poison control center accessible because toddlers are at risk for accidental poisonings. Toddlers should also have front-facing car seats. Syrup of ipecac is no longer recommended to induce emesis after poisonings. Infants, not toddlers,should sleep on their backs to prevent sudden infant death syndrome.

PTS: 1 DIF: Moderate REF: pp. 664, 670 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 2. During a thermometer exchange program at a local hospital, a person drops a mercury thermometer on the floor. Assume the nurse has been trained in cleanup of such a spill. Select all that are appropriate. How should the nurseintervene? 1) Using gloves and a paper towel, place the mercury in a plastic bag, and disposeof it. 2) Notify the hazardous material management team immediately.3) Evacuate the area immediately.4) After putting on a gown, gloves, and a mask, clean up the mercury.5) Wash her hands well after removing the spill.6) Ventilate the area well for several days.ANS: 1, 5, 6 The nurse should put on gloves and use a paper towel to pick up the mercury. Then place the

mercury, broken thermometer, and soiled paper towel into a plastic bag along with the gloves.

Next, the nurse should dispose of the plastic bag, wash her hands, and ventilate the area well. It is not necessary to notify the hazardous material management team or evacuate the area for a spill this small, unless agency policy actually mandates that. The nurse does not need toput on a gown and mask to dispose of the mercury.

PTS: 1 DIF: Moderate REF: pp. 674-675 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application COMPLETION 1. Rank the following leading causes of accidental death in the United States according to their frequency of occurrence. Rank as 1 the one that occurs mostfrequently; rank as 4 the one that occurs least frequently.

A. Motor vehicle accidents B. Falls C. Suffocation D. Poisonings ANS: A, D, B, C Motor vehicle accidents are the leading cause of accidental death in the UnitedStates, followed by poisonings, falls, and suffocation.

PTS:1DIF:EasyREF:p. 656

KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 2. When the nurse walks into the patients room, she notices fire coming from the patients trash can. Rank the following actions in the order they should be performed by the nurse. 1 should be done first; 4 should be last.

A. Activate the fire alarm.

B. Move the patient out of the room.

C. Close all doors and windows.

D. Put out the fire using the proper extinguisher.

ANS: B, A, C, D The nurse should first move the patient out of the room, then activate the alarm, close all doors and windows and turn off oxygen valves, and use the proper extinguisher to put out the fire.

PTS:1DIFifficultREF:p. 658 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis

Chapter 22. Facilitating Hygiene Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patients care plan? Teach the patient to: 1) use an electric razor for shaving.

2) apply skin moisturizer.

3) use less soap when bathing.

4) floss teeth daily. ANS: 1 The nurse should instruct the patient prescribed an anticoagulant to use an electric razor instead of a double-edge razor for shaving to prevent the risk of excess bleeding. Older adults should be encouraged to use skin moisturizers anduse less soap while bathing to combat excess drying of the skin that occurs as a result of aging. However, even if this patient is an older adult, a risk for bleedingtakes priority over a risk for dry skin.

Everyone should be encouraged to floss their teeth daily; however, some patients with severe bleeding risk may be told not to floss.

PTS: 1 DIF: Easy REF: p. 702 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 2. The nurse is caring for a patient admitted with a closed head injury.Which action by the nurse is appropriate when providing hygiene for this patient?

1) Avoid bathing the patient.2) Use cool water for bathing.3) Provide care in small intervals.4) Rub briskly when towel drying.ANS: 3 The nurse should provide care in small intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary toavoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure.

PTS: 1 DIF: Difficult REF: pp. 685-686 answer is not expressly given. KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 3. A patient has sustained a spinal cord injury and is no longer able to get inand out of the bathtub without assistance. Which nursing diagnosis appropriately addresses this problem?

1) Total Self-care Deficit2) Bathing/Hygiene Self-care Deficit3) Dressing/Grooming Self-care deficit4) Activity IntoleranceANS: 2 The nursing diagnosis Bathing/Hygiene Self-care Deficit is most appropriate for addressing the patients inability to get in and out of the bathtub independently. There are no data to suggest that the patient is completely unable to care for himself; therefore, Total Self-care Deficit is not appropriate. There is nothing to suggest that the patient is unable to dress or groom himself.

Activity Intolerance 3) is present when a patient exhibits extreme fatigue, which is not mentioned inthis scenario.

PTS: 1 DIF: Moderate REF: ESG, Chapter 24, Standardized Language, Table:Selected

Standardized Outcomes and Interventions for Self-Care KEY: Nursing process: Nursing diagnosis | Client need: PHSI | Cognitive level:Analysis 4. Which scheduled hygiene care is usually thought of as including a backmassage to help the patient relax?

1) Afternoon care2) Early morning care3) Morning care4) Hour of sleep careANS: 4 The nurse should offer a back massage during hour of sleep (HS) care to promote relaxation.

During afternoon care the nurse should prepare the patient to receive visitors or for afternoon rest. Early morning care is provided after the patient awakens. It commonly prepares the patient for breakfast or procedures, such as diagnostic testing.

Early morning care typically consists of assisting withtoileting, face and hand washing, and mouth care. Morning care occurs after breakfast and commonly consists of toileting, bathing, and mouth, skin, and haircare. It may also include dressing and positioning or assisting the patient to the chair.

PTS: 1 DIF: Easy REF: p. 687 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 5. For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition.

Assume there are no complications other than theconditions stated. 1) 32-year-old admitted with a closed head injury2) 76year-old admitted with septic shock3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertionANS: 3 Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care.

Therefore, he requires the critical thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. Thepatient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical thinking skills of a registered nurse to detect respiratory compromise quickly.

PTS: 1 DIF: Difficult REF: p. 687 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 6. A clients epidermis has insufficient melanin. Which nursing diagnosis is appropriate?

1) Risk for Infection2) Risk for Impaired Skin Integrity3) Risk for Deficient Fluid Volume4) Impaired Skin IntegrityANS: 2 The epidermis contains melanin, a pigment that protects against the sunsultraviolet rays; therefore, a person with insufficient melanin is at Risk For Impaired Skin Integrity (sunburn). There are no symptoms to indicate that the client has a sunburn (actual Impaired Skin Integrity), only that a risk factor ispresent. The dermis contains blood and lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands; melanin does not prevent fluid loss.

Fibroblasts (not melanin), also found in the dermis, produce new cells and assistin wound healing, thereby helping to prevent infection.

PTS: 1 DIF: Difficult REF: pp. 688 for coverage of aging effects including loss of melanin, 689 for coverage of impaired skin integrity; students must synthesizethe information to answer the question; answer is not directly stated in text KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis 7. What is the bodys first line of defense against bacteria?1) Intact skin2) White blood cells3) Lymph glands4) Inflammatory responseANS: 1 Intact skin is the bodys first line of defense against bacteria. Once bacteria enter the body, the inflammatory response, white blood cells, and lymph glands play a role in fighting against the bacteria.

PTS: 1 DIF: Easy REF: p. 687 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 8. While bathing a patient with liver dysfunction, the nurse notes yellowskin tone. The nurse should document this finding as: 1) Pallor.2) Erythema.

3) Jaundice.4) Cyanosis.ANS: 3 A yellow skin tone, known as jaundice, commonly occurs in patients with impaired liver function. Pallor is pale skin without underlying pink tones in thelight-skinned person.

Pallor occurs with anemia. Erythema, or redness of the skin, commonly occurs with inflammation or vasodilation. Cyanosis, a bluish coloring of the skin, is caused by poor peripheral circulation or decreased oxygen in the blood.

PTS: 1 DIF: Moderate REF: p. 688 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 9. A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding bythe nurse led to this documentation?

1) 3) Skin was softened from prolonged exposure to moisture.2) Superficial layers of skin were absent.3) The epidermal layer of skin was rubbed away.4) A lesion caused by tissue compression was present.ANS: 2 Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or searing forces that occur when a patient moves in bed. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility.

PTS: 1 DIF: Moderate REF: p. 689 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 10. For which patient is it most important to provide frequent perineal care?The patient: 1)

with active lower gastrointestinal bleeding.2) after an episode of diabetic ketoacidosis.3) who has a circumcised penis.4) with a history of acute asthma.ANS: 1 The patient admitted with active lower GI bleeding will require frequent perinealcare because of the irritating effect of enzymes in the stools. The uncircumcisedpatient, not the circumcised patient, may require frequent perineal care. Those with diabetic ketoacidosis or who have had acute asthma do not require frequent perineal care.

PTS: 1 DIF: Moderate REF: pp. 692, 714-716 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 11. A patient with dementia becomes belligerent when the nurse attemptsto give him a tub bath. How should the nurse proceed?

1) Call for assistance to help the patient into the bathtub.2) Wait for the patient to calm down, and then give him a towel bath.3) Allow the patient to go without bathing for a day or two.4) Ask another staff member to attempt the tub bath.ANS: 2 Nurses need to individualize bathing to meet the needs of the patient. If the patient becomes belligerent, the nurse should wait until the patient calms down and then attempt a towel bath. Towel baths have been shown to reduce agitation significantly.

The patient should not be forced into the tub. Having another staff member attempt the tub bath will most likely increase the patientsagitation, as consistency of caregivers is important for patients with dementia.

PTS: 1 DIF: Moderate REF: pp. 692-693 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 12. The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include?

1) Cleanse only those areas likely to cause odor.2) Provide the patient with warm water for washing his perineum.3) 3) Wash the patients back, buttocks, and perineum first.4) Bathe the patient from head-to-toe, cleanest areas first.ANS: 4 The nurse should instruct the NAP to give a complete bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), in head-to-toe fashion, beginning with the cleanest part of the body and ending with the dirtiest. The NAP should provide the patient with a basin of warm waterand allow him to wash his perineum when giving an assist bath or bed bath (thisis a total bed bath). During a partial bath, the NAP should cleanse only the areasthat may cause odor or discomfort. The NAP should never begin the bath with the back, buttocks, and perineum because this violates the principle of clean to dirty.

PTS: 1 DIF: Moderate REF: pp. 690-691; 707-711 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application 13. Which action should the nurse take when preparing a patient for a bedbath? 1) Place the nurse call device within reach for safety.2) Cover the patient with the top linens from the bed.3) Have the patient completely bathe himself to promote independence.4) Wash the patients body without assistance from the patient.ANS: 1 When preparing a patient for a bed bath (a bath for patients who must remain inbed but who are able to bathe themselves), place a basin of warm water, bath linens, a clean gown, and

other bathing supplies on the overbed table. Provide privacy, and place the nurse call device within reach. Remove the top linens from the bed, and cover the patient with a bath blanket. If the patient cannot bathe all areas of his body, complete the bath for him. The nurse performs at least part of a bed bath; if the patient bathes himself completely while remaining in bed, it is referred to as an assist bath.

PTS: 1 DIF: Moderate REF: p. 690 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 14. A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type ofbath is preferred for this patient?

1) Tub bath2) Complete bed bath3) Towel bath4) Bed bathANS: 3 A towel bath is a modification of the bed bath, in which a large towel and a bathblanket are placed in a plastic bag and saturated with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water. The bag and its contents are then placed in the microwave, and they are used to bathe the patient. This bathing method is preferred for patients who have Activity Intolerance. A tub bath, complete bed bath, and conventional bed bath may deplete this patients energy.

PTS: 1 DIF: Easy REF: p. 690 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 15. Wearing poorly fitting shoes may result in which condition?1) 3) Tinea pedis2) Plantar wart3) Excoriation4) Ingrown toenailANS: 4 Wearing poorly fitting shoes and improperly trimming the toenails may cause an ingrown toenail. Tinea pedis occurs when moisture accumulates in unventilated shoes. Plantar wart is a painful growth that is caused by a virus. Excoriation occurs when digestive enzymes come in contact with skin.

PTS: 1 DIF: Moderate REF: p. 694 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 16. The school nurse is teaching a group of middle school students how to prevent tinea pedis. Which remark by a student provides evidence of learning?1) I can contract the infection by walking barefoot in the gymnasiums showers. 2) The best way to avoid contracting the infection is to use good hand washing.

Wearing unventilated shoes prevents the fungus from gaining contact with myfeet. 4) There is really no way to prevent its spread; its highly contagious.ANS: 1 One can contract the infection by walking barefoot in public showers, such as those in the schools gymnasium. Good hand washing does not prevent a personfrom contracting tinea pedis. Wearing unventilated shoes may actually aggravate the infection by allowing moisture to accumulate in the shoes.

Although the infection is highly contagious, the spread of infection can beprevented by wearing special footwear in the shower.

PTS: 1 DIF: Moderate REF: p. 694

KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application 17. Bath water should be prepared at which temperature to prevent chillingand excess drying of the skin?

1) 99F (37.2C) 2) 102F (38.9C) 3) 103F (39.4C) 4) 105F (40.6C)ANS: 4 Bath water temperature should be 105F (40.6C) to prevent chilling, burning, andexcess drying of the skin.

PTS: 1 DIF: Easy REF: p. 707 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 18. While assessing a patient, the nurse notes that the patients nails areexcessively brittle.

What does this finding suggest?

1) Inadequate dietary intake Normal aging process3) Fungal infection4) Excessive use of silver saltsANS: 1 Inadequate dietary intake or metabolic changes can cause the nails to becomebrittle. As a person ages, nails thicken, become ridged, and may yellow or become concave in shape.

Brown or black discoloration of the nail plate may indicate a fungal infection.

Bluish gray discoloration of the nail plate signals excessive intake of silver salts. PTS: 1 DIF: Moderate REF: p. 695 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 19. A patient with a history of seizures who takes phenytoin is at risk forwhich oral problem?

1) Dryness of the mouth2) Bitter taste3) Demineralization of the tooth enamel4) Gingival hyperplasiaANS: 4 Phenytoin causes gingival hyperplasia. Medications, such as atropine, cause drymouth. Bitter taste can result from drugs, such as docusate sodium, a stool softener. Phenytoin does not cause demineralization of the tooth enamel.

PTS: 1 DIF: Moderate REF: p. 698 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level:Comprehension 20. The nurse has been teaching a student how to perform mouth care forher unconscious patient. The student will show evidence of learning if she placesthe patient in which position for this care?

1) Supine2) Prone3) Semi-Fowlers4) Side-lyingANS: 4 The nurse should position an unconscious patient in a side-lying position to provide mouth care

to prevent aspiration. Supine, prone, and semi-Fowlers positions are unsafe positions for providing mouth care for the unconscious patient.

PTS: 1 DIF: Moderate REF: p. 725 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level:Comprehension 21. Which item is best for providing mouth care for an unconscious patient?1) Foam swabs2) Lemon-glycerin swabs3) Hydrogen peroxide4) Cotton-tipped applicator soaked in mouthwashANS: 1 Commercially packaged applicators or foam swabs are typically used to provide mouth care.

Lemon-glycerin swabs are not recommended because they are drying to the oral mucosa.

Hydrogen peroxide should be avoided because it is irritating to oral mucosa and may alter the balance of normal floras that occur in the mouth. Mouthwash can be used by conscious patients as part of their routine mouth care.

However, cotton-tipped applicators should not be soaked init to perform mouth care.

PTS: 1 DIF: Moderate REF: p. 725 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall 22. After receiving a course of chemotherapy, a patient begins losing hair.This adverse effect of chemotherapy should be documented as: 1) pediculosis.2) alopecia.3) dandruff.4) hirsutism.

ANS: 2 Alopecia is abnormal hair loss that can occur as a result of chemotherapy. Pediculosis is an infestation of head lice. Dandruff is a condition in which there isexcessive shedding of the epidermal layer of the scalp. Hirsutism is the excessive growth of body hair in women.

PTS: 1 DIF: Moderate REF: p. 702 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 23. Which of the following is a correct step in removing and cleaning ahearing aid? 1) Clean only the external surfaces, not the canal portion.2) Clean the top part of the canal portion of the device.3) Insert a wax loop or toothpick into the hearing aid.4) Remove the battery before taking the hearing aid from the ear. ANS: 2 The nurse should clean the top part of the canal portion of the hearing aid using the wax loop and wax brush, cotton-tipped applicator, pipe cleaner, or toothpick.Nothing should be inserted into the hearing aid. The external surfaces are cleaned with a damp cloth.

The hearing aid should be turned off before removing it from the ear, but the battery is not removed at that step of the procedure. It would not likely be possible to remove the battery while the devicewas still in the ear.

PTS: 1 DIF: Difficult REF: pp. 739-742 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 24. The patient is sitting in a chair at the bedside. The nurse is preparing to remove the patients artificial eye. What should the nurse do to best position the patient for this procedure? Ask the patient to: 1) Lean forward and rest the arms on the overbed table.2) Sit

back in the chair and tilt the head back.3) Move to the bed and lie down.4) Stand up and lean over the bed.ANS: 3 The nurse should have the patient lie down so that if the eye is dropped when removing it, it will fall onto the bed instead of the floor. Sitting back in the chairwould allow access to the eye but would not protect the artificial eye from fallingto the floor. Leaning forward and resting the arms on an overbed table, as well as standing up and leaning over the bed, would not provide the nurse access to the eye to remove the prosthesis.

PTS: 1 DIF: Moderate REF: p. 739 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which area(s) should the nurse inspect when assessing for cyanosis in adarkskinned patient? Select all that apply.

1) Buccal mucosa2) Around the lips3) Palms4) Tongue ANS: 1, 3, 4 In dark-skinned people, cyanosis can be best assessed by examining the palmsof the hands, soles of the feet, tongue, conjunctivae, or the buccal mucosa. In light-skinned people, the nailbeds and the area around the lips can be used.

PTS: 1 DIF: Moderate REF: p. 689 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 2. Which of the following is/are a benefit of bathing? Choose all that apply.1) Constricts blood vessels2) Increases depth of respirations3) Gives opportunity for assessments4) Reduces sensory inputANS: 2, 3 Bathing presents an opportunity to perform a variety of assessments. Bathingalso dilates blood vessels near the skins surface, increasing circulation.

Moreover, bathing stimulates the depth of respirations and provides sensoryinput. PTS: 1 DIF: Easy REF: p. 690 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 3. For which patient(s) should the nurse avoid using back massage? Onewho (select all that apply): 1) underwent heart surgery 3 days ago.2) sustained rib fractures from a fall.3) underwent a lumbar laminectomy.4) sustained a leg fracture in a sledding accident.ANS: 1, 2 Back massage is contraindicated with rib fractures, burns, and recent heart surgery. Massage is acceptable for the patients with lumbar laminectomy or legfracture.

PTS: 1 DIF: Moderate REF: p. 690 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application Completion 1. The nurse is making an occupied bed. Arrange the following steps in the orderin which the nurse should perform them.

A. Position the patient laterally near the side rail farthest from you (that side railis up); roll the soiled linens under him.

B. Lower the side rail on the side of the bed you are working on.

C. Raise the side rail on the side of the bed you are working on.

D. After placing clean linens and tucking them under the soiled linens, roll the patient over the hump and position him facing you on the near side of the bed.ANS: B, A, D, C First lower the side rail on your side of the bed. This allows you to maintain goodbody mechanics while positioning the patient. Position the patient laterally near the far side rail, and roll soiled linens under him. Then place clean linens on the side nearest you, and tuck them under soiled linens.

Next, roll the patient over the hump, and position him on his other side, facing you. Do this before raising the near side rail so you do not have to reach across the side rail to help thepatient roll and turn to his other side.

PTS: 1 DIF: Difficult REF: pp. 736-738 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application

Chapter 23. Administering Medications Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The primary care provider prescribes furosemide 40 mg IV for a patient with heart failure. Which drug name is used in this prescription?

1)Chemical 2) Brand 3) Trade 4) Generic ANS: 4 Furosemide, the generic name, was used by the physician in the drug order. The brand or trade name of the drug is Lasix; the chemical name is 4-chloro-N- furfuryl-5- sulfamoylanthranilic acid.

PTS:1DIFifficult REF:p. 746 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension 2. A patient is prescribed fluoxetine 20 mg by mouth daily for treatment of depression.

The nurse caring for the patient is unfamiliar with this drug. Which action should she take before administering the medication?

1) Inform the prescriber that she is not comfortable administering the drug.2) Ask a nursing colleague for relevant information about the drug.3) Consult the drug formulary accessible to staff at the patient care unit.4) Trust the prescriber writes the dose and administer the drug as intended.ANS: 3 The nurse is responsible for every medication she administers. Therefore, the nurse must be familiar with the indications, routes of administration, dosages, contraindications, adverse reactions, drug interactions, and any special administration guidelines associated with each drug before administration.

There are numerous ways to become more informed about medication, such asa drug formulary, Physicians Desk Reference, or registered pharmacist before administration. The nurse should not rely on information from a colleague because as a secondary source of information, there is a risk for inaccuracy, which can be dangerous in a patient care situation.

PTS:1DIF:ModerateREF:pp. 746-747 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 3. A surgeon prescribes potassium chloride 20 mEq by mouth for a patientwith a nasogastric (NG) tube for gastric drainage. How should the nurse proceed?

1) Seek clarification from the surgeon about the medication order.2) Clamp the NG tube while administering the dose by mouth.3) Instill the medication through the NG tube.4) Withhold the oral potassium chloride elixir.ANS: 1 The nurse should seek clarification from the surgeon about the medication ordered via the

nasogastric route. If the patient has a nasogastric tube in placeto release gastric drainage, any medication given by mouth would be lost into the drainage collection unit and, therefore, be unavailable to the patient for therapeutic use. The nurse does not have authority to electively withhold or alter the route of prescribed treatment without seeking clarification and resolving any discrepancy in the route by which the medication would be administered.

PTS: 1 DIF: Moderate REF: pp. 750, 767 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 4. A patient calls the nurse because he is having incision pain and wants adose of analgesic medication. When the nurse checks the patients medication administration record, she notes that he is prescribed the narcotic, hydromorphone (Dilaudid). Where should the nurse expect to retrieve this drugfor administration?

1) Cabinet in the patients room2) Doublelocked medication drawer3) Stock supply cabinet4) Portable medication cartANS: 2 Hydromorphone (Dilaudid) is a controlled substance and must be kept in a double- locked medication drawer for control of inventory. Frequently used Schedule II medications, such as ibuprofen, are stored in the stock supply. Otherprescribed medications may be stored in a locked cabinet in the patients room or in the medication cart.

PTS:1DIF:ModerateREF:pp. 747-748 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 5. Which term refers to the movement of a drug from the site ofadministration to the bloodstream?

1) Absorption2) Distribution3) Metabolism4) ExcretionANS: 1 Absorption refers to the movement of drug from the site of administration into the bloodstream.

Distribution involves the transport of the drug in body fluids, such as blood, to the tissues and organs. Metabolism is the biotransformation of the drug into a more water-soluble form or into metabolites that can be excretedfrom the body.

Excretion, or the removal of drugs from the body, takes place in the kidneys, liver and gastrointestinal tract, lungs, and exocrine glands.

PTS:1DIF:ModerateREF:p. 749 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 6. A patient who just returned from the postanesthesia care unit is complaining of severe incision pain. Which drug contained in his medicationadministration record will offer him the fastest relief?

1)

Liquid acetaminophen with codeine2) Intravenous morphine sulfate3) Intramuscular meperidine4) Oral oxycodone tabletsANS: 2 Drugs administered by the intravenous route are injected directly into the bloodstream and do not have to be absorbed into it. Therefore, they act morequickly than drugs administered by the oral or intramuscular routes.

PTS: 1 DIF: Moderate REF: pp. 750-753 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 7. The time it takes for drug concentration to reach a therapeutic level inthe blood is known as: 1) peak action.2) duration of action.3) onset of action.4) halflife.ANS: 3 The onset of action is the time needed for drug concentration to reach a high enough level in the blood for its effects to appear. Peak action occurs when the concentration of a medication is highest in the blood. Duration of action is that period when the medication has a pharmacological effect. Half-life is the amountof time required for half of the drug to be eliminated.

PTS:1DIF:ModerateREF:p. 755 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 8. A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects ofthis drug? 1) 0930 2) 1000 3) 1100 4) 1500 ANS: 4 The nurse should no longer see the effects of furosemide around 1500 hours (3:00 p.m.). The effects of oral furosemide should be seen 30 to 60 minutes after administration, which is 0900 (9:30 a.m. in this case). Peak diuresis shouldoccur in 1 to 2 hours, which is 1000 hours (10:00 a.m.) to 1100 (11:00 a.m.) in the scenario above.

PTS:1DIF:EasyREF:p. 755 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 9. Which factor in a patients medical history is most likely to prolong thehalf-life of

certain drugs?

1) Heart disease 2) Liver disease 3)Rheumatoid arthritis 4)Tobacco useANS: 2 Metabolism takes place largely in the liver. If there is a decrease in liver function(e.g., because of liver disease), the drug will be eliminated more slowly, prolonging the drugs half-life.

Tobacco use can increase the elimination of some drugs, decreasing their effectiveness.

PTS:1DIF:ModerateREF:p. 754 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 10. The nurse receives a laboratory report that states her patients digoxinlevel is 1.2 ng/mL; therapeutic range for this drug is 0.5 to 2.0 ng/mL. Which action should the nurse take?

1) Notify the prescriber to reduce the dose.

2) Withhold the next dose of digoxin.

3)Administer the next dose as prescribed.

4)Notify the prescribing healthcare provider to increase the dose.

ANS: 3 Therapeutic range is a range whereby the medication is at a concentration to produce the desired effect. This patients level is within the therapeutic range, so the nurse should administer the next dose as prescribed. The dose should not be increased or decreased because the prescribed dose is producing a level within the therapeutic range. The dose should not be withheld; this action could result in detrimental cardiac effects for the patient.

PTS:1DIFifficultREF:pp. 755-756 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 11. The primary care provider orders peak and trough levels for a patientwho is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough?

1)With the morning routine laboratory studies 2)Approximately 30 minutes before the next dose 3) Two hours after the next dose infuses 4) While the drug infuses ANS: 2 Trough levels are typically obtained approximately 30 minutes before administering the next dose of the drug. Therefore, the trough cannot be collected with the morning routine laboratory studies. The vancomycin peak should be obtained 2 hours after the next dose infuses. Peak level must be measured when absorption is complete. This depends on all the factors that affect absorption. Trough levels would be inaccurate if the specimen is obtainedwhile the drug infuses.

PTS:1DIFifficultREF:p. 756 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 12. Teratogenic drugs should be avoided in which patient population?1)

Pregnant women2) Elderly3) Children4) AdolescentsANS: 1 Drugs that are known to cause developmental defects are termed teratogenic. These drugs are contraindicated during pregnancy because of the likelihood of adverse effects on the embryo or fetus.

PTS:1DIF:EasyREF:p. 756 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall 13. A patient with end-stage cancer is prescribed morphine sulfate toreduce pain. For which effect is this medication prescribed?

1) Supportive 2)Restorative 3)Substitutive 4)Palliative ANS: 4 Morphine was prescribed for its palliative effectsto relieve pain, a symptom of cancer.

Supportive effects support the integrity of body functions until other medications or treatments become effective. Restorative effects return the bodyto or maintain the body at optimal levels of health. Substitutive effects replace either body fluids or a chemical required by the body for improved functioning.

PTS:1DIF:ModerateREF:p. 756 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 14. After receiving diphenhydramine, a patient complains that his mouth isvery dry. This is not uncommon for patients taking this medication. Which drug effect is this patient experiencing?

1) Side effect 2) Adverse reaction 3) Toxic reaction 4)Supportive effectANS: 1 Dry mouth is a side effect of diphenhydramine. Side effects are unintended,often predictable, physiological effects that are well tolerated by patients.

Adverse reactions are harmful, unintended, usually unexpected reactions to a drug administered at a normal dosage. They are commonly more severe than side effects.

Toxic reactions are dangerous, damaging effects to an organ or tissue.

Supportive effects are intended effects that support the integrity of bodyfunctions.

PTS:1DIF:ModerateREF:p. 758 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 15. While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension.Which action should the nurse take first?

1) Administer epinephrine IM.2) Give bolus dose of intravenous fluids.3)

Stop the infusion of medication.4) Prepare for endotracheal intubation.ANS: 3 The patient is experiencing an anaphylactic reaction (severe shortness of breath, wheezing, and severe hypotension), a life-threatening allergic reaction.Therefore, the nurse should immediately discontinue the medication. The first priority is to eliminate the cause of the problem. Next, the nurse should notify the physician, give IV fluids, and administer epinephrine, steroids, and diphenhydramine. Respiratory support ranging from oxygen to endotracheal intubation and mechanical ventilation may also be necessary.

PTS:1DIFifficultREF:p. 759 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 16. A patient develops urticaria and pruritus 5 days after beginning phenytoin for treatment of seizures. Which type of reaction is the patient mostlikely experiencing?

1) Mild adverse reaction 2) Dose-related adverse reaction 3) Toxic reaction 4)Anaphylactic reaction ANS: 1 Urticaria and pruritus are considered minor adverse reactions. Dose-related adverse reactions are undesired effects that result from known pharmacologicaleffects of the medication. Toxic reactions are dangerous, damaging effects to anorgan or tissue.

Anaphylactic reaction is a life-threatening allergic reaction that occurs during or immediately after administration.

PTS:1DIFifficultREF:p. 758 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 17. Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extendedtime. The nurse suspects an interaction with herbal medications. What type of interaction does she suspect?

1) Antagonistic drug interaction 2.) Synergistic drug interaction 3)Idiosyncratic reaction 4) Drug incompatibility ANS: 1 In an antagonistic drug interaction, one drug interferes with the actions of another and decreases the resultant drug effect. In a synergistic drug interaction, there is an additive effect; that is, the effects of both drugs combined are greater than the individual effects. An idiosyncratic reaction is anunexpected, abnormal, or peculiar response to a medication. Drug incompatibilities occur when drugs are physically mixed together, causing a chemical deterioration of one or both drugs.

PTS:1DIF:ModerateREF:p. 759 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis 18. A patient with terminal cancer requires increasing doses of an opioidpain medication to obtain relief from pain. This patient is exhibiting signs of drug: 1)Abuse

2) Misuse 3)Tolerance 4.) DependenceANS: 3 Patients in the terminal stages of cancer commonly exhibit drug tolerance, a decreasing response to repeated doses of a medication. Therefore, pain management must be carefully planned to promote patient comfort. Drug abuseis the inappropriate intake of a substance continually or periodically. Drug misuse is the nonspecific, indiscriminate, or improper use of drugs, including alcohol, over-the-counter preparations, and prescription drugs. Drug dependence occurs when a person relies on or needs a drug.

Dependence leads to lifestyle changes that focus around obtaining and administering the drug.

PTS:1DIF:ModerateREF:p. 760 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 19. Before administering a medication, the nurse must verify the rights of medication administration, which include: 1) right patient, right room, right drug, right route, right dose, and right time.

2) right drug, right dose, right route, right time, right physician, and rightdocumentation.

3) right patient, right drug, right route, right time, right documentation, and right equipment.

4) right patient, right drug, right dose, right route, right time, and rightdocumentation. ANS: 4 The six rights of medication administration are the right patient, right drug, rightdose, right route, right time, and right documentation.

PTS: 1 DIF: Moderate REF: pp. 771-773 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 20. Which expected outcome is best for a patient with a nursing diagnosisof Deficient Knowledge related to new drug treatment regimen?

1) After an explanation and written materials, describes the expected actions andadverse reactions of his medication 2) In 1 week after instructional session, describes the expected actions andadverse reactions of his medications 3) Follows the treatment plan as prescribed4) Experiences no adverse effect from his prescribed treatment plan ANS: 2 The best phrasing for the expected outcome is the one with a specific, measurable time frame (1 week) and details for how to resolve the patients knowledge deficit. The other options provide no timeline for achieving the goaland are therefore not measurable.

Expected outcome statements must be measurable.

PTS:1DIF:Moderate REF:p. 770; Also requires knowledge of goals, from Chapter 5 1) KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 21. When the nurse enters a patients room to administer a medication, hecalls out from

the bathroom telling her to leave his medication on the bedside table. He reassures her that he will take the medication as soon as he is finished. How should the nurse proceed?

1) Inform the patient that she will return when he is finished in the bathroom.2) Wait outside the bathroom door until the patient is ready for the dose.3) Withhold the dose until the next administration time later in the day.4) Document that the dose was omitted in the medication administration record.ANS: 1 The nurse should inform the patient that she will return with the medication when he is finished in the bathroom. The nurse likely would not have time to stand outside the door and wait for the patient to finish in the bathroom. If the medication is left at the bedside for the patient, the nurse cannot be sure that the patient actually took the medication.

Withholding the dose until the next administration time may compromise the patients condition and is not appropriate nursing action. The drug should not be omitted; therefore, the nurseshould not document a missed dose in the medication administration record.

PTS:1DIF:ModerateREF:pp. 771-772 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 22. Which documentation entry related to PRN medication administration is complete?

1.)6/5/14 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8on a 110 scale, J. Williams RN 2) 0600 famotidine 20 mg IV given in right hand, S. Abraham RN 3) 9/2/14 0900 levothyroxine 50 mcg PO given4) 1/16/14 furosemide 40 mg PO given, J. Smith RNANS: 1 The longest option, signed by J. Williams, is complete because it contains the date and time the medication was administered, the name of the medication, the route of administration and injection site, and the name of the nurse administering the medication. Because the medication administered was a PRN order, the nurse also included the reason why the medication was administered.Other options are incomplete. PTS:1DIF:ModerateREF:pp. 772-773 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 23. A patient has difficulty taking liquid medications from a cup. How shouldthe nurse administer the medications?

1) Request that the prescriber change the order to the IV route.

2)Administer the medication by the IM route.

Use a needleless syringe to place the medication in the side of the mouth.4) Add the dose to a small amount of food or beverage to facilitate swallowing.ANS: 3 When a patient has difficulty taking liquid medications from a cup, the nurse should use a syringe without a needle to place the medication in the side of the patients mouth.

After placing the syringe between the gum and cheek, the nurseshould push the plunger to administer the medication slowly. It is not necessary to ask the prescriber to change the order to the IV route; it is preferable to use the least invasive route. The nurse cannot administer a drug by another route without a prescription to do so. Dosing might not necessarily be the same between oral and IM routes; thus, a prescription is needed to change the route. Some drugs are not compatible with various food or liquid substances and should be taken on an empty stomach. Consult a pharmacist, prescriber, or drug formulary.

PTS:1DIF:Moderate REF:pp. 774-775; under Special Situations. Inductive reasoning needed todetermine correct answer.

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 24. The primary care provider prescribes nitroglycerin 1/150 g SL for a patient experiencing chest pain. How should the nurse administer the drug?

1) Place the drug in the cheek and allow it to dissolve.2) Place the drug under the tongue and allow it to dissolve.

3)Inject the drug superficially into the subcutaneous tissue.4) Give the pill and water to the patient for him to swallow the tablet.ANS: 2 Drugs administered by the sublingual (SL) route should be placed under the patients tongue and allowed to dissolve. Drugs administered by the buccal routeare placed in the cheek and allowed to dissolve. A subcutaneous injection is administered into the subcutaneous tissue.

Placing the drug into the patients mouth, giving him water, and instructing him to swallow the tablet describe oral administration.

PTS: 1 DIF: Moderate REF: p. 800 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 25. Which action should the nurse take immediately after administering a medication through a nasogastric tube?

1) Verify correct nasogastric tube placement in the stomach.2) Auscultate the abdomen for presence of bowel sounds.3) Immediately administer the next prescribed medication.4) Flush the tube with water using a needleless syringe.ANS: 4 The nurse should flush the nasogastric tube with water using a needleless syringe after administering each medication. Some medications are less effective when given in combination with others. The nurse should verify nasogastric tube placement and auscultate the abdomen for bowel soundsbefore administering the medication.

PTS: 1 DIF: Moderate REF: p. 801 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 26. How should the nurse dispose of a contaminated needle afteradministering an injection?

1) Place the needle in a specially marked, puncture-proof container.2) Recap the needle, and carefully place it in the trash can.3) Recap the needle, and place it in a puncture-proof container.4) Place the needle in a biohazard bag with other contaminated supplies.ANS: 1 To avoid needlestick injuries, the nurse should place the uncapped needle, pointing downward, directly into a specially marked, puncture-proof container. Recapping the needle should only be done when no other feasible alternative is available. When recapping is necessary, use an acceptable technique such as the one-handed scoop technique in which the nurse places the needle cap on a sterile surface and, using one hand, scoops up the cap with the needle. Placing the needle in an improper container (biohazard bag) that could be punctured bythe contaminated needle places other staff members at risk.

PTS:1DIF:ModerateREF:pp. 785, 819

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 27. The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly to a 3day-old infant born to an HB Ag-positive mother. Whichinjection site should the nurse choose to administer this injection?

1)Ventrogluteal2) Vastus lateralis3) Deltoid4) DorsoglutealANS: 2 The preferred site for IM injections for infants who are not yet walking is the vastus lateralis muscle because there are no major blood vessels or nerves in the area and the gluteal muscles have not been developed by walking. For children who are walking, the site of choice is the ventrogluteal muscle. The dorsogluteal site is not recommended for children or adults. The deltoid musclecan be used for small volumes in older children and adults.

PTS: 1 DIF: Moderate REF: p. 787 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 28. Which action should the nurse take to relax the vastus lateralis musclebefore administering an intramuscular injection into the site?

22 Apply a warm compress.2) Massage the site in a circular motion.3) Apply a soothing lotion.4) Have the client assume a sitting position.ANS: 4 To relax the vastus lateralis for injection, the nurse should have the patient assume a sitting position or lie flat with his knee slightly flexed. Applying a warmcompress, massaging the site, and applying soothing lotion are inappropriate interventions before administering an IM injection. After injection, massaging thesite can enhance the absorption of medication into the muscle. Applying a warm compress increases circulation to the site, which can also enhance absorption.

This action would be performed after the injection and not before.

PTS:1DIF:ModerateREF:p. 834 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 29. The physician prescribes warfarin 5 mg orally at 1800 for a patient who underwent open reduction and internal fixation of his right hip. After administering the medication, the nurse realizes that she administered a 10 mgtablet instead of the prescribed 5 mg PO. Which of the following actions by the nurse is appropriate?

1) No action is necessary because an extra 5 mg of warfarin is not harmful. Call the prescriber and ask her to change the order to 10 mg.3) Document on the chart that the drug was given and indicate the drug was givenin error. 4) Complete an incident report according to the facilitys policy.ANS: 4 When a medication error is made, the nurse should first check the patient to assess for negative

effects. If she is unfamiliar with the side effects of the medication, she should consult a drug reference, the licensed pharmacist at the institution, or the prescriber.

Next she should verify that she made an error and identify the type. Notify the nurse in charge and the physician. Follow any ordersthe physician prescribes. Document the drug, the dose, site, route, date, and time in the patients healthcare record but do not document that the drug was given in error. Complete an incident report according to the facilitys policy; submit the signed report to the nurse manager. Finally, critically review the error, and identify ways to improve your practice.

PTS: 1 DIF: Moderate REF: p. 769 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level:Application 30. The nurse must administer eardrops to an infant. How should sheproceed? 1) Pull the pinna down and back before instilling the drops.2) Pull the pinna upward and outward before instilling the drops.

Instill the drops directly; no special positioning is necessary.4) Position the patient supine with the head of the bed elevated 30.ANS: 1 For a child younger than 3 years old, the nurse should pull the pinna down and back. For older children and adults, the nurse should pull the pinna upward andoutward.

Doing each straightens the ear canal for proper channeling of the medication. The patient should be assisted into a side-lying position with appropriate ear facing up before instillation.

PTS: 1 DIF: Moderate REF: p. 806 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 31. The nurse is teaching parents ways to give oral medication to theirchild. Which action would they implement to improve compliance?

1) Crush time-release capsules to put in his favorite food.2) Give medication quickly before he knows what is happening.3) Allow the child to eat a frozen pop before receiving the medication.4) Mask the flavor of medication in a toddler cup with orange juice.ANS: 3 The parent can give the child a frozen fruit bar or frozen flavored ice pop just before the medication. This helps to numb the taste buds to weaken the taste ofthe medication.

To mask bad-tasting medicines, parents can crush pills or empty the contents ofa capsule as long as it is not a time-release dose, and mix with soft foods, such as applesauce, hot cereal, or pudding. This is helpful for patients who might aspirate liquids, as well.

If the child is old enough to understand, warn him when a medication has an objectionable taste. Otherwise, his trust might be compromised if he is surprisedwith a bad taste.

Do not use essential foods in the childs diet (e.g., milk or orange juice) to maskthe taste of medications. The child may later refuse a food that he associates with the medicine.

PTS:1DIF:ModerateREF:p. 775 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 32. An adult patient admitted with lower gastrointestinal bleeding is prescribed a unit of packed red blood cells. Which gauge needle should beinserted to administer this blood product?

1)

18 gauge 2) 22 gauge 3) 24 gauge 4) 26 gauge ANS: 1 Large-gauge needles, 14 to 18 gauge, are used for blood products in adults because the bore is large enough to allow transfusion without cell damage (lysis). Smaller-gauge bores can cause clumping and breakage of the cell, thusleading to reduced effectiveness of the transfusion as well as contributing to fragmented by-product of red blood cell waste.

PTS:1DIF:EasyREF:p. 779 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall True/False Indicate whether the statement is true or false.

1. At times, patients may self-administer medications when hospitalized.ANS: T Occasionally, even in the hospital setting, patients self-administer medications, as their condition permits. For example, a patient admitted with chest pain maykeep sublingual nitroglycerin at his bedside so he has quick access should he experience chest pain.

PTS:1DIF:EasyREF:p. 748 KEY:Nursing process: N/A |Client need: PHSI | Cognitive level: Recall Completion 1. The nurse is drawing up a medication from an ampule. Arrange the followingsteps in the order in which they should be performed.

A. Use an ampule opener to break ampule neck.

B. Tap the ampule to remove medication trapped in the top of ampule.

C. Invert the ampule, and draw up the medication.

D. Dispose of the top and bottom of the ampule and filter needle in sharpscontainer.

E. Hold the syringe vertically, and tap it to remove air bubbles.

ANS: B, A, C, E, D

Medication must be removed from the ampule neck before breaking the top offthe ampule.

Otherwise, the dosage may be incorrect. There is no need to remove air bubbles until after the medication is drawn into the syringe. Finally,you would not dispose of the ampule and filter needle until you finish the procedure.

PTS: 1 DIF: Difficult REF: pp. 818-819 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 2. A nurse is administering a medication using a volume-control administrationset (e.g., Buretrol, Volutrol). Arrange the following steps in the order in which they would be performed.

A. Inject the ordered medication into the volume-control chamber.

B. Fill the volume-control chamber with the correct amount of intravenous fluidfrom the primary bag.

C. Cleanse the port on the volume-control chamber.

D. Prime the volume-control tubing.

E. Open the lower clamp and start the infusion at the correct flow rate.

ANS: B, D, C, A, E You must fill the volume-control chamber before injecting the medication so youcan prime the tubing without the risk of wasting medication. You must cleanse the port on the volume-control chamber before injecting the medication into it. The last thing you do is open the clamp and start the infusion.

PTS:1DIFifficultREF:p. 845 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis

Chapter 24. Nutrition Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which food provides the body with no usable glucose?

1)Wheat germ 2) Apple 3) White bread 4)White rice ANS: 1 Dietary fiber, such as wheat germ, contains no usable glucose. Apples, white bread, and white rice all contain carbohydrates, which provide usable glucose.

PTS: 1 DIF: Easy REF: p. 902; does not specify wheat germ, just indicates thatfiber provides no glucose.

KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 2. Which organ relies almost exclusively on glucose for energy?

1) Liver 2)Heart 3) Pancreas 4) Brain ANS: 4 The brain relies almost exclusively on glucose for energy. The heart and liver donot. The pancreas produces insulin for glucose utilization but does not use glucose.

PTS:1DIF:Easy REF: p. 902; ESG, Chapter 28, Supplemental Materials, Dietary Reference Intake: Macronutrients KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall 3. A patient with type 1 diabetes mellitus is admitted with hyperglycemia and associated acidosis. The presence of which alternative fuel in the body is responsible for the acidosis?

1)Glycogen 2) Insulin 3) Ketones 4) Proteins ANS: 3 When fats are converted to ketones for use as alternative fuel, as in diabetic ketoacidosis when glucose cannot by used by the cells, the acidity of the blood rises, leading to the acidosis.

Glycogen is converted to glucose to meet energy needs. Insulin, a pancreatic hormone, promotes the movement of glucose into cells for use. Proteins would not be used for fuel as long as fats were available.

PTS:1DIFifficultREF:pp. 902, 925 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

4. Which patient is most likely experiencing positive nitrogen balance? A patient admitted: 1)With third-degree burns of his legs.

2)In the sixth month of a healthy pregnancy.

3)From a nursing home who has been refusing to eat.

4) With acute pancreatitis.

ANS: 2 A positive nitrogen balance typically exists during pregnancy when new tissues are being formed. Patients with burns, malnutrition, and serious illness commonly experience negative nitrogen balance because tissues are lost.

PTS:1DIF:ModerateREF:p. 902 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 5. Which polysaccharide is stored in the liver?

1)Insulin 2) Ketones 3)Glycogen 4)Glucose ANS: 3 Humans store glucose in the liver as polysaccharides, known as glycogen. Glycogen can then be converted back into glucose to meet energy needs through a process known as glycogenolysis. If fats must be used for energy, they are converted directly into ketones.

Insulin is a pancreatic hormone that promotes the movement of glucose into cells.

PTS: 1 DIF: Moderate REF: p. 902 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 6. While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. She emphasizes that doing so greatly reduces the risk of which complication?

1)Kidney failure 2) Liver failure 3) Stroke 4)Lung cancer ANS: 3 Replacing saturated fats in the diet with mono- and polyunsaturated fats reduces the risk of heart disease, atherosclerosis, and stroke, not kidney failure,liver failure, or lung cancer.

PTS:1DIF:ModerateREF:p. 903 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application

7. Patients may be deficient in which vitamin during the winter months?

1) A 2)D 3)E 4)K ANS: 2 The body can synthesize vitamin D from a cholesterol compound in the skin when exposed to adequate sunlight. People at risk for vitamin D deficiency are those who spend little time outdoors, older people, and people who live in an institution (e.g., a nursing home). The deficiency can also occur in the winter at northern and southern latitudes, in people who keep their bodies covered (e.g., traditional Muslim women), and in those who use sunscreen. Also, because breast milk contains only small amounts of vitamin D, breastfed infants who are not exposed to enough sunlight are at risk of the deficiency and rickets. There isno seasonal tie to deficiencies in the other fat-soluble vitamins, A, E, and K. PTS: 1 DIF: Easy REF: p. 905 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 8. Which nutrient deficiency increases the risk for pressure ulcers?1) Carbohydrate2) Protein3) Fat4) Vitamin KANS: 2 Protein is necessary for growth and maintenance of body tissues. Protein deficiency places the patient at risk for skin breakdown and pressure ulcer formation.

Carbohydrates are the primary fuel of the body. Fat is a source ofenergy and contains essential nutrients. Vitamin K aids blood clotting.

PTS:1DIF:Moderate REF:p. 902; application is based on principle presented KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 9. A patient has anemia. An appropriate goal for that the patient would befor him to increase his intake of which nutrient?

1) Calcium 2)Magnesium 3)Potassium4) Iron ANS: 4 Iron deficiency causes anemia; therefore, the nurse should encourage the patient with anemia to increase his intake of iron. Increasing calcium intake helps prevent osteoporosis.

Magnesium supplementation may decrease the riskof hypertension and coronary artery disease in women. Potassium is essential for muscle contraction, acidbase balance, and blood pressure control.

PTS:1DIF:EasyREF:p. 907 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

10. A patient is brought to the emergency department experiencing leg cramps. He is irritable, his temperature is elevated, and his mucous membranesare dry. Based on these findings, the patient most likely has excess levels of which mineral?

1) Sodium2) Potassium3) Phosphorus4) MagnesiumANS: 1 Signs and symptoms associated with sodium excess include thirst, fever, dryand sticky tongue and mucous membranes, restlessness, irritability, and seizures.

Findings associated with potassium excess include cardiac arrhythmias, weakness, abdominal cramps, diarrhea, anxiety, and paresthesia.Phosphorus excess leads to tetany and seizures. Magnesium excess causes weakness, nausea, and malaise.

PTS:1DIFifficultREF:p. 908 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 11. A patient who was prescribed furosemide (Lasix) is deficient in potassium. Which of the following is an appropriate goal for this patient? Thepatient will increase his consumption of: 1) Bananas, peaches, molasses, and potatoes.2) Eggs, baking soda, and baking powder.3) Wheat bran, chocolate, eggs, and sardines.4) Egg yolks, nuts, and sardines.ANS: 1 Foods rich in potassium include bananas, peaches, molasses, meats, avocados,milk, shellfish, dates, figs, and potatoes. Eggs, baking soda, and baking powderhave high sodium content.

Dairy products, beef, pork, beans, sardines, eggs, chicken, wheat bran, and chocolate are rich in phosphorus. Egg yolks, nuts, sardines, dairy products, broccoli, and legumes are rich in calcium.

PTS:1DIF:ModerateREF:p. 908 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 12. During the day shift, a patients temperature measures 97F (36.1C) orally. At 2000, the patients temperature measures 102F (38.9C). What effectdoes this rise in temperature have on the patients basal metabolic rate?

1) Increases the rate by 7%2) Decreases the rate by 14%3) Increases the rate by 35%4) Decreases the rate by 28%ANS: 3 Basal metabolic rate increases 7% for each degree Fahrenheit (0.56C);therefore, this patients temperature rise is an increase of 35%.

PTS:1DIFifficultREF:p. 910 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application

13. A mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returningto work. Which response by the nurse is appropriate?

1) Make sure you give your baby an iron-fortified formula to supplement any storedbreast milk you have.

2) You really need to continue breastfeeding your baby.3) Give your baby formula until he is 6 months old; then you can introduce wholemilk.

4)Your baby weighs 14 pounds, so he will require about 36 ounces of formula aday. ANS: 1 The nurse should not make the mother feel guilty about her decision to stop breastfeeding.

Instead, she should provide the mother with instruction about bottle feeding. She can give it to supplement any stored breast milk she might have in supply. She should emphasize the importance of giving the baby iron- fortified formula because fetal iron stores become depleted by 4 to 6 months ofage. Infants younger than 1 year of age should not receive regular cows milk because it may place a strain on the immature kidneys. Because the baby weighs 14 pounds, he will require about 21 ounces of formula a day (not 36 ounces), based on the nutritional recommendations that infants require 80 to 100 mL of formula or breast milk per kilogram of body weight per day.

PTS:1DIF:ModerateREF:p. 912 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application 14. After instructing a mother about nutrition for a preschool-age child, which statement by the mother would indicate correct understanding of the topic?

1) I usually use dessert only as a reward for eating other foods.

I will hide vegetables in casseroles and stews to get my child to eat them.3) I do not give my child snacks; they simply spoil his appetite for meals.4) I know that lifelong food habits are developed during this stage of life.ANS: 4 Lifelong food habits are developed during the preschool stage of life. Therefore, the mother should widen the variety of foods she introduces to her child.

Desserts should not be used as rewards for eating other foods. This practice canshape an attitude about food that can lead to eating disorders later in life.

Preschool-age children often refuse combined foods such as casseroles and stews. Because they are active, preschoolers require nutritious between-mealsnacks.

PTS: 1 DIF: Moderate REF: p. 913 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application 15. The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming whichnutrient to prevent neural tube defects?

1) Folic acid2) Calcium3)

Protein Vitamin DANS: 1 The nurse should emphasize the importance of consuming folic acid even before conception to prevent neural tube defects from developing. Calcium and protein needs also increase during pregnancy; however, their consumption does not prevent neural tube defects. Vitamin D consumption does not prevent neural tube defects.

PTS:1DIF:EasyREF:p. 913 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Comprehension 16. A middle-aged patient with a history of alcohol abuse is admitted withacute pancreatitis. This patient will most likely be deficient in which nutrients?

1) Iron 2) B vitamins 3)Calcium 4)Phosphorus ANS: 2 Patients who regularly abuse alcohol may be deficient in many nutrients; however, they are commonly deficient in the B vitamins and folic acid. Vitamin Adeficiency can be associated with night blindness in heavy drinkers; vitamin Ddeficiency leads to softening of the bones.

Because some alcoholics are deficient in vitamins A, C, D, E, and K and the B vitamins, they experience delayed wound healing. In particular, because vitamin K, the vitamin needed for blood clotting, is commonly deficient in those who regularly abuse alcohol, thosepatients can have delayed clotting, resulting in excess bleeding. Deficiencies of other vitamins involved in brain function can cause severe neurological damage.

PTS:1DIF:ModerateREF:p. 915 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 17. A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurseprovide for the patient?

1) Tea with cream2) Orange juice3) Gelatin4) Skim milkANS: 3 A clear liquid diet consists of water; tea (without cream); coffee; broth; clear juices, such as apple, grape, or cranberry; popsicles; carbonated beverages; andgelatin. Skim milk, tea with cream, and orange juice are included in a full liquid diet.

PTS:1DIF:EasyREF:p. 917 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 18. A patient with trigeminal neuralgia is prescribed a mechanical soft diet.This diet places the patient at risk for which complication?

1) Dehydration2) Constipation3) Hyperglycemia4)

DiarrheaANS: 2 Because of its lack of fiber, a mechanical soft diet places the patient at risk for constipation. It does not place the patient at risk for dehydration, hyperglycemia, or diarrhea.

PTS:1DIF:ModerateREF:p. 917 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 19. Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will: 1) Limit his intake of protein.

2) Avoid foods containing gluten.

3) Restrict his use of sodium.

4) Limit his intake of potassium-rich foods.ANS: 3 Patients with hypertension should limit their intake of sodium. Those with liver disease should control their protein intake. Patients with renal disease must limittheir intake of potassium-rich foods. Patients with celiac disease should avoid foods containing gluten. PTS: 1 DIF: Easy REF: p. 917 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 20. The nurse notices that a patient has spoon-shaped, brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less Than BodyRequirements related to deficiency of which of the following nutrients?

1) Iron 2) Vitamin A 3)Protein 4)Vitamin CANS: 1 Patients with iron deficiency may have spoon-shaped, brittle nails. Otherabnormal nail findings include dull nails with transverse ridge (protein eficiency); pale, poor blanching, or mottled nails (vitamin A or C deficiency); splinter hemorrhages (vitamin C deficiency); and bruising or bleeding beneathnails (protein or caloric deficiency).

PTS:1DIFifficultREF:p. 920 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level:Comprehension 21. Which portion of a nutritional assessment must the registered nursecomplete? 1) Analyzing the data2) Obtaining intake and output3) Weighing the patient4) Obtaining the historyANS: 1 The registered nurse should review and interpret (analyze) the data collected aspart of a nutritional assessment. The registered nurse can delegate height, weight, and intake and output to nursing assistive personnel. History taking can be safely delegated to the licensed practical nurse.

PTS:1DIF:ModerateREF:p. 925 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 22. Which laboratory test result most accurately reflects a patientsnutritional status?

Albumin2) Prealbumin3) Transferrin4) HemoglobinANS: 2 Prealbumin levels fluctuate daily and give the best indication of the patients immediate nutritional status. Albumin level is not as accurate because the half- life of albumin is 18 to 21 days, causing a delay in detection of nutritional problems. Transferrin, a protein that binds to iron, has a half-life of 8 to 9 days;therefore, it allows for faster detection of protein deficiency than does albumin. However, transferrin is not as fast as prealbumin. Hemoglobin level reflects ironintake or blood loss.

PTS:1DIF:ModerateREF:p. 925 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 23. A 52-year-old man has a triceps skinfold thickness of 18 mm, and hisweight exceeds the ideal body weight for his height by 23%. Which nursing diagnosis should the nurse identify for this patient?

1) Imbalanced Nutrition: More Than Body Requirements2) Risk for Imbalanced Nutrition: More Than Body Requirements Imbalanced Nutrition: Less Than Body Requirements4) Readiness for Enhanced NutritionANS: 1 This patient has defining characteristics for the nursing diagnosis Imbalanced Nutrition: More Than Body Requirements: triceps skinfold thickness more than 15 mm in men and weight that is 20% over ideal for height and frame. The patient does not have defining characteristics for the other nursing diagnoses.

PTS:1DIF:ModerateREF:p. 929 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 24. A patients 2:1 parenteral nutrition container infuses before the pharmacy prepares the next container. This places the patient at risk for whichcomplication? 1) Sepsis2) Pneumothorax3) Hypoglycemia4) ThrombophlebitisANS: 3 Because of the high glucose content of 2:1 parenteral nutrition, any interruptionin therapy places the patient at risk for hypoglycemia. A PN of this type should not be discontinued abruptly, but rather over several (as many as 48) hours to prevent a sudden drop in blood sugar. Hypoglycemia is unlikely to occur with a 3:1 solution (containing lipids), as the final concentration of glucose is less than10%. Sepsis is a complication that can occur if a break in aseptic technique occurs during therapy.

Pneumothorax can occur as a result of central venous catheter insertion. Central venous catheters are typically employed for parenteral nutrition. Thrombophlebitis is a complication of central venous catheter use.

PTS: 1 DIF: Difficult REF: pp. 959-960

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 25. Which of the following interventions would help to prevent or relievepersistent nausea?

1) Assess for signs of dehydration.2) Provide dietary supplements.3) Have the patient sit in an upright position for 30 minutes after eating.4) Immediately remove any food that the patient cannot eat.ANS: 4 Dehydration can occur as a result of continued nausea and vomiting, so the nurse should assess for it. However, this intervention does not prevent nausea. Dietary supplements might help to prevent malnutrition. However, they do not prevent nausea; in fact, they often cause nausea. Having the patient sit uprighthelps to prevent respiratory aspiration should the patient vomit; it does not prevent or relieve nausea.

Odors (even pleasant ones) and even the sight of food can cause nausea, so any uneaten food should be removed immediatelyfrom the room.

PTS:1DIFifficultREF:p. 928 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. The nurse will evaluate that learning has occurred if the patient recognizes which food(s) as an incomplete protein thatshould be consumed with a complementary protein? Choose all that apply.

1) Whole grain bread 2) Peanut butter 3)Chicken 4)Eggs ANS: 1, 2 Incomplete protein foods do not provide all of the essential amino acids necessary for protein synthesis. Therefore, the nurse should inform the patient that whole grain bread and peanut butter should be consumed with a complementary protein. For example, they could be eaten together as a peanutbutter sandwich.PTS:1DIF:ModerateREF:p. 901 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level:Comprehension 2. The nurse is teaching a patient about the importance of reducing saturated fats in his diet. The nurse will recognize that learning has occurred if,upon questioning, the patient replies that he should read product labels to eliminate the intake of which saturated fat(s)?

Choose all that apply.

1) Palm oil2) Coconut oil3) Canola oil4)

Peanut oilANS: 1, 2 Palm and coconut oils are sources of saturated fat that are contained in many processed foods.

The patient should be encouraged to read product labels to eliminate them from his diet. Olive, canola, and peanut oils are unsaturated fatsand should be substituted for saturated fats in the diet.

PTS: 1 DIF: Moderate REF: p. 901 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level:Comprehension 3. Which instruction(s) should the nurse give to the patient complaining of constipation? Choose all that apply.

1) Drink at least eight glasses of water or non-caffeinated fluid per day.2) Include a minimum of four servings of meat per day.3) Consume a high-fiber diet.4) Exercise as you feel necessary.ANS: 1, 3 To prevent constipation, the nurse should instruct the patient to consume a high-fiber diet, drink at least eight glasses of water or non-caffeinated fluid per day, exercise regularly, and eat meals on a regular schedule. Caffeine can aggravate constipation. PTS:1DIF:ModerateREF:p.

929 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 4. Where in the body is glucose stored? Choose all that apply.1) Brain2) Liver3) Skeletal muscles4) Smooth muscles ANS: 2, 3 Human beings store glucose in liver and skeletal muscle tissue as glycogen.Glycogen is converted back into glucose to meet energy needs.

PTS:1DIF:ModerateREF:p. 902 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 5. For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements related to Impaired Swallowing, which nursing interventions areappropriate? Choose all that apply.

1) Check inside the mouth for pocketing of food after eating.2) Provide a full liquid diet that is easy to swallow.3) Remind the patient to raise the chin slightly to prepare for swallowing.4) Keep the head of the bed elevated for 30 to 45 minutes after feeding.ANS: 1, 4 The nurse should check for pocketing of food that the patient has not been ableto swallow, and should keep the head of the bed elevated for 30 to 45 minutes after feeding. Liquids should be avoided unless thickeners are added. The patient should flex the head forward (tuck the chin) in preparation for swallowing.

PTS:1DIF:ModerateREF:pp. 927-928 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application

Chapter 24. Nutrition Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which food provides the body with no usable glucose?

1)Wheat germ 2) Apple 3) White bread 4)White rice ANS: 1 Dietary fiber, such as wheat germ, contains no usable glucose. Apples, white bread, and white rice all contain carbohydrates, which provide usable glucose.

PTS: 1 DIF: Easy REF: p. 902; does not specify wheat germ, just indicates thatfiber provides no glucose.

KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 2. Which organ relies almost exclusively on glucose for energy?

1) Liver 2)Heart 3) Pancreas 4) Brain ANS: 4 The brain relies almost exclusively on glucose for energy. The heart and liver donot. The pancreas produces insulin for glucose utilization but does not use glucose.

PTS:1DIF:Easy REF: p. 902; ESG, Chapter 28, Supplemental Materials, Dietary Reference Intake: Macronutrients KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall 3. A patient with type 1 diabetes mellitus is admitted with hyperglycemia and associated acidosis. The presence of which alternative fuel in the body is responsible for the acidosis?

1)Glycogen 2) Insulin 3) Ketones 4) Proteins ANS: 3 When fats are converted to ketones for use as alternative fuel, as in diabetic ketoacidosis when glucose cannot by used by the cells, the acidity of the blood rises, leading to the acidosis.

Glycogen is converted to glucose to meet energy needs. Insulin, a pancreatic hormone, promotes the movement of glucose into cells for use. Proteins would not be used for fuel as long as fats were available.

PTS:1DIFifficultREF:pp. 902, 925 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

4. Which patient is most likely experiencing positive nitrogen balance? A patient admitted: 1)With third-degree burns of his legs.

2)In the sixth month of a healthy pregnancy.

3)From a nursing home who has been refusing to eat.

4) With acute pancreatitis.

ANS: 2 A positive nitrogen balance typically exists during pregnancy when new tissues are being formed. Patients with burns, malnutrition, and serious illness commonly experience negative nitrogen balance because tissues are lost.

PTS:1DIF:ModerateREF:p. 902 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 5. Which polysaccharide is stored in the liver?

1)Insulin 2) Ketones 3)Glycogen 4)Glucose ANS: 3 Humans store glucose in the liver as polysaccharides, known as glycogen. Glycogen can then be converted back into glucose to meet energy needs through a process known as glycogenolysis. If fats must be used for energy, they are converted directly into ketones.

Insulin is a pancreatic hormone that promotes the movement of glucose into cells.

PTS: 1 DIF: Moderate REF: p. 902 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 6. While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. She emphasizes that doing so greatly reduces the risk of which complication?

1)Kidney failure 2) Liver failure 3) Stroke 4)Lung cancer ANS: 3 Replacing saturated fats in the diet with mono- and polyunsaturated fats reduces the risk of heart disease, atherosclerosis, and stroke, not kidney failure,liver failure, or lung cancer.

PTS:1DIF:ModerateREF:p. 903 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application

7. Patients may be deficient in which vitamin during the winter months?

1) A 2)D 3)E 4)K ANS: 2 The body can synthesize vitamin D from a cholesterol compound in the skin when exposed to adequate sunlight. People at risk for vitamin D deficiency are those who spend little time outdoors, older people, and people who live in an institution (e.g., a nursing home). The deficiency can also occur in the winter at northern and southern latitudes, in people who keep their bodies covered (e.g., traditional Muslim women), and in those who use sunscreen. Also, because breast milk contains only small amounts of vitamin D, breastfed infants who are not exposed to enough sunlight are at risk of the deficiency and rickets. There isno seasonal tie to deficiencies in the other fat-soluble vitamins, A, E, and K. PTS: 1 DIF: Easy REF: p. 905 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 8. Which nutrient deficiency increases the risk for pressure ulcers?1) Carbohydrate2) Protein3) Fat4) Vitamin KANS: 2 Protein is necessary for growth and maintenance of body tissues. Protein deficiency places the patient at risk for skin breakdown and pressure ulcer formation.

Carbohydrates are the primary fuel of the body. Fat is a source ofenergy and contains essential nutrients. Vitamin K aids blood clotting.

PTS:1DIF:Moderate REF:p. 902; application is based on principle presented KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 9. A patient has anemia. An appropriate goal for that the patient would befor him to increase his intake of which nutrient?

1) Calcium 2)Magnesium 3)Potassium4) Iron ANS: 4 Iron deficiency causes anemia; therefore, the nurse should encourage the patient with anemia to increase his intake of iron. Increasing calcium intake helps prevent osteoporosis.

Magnesium supplementation may decrease the riskof hypertension and coronary artery disease in women. Potassium is essential for muscle contraction, acidbase balance, and blood pressure control.

PTS:1DIF:EasyREF:p. 907 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

10. A patient is brought to the emergency department experiencing leg cramps. He is irritable, his temperature is elevated, and his mucous membranesare dry. Based on these findings, the patient most likely has excess levels of which mineral?

1) Sodium2) Potassium3) Phosphorus4) MagnesiumANS: 1 Signs and symptoms associated with sodium excess include thirst, fever, dryand sticky tongue and mucous membranes, restlessness, irritability, and seizures.

Findings associated with potassium excess include cardiac arrhythmias, weakness, abdominal cramps, diarrhea, anxiety, and paresthesia.Phosphorus excess leads to tetany and seizures. Magnesium excess causes weakness, nausea, and malaise.

PTS:1DIFifficultREF:p. 908 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 11. A patient who was prescribed furosemide (Lasix) is deficient in potassium. Which of the following is an appropriate goal for this patient? Thepatient will increase his consumption of: 1) Bananas, peaches, molasses, and potatoes.2) Eggs, baking soda, and baking powder.3) Wheat bran, chocolate, eggs, and sardines.4) Egg yolks, nuts, and sardines.ANS: 1 Foods rich in potassium include bananas, peaches, molasses, meats, avocados,milk, shellfish, dates, figs, and potatoes. Eggs, baking soda, and baking powderhave high sodium content.

Dairy products, beef, pork, beans, sardines, eggs, chicken, wheat bran, and chocolate are rich in phosphorus. Egg yolks, nuts, sardines, dairy products, broccoli, and legumes are rich in calcium.

PTS:1DIF:ModerateREF:p. 908 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 12. During the day shift, a patients temperature measures 97F (36.1C) orally. At 2000, the patients temperature measures 102F (38.9C). What effectdoes this rise in temperature have on the patients basal metabolic rate?

1) Increases the rate by 7%2) Decreases the rate by 14%3) Increases the rate by 35%4) Decreases the rate by 28%ANS: 3 Basal metabolic rate increases 7% for each degree Fahrenheit (0.56C);therefore, this patients temperature rise is an increase of 35%.

PTS:1DIFifficultREF:p. 910 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application

13. A mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returningto work. Which response by the nurse is appropriate?

1) Make sure you give your baby an iron-fortified formula to supplement any storedbreast milk you have.

2) You really need to continue breastfeeding your baby.3) Give your baby formula until he is 6 months old; then you can introduce wholemilk.

4)Your baby weighs 14 pounds, so he will require about 36 ounces of formula aday. ANS: 1 The nurse should not make the mother feel guilty about her decision to stop breastfeeding.

Instead, she should provide the mother with instruction about bottle feeding. She can give it to supplement any stored breast milk she might have in supply. She should emphasize the importance of giving the baby iron- fortified formula because fetal iron stores become depleted by 4 to 6 months ofage. Infants younger than 1 year of age should not receive regular cows milk because it may place a strain on the immature kidneys. Because the baby weighs 14 pounds, he will require about 21 ounces of formula a day (not 36 ounces), based on the nutritional recommendations that infants require 80 to 100 mL of formula or breast milk per kilogram of body weight per day.

PTS:1DIF:ModerateREF:p. 912 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application 14. After instructing a mother about nutrition for a preschool-age child, which statement by the mother would indicate correct understanding of the topic?

1) I usually use dessert only as a reward for eating other foods.

I will hide vegetables in casseroles and stews to get my child to eat them.3) I do not give my child snacks; they simply spoil his appetite for meals.4) I know that lifelong food habits are developed during this stage of life.ANS: 4 Lifelong food habits are developed during the preschool stage of life. Therefore, the mother should widen the variety of foods she introduces to her child.

Desserts should not be used as rewards for eating other foods. This practice canshape an attitude about food that can lead to eating disorders later in life.

Preschool-age children often refuse combined foods such as casseroles and stews. Because they are active, preschoolers require nutritious between-mealsnacks.

PTS: 1 DIF: Moderate REF: p. 913 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application 15. The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming whichnutrient to prevent neural tube defects?

1) Folic acid2) Calcium3)

Protein Vitamin DANS: 1 The nurse should emphasize the importance of consuming folic acid even before conception to prevent neural tube defects from developing. Calcium and protein needs also increase during pregnancy; however, their consumption does not prevent neural tube defects. Vitamin D consumption does not prevent neural tube defects.

PTS:1DIF:EasyREF:p. 913 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Comprehension 16. A middle-aged patient with a history of alcohol abuse is admitted withacute pancreatitis. This patient will most likely be deficient in which nutrients?

1) Iron 2) B vitamins 3)Calcium 4)Phosphorus ANS: 2 Patients who regularly abuse alcohol may be deficient in many nutrients; however, they are commonly deficient in the B vitamins and folic acid. Vitamin Adeficiency can be associated with night blindness in heavy drinkers; vitamin Ddeficiency leads to softening of the bones.

Because some alcoholics are deficient in vitamins A, C, D, E, and K and the B vitamins, they experience delayed wound healing. In particular, because vitamin K, the vitamin needed for blood clotting, is commonly deficient in those who regularly abuse alcohol, thosepatients can have delayed clotting, resulting in excess bleeding. Deficiencies of other vitamins involved in brain function can cause severe neurological damage.

PTS:1DIF:ModerateREF:p. 915 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 17. A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurseprovide for the patient?

1) Tea with cream2) Orange juice3) Gelatin4) Skim milkANS: 3 A clear liquid diet consists of water; tea (without cream); coffee; broth; clear juices, such as apple, grape, or cranberry; popsicles; carbonated beverages; andgelatin. Skim milk, tea with cream, and orange juice are included in a full liquid diet.

PTS:1DIF:EasyREF:p. 917 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 18. A patient with trigeminal neuralgia is prescribed a mechanical soft diet.This diet places the patient at risk for which complication?

1) Dehydration2) Constipation3) Hyperglycemia4)

DiarrheaANS: 2 Because of its lack of fiber, a mechanical soft diet places the patient at risk for constipation. It does not place the patient at risk for dehydration, hyperglycemia, or diarrhea.

PTS:1DIF:ModerateREF:p. 917 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 19. Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will: 1) Limit his intake of protein.

2) Avoid foods containing gluten.

3) Restrict his use of sodium.

4) Limit his intake of potassium-rich foods.ANS: 3 Patients with hypertension should limit their intake of sodium. Those with liver disease should control their protein intake. Patients with renal disease must limittheir intake of potassium-rich foods. Patients with celiac disease should avoid foods containing gluten. PTS: 1 DIF: Easy REF: p. 917 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 20. The nurse notices that a patient has spoon-shaped, brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less Than BodyRequirements related to deficiency of which of the following nutrients?

1) Iron 2) Vitamin A 3)Protein 4)Vitamin CANS: 1 Patients with iron deficiency may have spoon-shaped, brittle nails. Otherabnormal nail findings include dull nails with transverse ridge (protein eficiency); pale, poor blanching, or mottled nails (vitamin A or C deficiency); splinter hemorrhages (vitamin C deficiency); and bruising or bleeding beneathnails (protein or caloric deficiency).

PTS:1DIFifficultREF:p. 920 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level:Comprehension 21. Which portion of a nutritional assessment must the registered nursecomplete? 1) Analyzing the data2) Obtaining intake and output3) Weighing the patient4) Obtaining the historyANS: 1 The registered nurse should review and interpret (analyze) the data collected aspart of a nutritional assessment. The registered nurse can delegate height, weight, and intake and output to nursing assistive personnel. History taking can be safely delegated to the licensed practical nurse.

PTS:1DIF:ModerateREF:p. 925 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 22. Which laboratory test result most accurately reflects a patientsnutritional status?

Albumin2) Prealbumin3) Transferrin4) HemoglobinANS: 2 Prealbumin levels fluctuate daily and give the best indication of the patients immediate nutritional status. Albumin level is not as accurate because the half- life of albumin is 18 to 21 days, causing a delay in detection of nutritional problems. Transferrin, a protein that binds to iron, has a half-life of 8 to 9 days;therefore, it allows for faster detection of protein deficiency than does albumin. However, transferrin is not as fast as prealbumin. Hemoglobin level reflects ironintake or blood loss.

PTS:1DIF:ModerateREF:p. 925 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 23. A 52-year-old man has a triceps skinfold thickness of 18 mm, and hisweight exceeds the ideal body weight for his height by 23%. Which nursing diagnosis should the nurse identify for this patient?

1) Imbalanced Nutrition: More Than Body Requirements2) Risk for Imbalanced Nutrition: More Than Body Requirements Imbalanced Nutrition: Less Than Body Requirements4) Readiness for Enhanced NutritionANS: 1 This patient has defining characteristics for the nursing diagnosis Imbalanced Nutrition: More Than Body Requirements: triceps skinfold thickness more than 15 mm in men and weight that is 20% over ideal for height and frame. The patient does not have defining characteristics for the other nursing diagnoses.

PTS:1DIF:ModerateREF:p. 929 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 24. A patients 2:1 parenteral nutrition container infuses before the pharmacy prepares the next container. This places the patient at risk for whichcomplication? 1) Sepsis2) Pneumothorax3) Hypoglycemia4) ThrombophlebitisANS: 3 Because of the high glucose content of 2:1 parenteral nutrition, any interruptionin therapy places the patient at risk for hypoglycemia. A PN of this type should not be discontinued abruptly, but rather over several (as many as 48) hours to prevent a sudden drop in blood sugar. Hypoglycemia is unlikely to occur with a 3:1 solution (containing lipids), as the final concentration of glucose is less than10%. Sepsis is a complication that can occur if a break in aseptic technique occurs during therapy.

Pneumothorax can occur as a result of central venous catheter insertion. Central venous catheters are typically employed for parenteral nutrition. Thrombophlebitis is a complication of central venous catheter use.

PTS: 1 DIF: Difficult REF: pp. 959-960

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 25. Which of the following interventions would help to prevent or relievepersistent nausea?

1) Assess for signs of dehydration.2) Provide dietary supplements.3) Have the patient sit in an upright position for 30 minutes after eating.4) Immediately remove any food that the patient cannot eat.ANS: 4 Dehydration can occur as a result of continued nausea and vomiting, so the nurse should assess for it. However, this intervention does not prevent nausea. Dietary supplements might help to prevent malnutrition. However, they do not prevent nausea; in fact, they often cause nausea. Having the patient sit uprighthelps to prevent respiratory aspiration should the patient vomit; it does not prevent or relieve nausea.

Odors (even pleasant ones) and even the sight of food can cause nausea, so any uneaten food should be removed immediatelyfrom the room.

PTS:1DIFifficultREF:p. 928 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. The nurse will evaluate that learning has occurred if the patient recognizes which food(s) as an incomplete protein thatshould be consumed with a complementary protein? Choose all that apply.

1) Whole grain bread 2) Peanut butter 3)Chicken 4)Eggs ANS: 1, 2 Incomplete protein foods do not provide all of the essential amino acids necessary for protein synthesis. Therefore, the nurse should inform the patient that whole grain bread and peanut butter should be consumed with a complementary protein. For example, they could be eaten together as a peanutbutter sandwich.PTS:1DIF:ModerateREF:p. 901 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level:Comprehension 2. The nurse is teaching a patient about the importance of reducing saturated fats in his diet. The nurse will recognize that learning has occurred if,upon questioning, the patient replies that he should read product labels to eliminate the intake of which saturated fat(s)?

Choose all that apply.

1) Palm oil2) Coconut oil3) Canola oil4)

Peanut oilANS: 1, 2 Palm and coconut oils are sources of saturated fat that are contained in many processed foods.

The patient should be encouraged to read product labels to eliminate them from his diet. Olive, canola, and peanut oils are unsaturated fatsand should be substituted for saturated fats in the diet.

PTS: 1 DIF: Moderate REF: p. 901 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level:Comprehension 3. Which instruction(s) should the nurse give to the patient complaining of constipation? Choose all that apply.

1) Drink at least eight glasses of water or non-caffeinated fluid per day.2) Include a minimum of four servings of meat per day.3) Consume a high-fiber diet.4) Exercise as you feel necessary.ANS: 1, 3 To prevent constipation, the nurse should instruct the patient to consume a high-fiber diet, drink at least eight glasses of water or non-caffeinated fluid per day, exercise regularly, and eat meals on a regular schedule. Caffeine can aggravate constipation. PTS:1DIF:ModerateREF:p.

929 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 4. Where in the body is glucose stored? Choose all that apply.1) Brain2) Liver3) Skeletal muscles4) Smooth muscles ANS: 2, 3 Human beings store glucose in liver and skeletal muscle tissue as glycogen.Glycogen is converted back into glucose to meet energy needs.

PTS:1DIF:ModerateREF:p. 902 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 5. For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements related to Impaired Swallowing, which nursing interventions areappropriate? Choose all that apply.

1) Check inside the mouth for pocketing of food after eating.2) Provide a full liquid diet that is easy to swallow.3) Remind the patient to raise the chin slightly to prepare for swallowing.4) Keep the head of the bed elevated for 30 to 45 minutes after feeding.ANS: 1, 4 The nurse should check for pocketing of food that the patient has not been ableto swallow, and should keep the head of the bed elevated for 30 to 45 minutes after feeding. Liquids should be avoided unless thickeners are added. The patient should flex the head forward (tuck the chin) in preparation for swallowing.

PTS:1DIF:ModerateREF:pp. 927-928 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application

Chapter 25. Urinary Elimination

Multiple Choice Identify the choice that best completes the statement or answers the question.

1. What is the most significant change in kidney function that occurs withaging? 1) Decreased glomerular filtration rate2) Proliferation of micro blood vessels to renal cortex3) Formation of urate crystals4) Increased renal massANS: 1 Glomerular filtration rate is the amount of filtrate formed by the kidneys in 1 minute. Renal blood flow progressively decreases with aging primarily because of reduced blood supply through the micro blood vessels of the kidney. A decrease in glomerular filtration is the most important functional deficit caused by aging. Urate crystals are somewhat common in the newborn period. They might indicate that the infant is dehydrated. In older people, they result from too much uric acid in the blood, although this is not related to aging. Renal mass(weight) decreases over time, starting around age 30 to 40.

PTS:1DIFifficultREF:p. 1013 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 2. While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patients bladder. Which statement by theinstructor is best? You should: 1) Try to palpate it again; it takes practice but you will locate it.2) Palpate the patients bladder only when it is distended by urine.3) Document this abnormal finding on the patients chart.4) Immediately notify the nurse assigned to the care of your patient.ANS: 2 The bladder is not palpable unless it is distended by urine. It is not difficult to palpate the bladder when distended. The nurse should document her finding, but it is not an abnormal finding. It is not necessary to notify the nurse assignedto the patient.

PTS:1DIF:EasyREF:p. 1014 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 3. Which urine specific gravity would be expected in a patient admitted with dehydration?

1) 1.002 2) 1.010

1.025 1.030 ANS: 4 Normal urine specific gravity ranges from 1.010 to 1.025. Specific gravity lessthan 1.010 indicates fluid volume excess, such as when the patient has fluid overload (too much IV fluid) or when the kidneys fail to concentrate urine.

Specific gravity greater than 1.025 is a sign of deficient fluid volume that occurs,for example, as a result of blood loss or dehydration.

PTS:1DIF:ModerateREF:p. 1015 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 4. Which medication class will the primary care provider most likely prescribe to increase urine output in the patient admitted with congestive heartfailure?

1) Thiazide diuretic2) Loop diuretic3) MAO inhibitor4) AnticholinergicANS: 2 A loop diuretic [e.g., Furosemide (Lasix)] increases urine elimination. It works by limiting the reabsorption of water in the renal tubules and is used to reduce congestion in the cardiopulmonary circulation. A thiazide diuretic is used to treathigh blood pressure by reducing the amount of sodium and water in the blood vessels. An MAO inhibitor [e.g., phenelzine (Nardil)] is an antidepressant that is used after other medications have proven unsuccessful in lifting symptoms of serious depression. Anticholinergics [e.g., ipratropium (Atrovent)] relax smooth muscle in the airways. Also known as antispasmodics, they reduce airway constriction experienced by those with asthma, for example. is a cholesterol-lowering drug. Although high cholesterol is a leading factor forheart disease, the medication is used to reduce cholesterol in the bloodnot to promote diuresis to reduce the demand on the heart and backflow into the lungs.

PTS:1DIF:ModerateREF:p. 1016; not stated directly in the text and requirescritical thinking KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 5. The nurse identifies the nursing diagnosis Urinary Incontinence (Total) inan older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication?

1) Skin breakdown2) Urinary tract infection3) Bowel incontinence4) Renal calculi ANS: 1 Urine contains ammonia, which may cause excoriation with prolonged contactwith the skin.

Bowel incontinence, not urinary incontinence, increases the patients risk for urinary tract infection. Immobility and high consumption of calcium-containing foods increase the risk for renal calculi.

PTS: 1 DIF: Moderate REF: p. 1021 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 6. The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take?

1) Do nothing; this is normal postoperative urine output.2) Increase the infusion rate of the patients IV fluids.3) Notify the provider about the patients oliguria.4) Administer the patients routine diuretic dose early.ANS: 3 50 mL in 2 hours is not normal output. The kidneys typically produce 60 mL of urine per hour. Therefore, the nurse should notify the provider when the patientshows diminished urine output (oliguria). Patients who undergo abdominal surgery commonly require increased infusions of IV fluid during the immediate postoperative period. The nurse cannot provide increased IV fluids without a providers order. The nurse should not administer any medications before the scheduled time without a prescription. The provider may hold the patients scheduled dose of diuretic if he determines that the patient is experiencingdeficient fluid volume.

PTS: 1 DIF: Difficult REF: p. 1025 KEY: Nursing process: Interventions | Client need: PSI| Cognitive level:Application 7. The nurse measures the urine output of a patient who requires a bedpanto void.

Which action should the nurse take first? Put on gloves and: 1) Have the patient void directly into the bedpan.2) Pour the urine into a graduated container.3) Read the volume with the container on a flat surface at eye level.4) Observe the color and clarity of the urine in the bedpan.ANS: 1 First, the nurse should put on gloves and have the patient void directly into thebedpan. Next, she should pour the urine into a graduated container, place the measuring device on a flat surface, and read the amount at eye level. She should observe the urine for color, clarity, and odor. Then, if no specimen is required, she should discard the urine in the toilet and clean the container and bedpan. Finally, she should record the amount of urine voided on the patients intake and output record.

PTS: 1 DIF: Easy REF: p. 1041 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 8. The nurse instructs a woman about providing a clean-catch urine specimen. Which of the following statements indicates that the patient correctlyunderstands the procedure?

1) I will be sure to urinate into the hat you placed on the toilet seat.2) I will wipe my genital area from front to back before I collect the specimenmidstream. 3)

I will need to lie still while you put in a urinary catheter to obtain the specimen.4) I will collect my urine each time I urinate for the next 24 hours.ANS: 2 To obtain a clean-catch urine specimen, the nurse should instruct the patient to cleanse the genital area from front to back and collect the specimen midstream.This follows the principle of going from clean to dirty. The nurse should have theambulatory patient void into a hat (container for collecting the urine of an ambulatory patient) when monitoring urinary output, but not when obtaining a clean-catch urine specimen. A urinary catheter is required for a sterile urine specimen, not a clean-catch specimen. A 24-hour urine collection may be necessary to evaluate some disorders, but a clean-catch specimen is a one-timecollection.

PTS: 1 DIF: Moderate REF: pp. 1043-1044 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis 9. What position should the patient assume before the nurse inserts anindwelling urinary catheter?

Modified Trendelenburg2) Prone3) Dorsal recumbent4) Semi-FowlersANS: 3 The nurse should have the patient lie supine with knees flexed, feet flat on the bed (dorsal recumbent position). If the patient is unable to assume this position,the nurse should help the patient to a side-lying position. Modified Trendelenburg position is used for central venous catheter insertion. Prone position is sometimes used to improve oxygenation in patients with adult respiratory distress syndrome. Semi-Fowlers position is used to prevent aspiration in those receiving enteral feedings.

PTS: 1 DIF: Easy REF: p. 1031 KEY: Nursing process: Interventions | Client need: Physiological Integrity |Cognitive level: Application 10. A patient complains that she passes urine whenever she sneezes orcoughs. How should the nurse document this complaint in the patients healthcare record? 1) Transient incontinence2) Overflow incontinence Urge incontinence4) Stress incontinenceANS: 4 Stress incontinence is an involuntary loss of urine that occurs with increased intra- abdominal pressure. Activities that typically produce the symptom include sneezing, coughing, laughing, lifting, and exercise. Transient incontinence is a short-term incontinence that is expected to resolve spontaneously. It is typicallycaused by urinary tract infection or medications, such as diuretics. Overflow incontinence is the loss of urine when the bladder becomes distended; it is commonly associated with fecal impaction, enlarged prostate, and neurological conditions. Urge incontinence is the involuntary loss of urine associated with a strong urge to void.

PTS:1DIF:ModerateREF:p. 1018 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 11. Which outcome is appropriate for the patient who underwent urinary diversion

surgery and creation of an ileal conduit for invasive bladder cancer?

1) Patient will resume his normal urination pattern by (target date).2) Patient will perform urostomy self-care by (target date).3) Patient will perform self-catheterization by (target date).4) Patients urine will remain clear with sufficient volume.ANS: 2 The most appropriate outcome for this patient is the patient will perform urostomy self- care by a specific date. The patient with an ileal conduit is unableto resume a normal urination pattern; urine, along with mucus, drains continuously from the stoma site, so the urine will not be clear.

Also, the phrasesufficient volume is too vague for an outcome statement. The patient with a continent urostomy inserts a catheter into the stoma to drain urine.

PTS:1DIF:ModerateREF:p. 1039 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 12. Which intervention should the nurse take first to promote micturition ina patient who is having difficulty voiding?

1) Insert an indwelling urinary catheter.2) Notify the provider immediately.3) Insert an intermittent, straight catheter.4) Pour warm water over the patients perineum.ANS: 4 The nurse should perform independent nursing measures, such as pouring warmwater over the patients perineum before notifying the provider. If nursing measures fail, the nurse should notify the provider. The provider may order an indwelling urinary catheter or a straight catheter to relieve the patients urinary retention.

PTS:1DIF:ModerateREF:p. 1028 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 2) 13. The student nurse asks the provider if she will prescribe an indwellingurinary catheter for a hospitalized patient who is incontinent. The provider explains that catheters should be utilized only when absolutely necessary because: 1) They are the leading cause of nosocomial infection.2) They are too expensive for routine use.3) They contain latex, increasing the risk for allergies.4) Insertion is painful for most patients.ANS: 1 Indwelling urinary catheters should not be routinely used for hospitalized patients with incontinence because they are the leading cause of healthcare-acquired infection (nosocomial).

The cost of an indwelling urinary catheter should not deter its use if necessary. Latex-free catheters are available for patients with or at risk for latex allergy. Insertion may be somewhat uncomfortable, but it should not be painful.

PTS:1DIF:ModerateREF:p. 1028 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application

14. A patient who sustained a spinal cord injury will perform intermittent selfcatheterization after discharge. After discharge teaching, which statementby the patient would indicate correct understanding of the procedure?

1) I will need to replace the catheter weekly.

I can use clean, rather than sterile, technique at home.3) I will remember to inflate the catheter balloon after insertion.4) I will dispose of the catheter after use and get a new one each time.ANS: 2 The nurse should inform the patient that clean technique can be used after discharge. The patient should wash his hands before the procedure, then wash the reusable catheter in soap and water, and rinse and store it in a clean, dry place. It is not necessary for the patient to use a new catheter for each catheterization. The patient should use a straight catheter; therefore, a balloonis not inflated after insertion. Straight catheters are removed immediately afteruse.

PTS: 1 DIF: Moderate REF: p. 1029 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 15. The nurse notes that a patients indwelling urinary catheter tubing contains sediment and crusting at the meatus. Which action should the nursetake?

1) Notify the provider immediately.2) Flush the catheter tubing with saline solution.3) Replace the indwelling urinary catheter.

Encourage fluids that increase urine acidity.ANS: 3 The catheter needs to be changed when sediment collects in the tubing or catheter and crusting at the meatus occurs. It is not necessary to notify the provider immediately. The nurse should not flush the catheter tubing. The patient should be encouraged to consume fluids that increase urine acidity to prevent urinary tract infection; however, it will not help clear the catheter tubingof sediment.

PTS:1DIF:ModerateREF:p. 1031 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 16. The surgeon orders hourly urine output measurement for a patient after abdominal surgery. The patients urine output has been greater than 60 mL/hour for the past 2 hours. Suddenly the patients urine output drops to almost nothing. What should the nurse do first?

1) Irrigate the catheter with 30 mL of sterile solution.2) Replace the patients indwelling urinary catheter.3) Infuse 500 mL of normal saline solution IV over 1 hour.4) Notify the surgeon immediately.ANS: 1 If the patients urinary output suddenly ceases, the nurse should irrigate the urinary catheter to assess whether the catheter is blocked. If no blockage is detected, the nurse should notify the surgeon. The surgeon may request that the catheter be changed if irrigation does not help or if the tubing is not kinked.However, the nurse should not change a catheter in the immediate

postoperative period without consulting with the surgeon. The surgeon may prescribe an IV fluid bolus if the patient is suspected to have a deficient fluid volume.

PTS:1DIFifficultREF:p. 1058 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 17. A patient is admitted with high BUN and creatinine levels, low blood pH,and elevated serum potassium level. Based on these laboratory findings the nurse suspects which diagnosis?

1) Cystitis2) Renal calculi3) Enuresis4) Renal failureANS: 4 Elevated BUN, creatinine, and serum potassium levels and low blood pH are signs of renal failure. Cystitis is an infection of the bladder and would not result in abnormal renal function. Renal calculi typically produce blood in the urine butdo not lead to marked renal dysfunction and failure. Enuresis is involuntary urination, particularly common in children, and does not produce renal dysfunction. The cause of enuresis is often emotional, developmental, or traumarelated.

PTS:1DIFifficultREF:p. 1023 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 18. A mother tells the nurse at an annual well-child checkup that her 6-year-old son occasionally wets himself. Which response by the nurse is appropriate?

1) Explain that occasional wetting is normal in children of this age.2) Tell the mother to restrict her childs activities to avoid wetting.3) Suggest time out to reinforce the importance of staying dry.4) Inform the mother that medication is commonly used to control wetting.ANS: 1 The nurse should explain that occasional wetting is normal in children during theearly school years. The mother should handle the situation calmly and avoid punishing the child.

Medications are occasionally prescribed for nocturnal enuresis when the child is older and not sleeping at home, but not for occasionaldaytime wetting.

PTS:1DIF:ModerateREF:pp. 1038-1039 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application 19. Which task can the nurse safely delegate to the nursing assistivepersonnel? 1) Palpating the bladder of a patient who is unable to void2) Administering a continuous bladder irrigation3) Providing indwelling urinary catheter care4) Obtaining the patients history and physical assessmentANS: 3 The nurse can safely delegate indwelling urinary catheter care to nursing assistive personnel who are adequately trained to do so. Palpating the bladder,administering continuous bladder irrigation, and obtaining the patients history and physical assessment involve the critical

thinking skills of a professional nurse.

PTS:1DIF:Moderate REF: p. 1048, 1058; not directly stated in text KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 20. Which action should the nurse take when beginning bladder trainingusing scheduled voiding?

1) Offer the patient a bedpan every 2 hours while she is awake.2) Increase the voiding interval by 30 to 60 minutes each week.3) Frequently ask the patient if she has the urge to void.4) Increase the frequency between voiding even if urine leakage occurs.ANS: 1 The nurse should offer the patient the bedpan or assist the patient to the bathroom every 2 hours while she is awake. You would encourage the patient to get up once during the night to void, but awakening the patient every 2 hours would lead to fatigue. If the patient adheres to the schedule, the voiding intervalshould be increased by 15 to 30 minutes each week. Simply asking the patient about the urge to void does not help to manage bladder emptying.

PTS:1DIF:ModerateREF:p. 1033 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 21. A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug?

1) Hypocalcemia2) Hypokalemia3) Hypomagnesemia4) HypophosphatemiaANS: 2 Furosemide is a loop diuretic, which causes potassium to pass into the urine.This drug increases the risk for hypokalemia (low potassium); it does not causehypocalcemia (low calcium in the blood), hypomagnesemia (low blood magnesium), or hypophosphatemia (low blood phosphorous).

PTS:1DIF:ModerateREF:p. 1016, not stated directly in the text and requirescritical thinking KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension 22. Which daily urine output is within normal limits for a newborn weighing8 pounds?

1) 288 mL 2) 180 mL 36 mL

18 mL ANS: 2 A newborn weighing 8 pounds (3.6 kg) should produce 15 to 60 mL of urine per kilogram per day. If the newborn produces 50 mL/kg/day and weighs 3.6 kg, he will produce a total of 180 mL in 24 hours. The other options are not within normal limits and require further assessment.

PTS:1DIFifficultREF:p. 1015 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis 23. The nurse is teaching an older female patient how to manage urge incontinence at home. What is the first-line approach to reducing involuntaryleakage of urine?

1) Insertion of a pessary2) Intermittent self-catheterization3) Bladder training4) Anticholinergic medicationANS: 3 The goal of bladder training is to enable the patient to hold increasingly greatervolumes of urine in the bladder and to increase the interval between voiding.

This involves patient teaching, scheduled voiding, and self-monitoring using avoiding diary.

In addition to teaching the mechanisms of urination, teach distraction and relaxation strategies to help inhibit the urge to void. Other techniques include deep breathing and guided imagery.

A pessary is an incontinence device that is inserted into the vagina to reduce organ prolapse or pressure on the bladder. Clean, intermittent self- catheterization is a good option for managing incontinence that is resistant to conservative measure, such as bladder training, Kegel exercises, lifestyle modification, and medication.

Anticholinergic medication can be highly effectivefor improving urinary incontinence. However, more conservative measures, suchas timed voiding and Kegel exercises, are recommended first.

PTS:1DIF:ModerateREF:p. 1033 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 24. What is the best technique for obtaining a sterile urine specimen froman indwelling urinary catheter?

1) Use antiseptic wipes to cleanse the meatus prior to obtaining the sample.2) Briefly disconnect the catheter from the drainage tube to obtain the sample.3) Withdraw urine through the port using a needleless access device.4) Obtain the urine specimen directly from the collection bag.ANS: 3 To obtain a specimen from an indwelling catheter, insert the needleless access device with a 20- or 30-mL syringe into the specimen port, and aspirate to withdraw the amount of urine you need. Wiping the meatus with an antiseptic material helps to minimize contamination for a clean-catch voided specimen, not a sample collected from a closed system such as an indwelling catheter system. Never disconnect the catheter from the drainage tube to obtain a sample. Interrupting the system creates a portal of entry for pathogens, therebyincreasing the risk of contamination. Do not take the specimen from the collection bag because that urine may be several hours old.

PTS: 1 DIF: Moderate REF: p. 1024

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which of the following is/are an appropriate goal(s) for a patient withurinary incontinence? Choose all that apply.

1) Increase the intake of citrus fruits.2) Maintain daily oral fluids to 8 to 10 servings per day.3) Limit daily caffeine intake to less than 100 mg.4) Engage in high-impact, aerobic exercise.ANS: 2, 3 The nurse should encourage lifestyle changes such as limiting caffeine intake to fewer than 100 mg per day; limiting intake of alcohol, artificial sweeteners, spicyfoods, and citrus fruit; and maintaining daily oral fluid intake to 8 to 10 servings per day. High- impact exercise can be associated with stress incontinence for those with weakened pelvic muscles that support the bladder and urethra.

PTS:1DIF:ModerateREF:p. 1033 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application True/False Indicate whether the statement is true or false.

1. Nurses should obtain information about urinary control from all femalepatients. ANS: T All women, especially older women and those who have experienced childbirth,should be screened for different types of urinary incontinence.

PTS:1DIF:Moderate REF: p. 1017; implied from the information under Urinary Incontinence KEY: Nursing process: Assessment | Client need: PSI | Cognitive level:Comprehension

Chapter 26. Bowel Elimination Multiple Choice Identify the choice that best completes the statement or answers the question.

1. When changing a diaper, the nurse observes that a 2-day-old infant has passed a greenblack, tarry stool. What should the nurse do?

1)Notify the provider immediately.

2) Do nothing; this is normal.

3)Give the baby sterile water until the mother’s milk comes in 4)Apply a skin barrier cream to the buttocks to prevent irritation.

ANS: 2 The nurse should do nothing; this is normal. During the first few days of life, a term newborn passes green-black, tarry stools known as meconium. Stools transition to a yellow-green color over the next few days. After that, the appearance of stools depends upon the feedings the newborn receives. Sterile water does nothing to alter this progression. Meconium stools are more irritatingto the buttocks than other stools because they are so sticky and the skin usuallymust be rubbed to cleanse it. However, meconium leads to skin breakdown like a watery stool does.

PTS:1DIF:ModerateREF:p. 968 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application 2. Considering normal developmental and physical maturation in children, for which age would a goal of Achieves bowel control by the end of this month be most realistic?

1) 18 months 2) 3 years 4 years 5 years ANS: 2 Between ages 2 and 3 years, a child can typically control defecation, thereby making toilet training possible. Nevertheless, some children, especially boys, may not achieve consistent bowel control until somewhat later.

PTS:1DIF:ModerateREF:pp. 968-969 KEY: Nursing process: Planning | Client need: HPM | Cognitive level:Comprehension 3. The nurse educates a patient about the primary risk factors for irritable bowel syndrome. Which behavior by the patient would be evidence of learning?The patient: 1) Reduces her intake of gluten-containing products.2) Does

not consume foods that contain lactose.3) Consumes only two servings of caffeinated beverages per day.4) Takes measures to reduce her stress level.ANS: 4 Stress is a primary factor in the development of irritable bowel syndrome. Other risk factors include caffeine consumption and lactose intolerance; however, they are not primary risk factors.

Celiac disease is associated with gluten intake.

PTS:1DIF:ModerateREF:p. 969 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 4. Which of the following goals is appropriate for a patient with a nursingdiagnosis of Constipation? The patient increases the intake of: 1) Milk and cheese.2) Bread and pasta.3) Fruits and vegetables.4) Lean meats.ANS: 3 The nurse should encourage the patient to increase his intake of foods rich infiber because they promote peristalsis and defecation, thereby relieving constipation. Low- fiber foods, such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis.

PTS:1DIF:ModerateREF:p. 978 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 5. A patient is diagnosed with an intestinal infection after traveling abroad.The nurse should encourage the intake of which food to promote healing?

1) Yogurt2) Pasta 3) Oatmeal4) BroccoliANS: 1 Although the patient may have diarrhea, the goal is not to stop the diarrhea, butto eliminate the pathogens from the digestive tract. The active bacteria in yogurt stimulate peristalsis and promote healing of intestinal infections. Pasta is a low-fiber food that slows peristalsis. It does not promote healing of intestinal infections. Oatmeal stimulates peristalsis, but it does not promote healing of intestinal infections. Broccoli stimulates gas production; it is ineffective against intestinal infections.

PTS: 1 DIF: Moderate REF: p. 969 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 6. A nurse is teaching wellness to a womens group. The nurse should explain the importance of consuming at least how much fluid to promote healthybowel function (assume these are 8-ounce servings)?

1) 3 to 4 servings a day

2) 5 to 6 servings a day 7 to 8 servings a day 9 to 10 servings a day ANS: 3 A minimum of 7 to 8 servings of fluid should be consumed each day to promotehealthy bowel function.

PTS:1DIF:EasyREF:p. 969 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Recall 7. A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally q 12 hours. The patient complains that the last time he took this medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient?

1) Stop taking the drug immediately if diarrhea develops.2) Take an antidiarrheal agent, such as diphenoxylate.3) Consume yogurt daily while taking the antibiotic.4) Increase your intake of fiber until the diarrhea stops.ANS: 3 Antibiotics such as cephalexin, given to combat infection, decrease the normal flora in the colon that cause diarrhea. Bacterial populations can be maintained by encouraging the patient to consume yogurt daily while taking the drugs.

Diarrhea is a common adverse effect of antibiotics; stopping the drug is not necessary. The patient should not be encouraged to take an antidiarrheal agentat this time.

Increasing the intake of fiber combats constipation, not diarrhea.

PTS:1DIF:ModerateREF:p. 969 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 8. Which collaborative interventions will help prevent paralytic ileus in apatient who underwent right hemicolectomy for colon cancer?

1) Administer morphine 4 mg IV every 2 hours for pain.2) Administer IV fluids at 125 mL/hr.3) Insert an indwelling urinary catheter to monitor I&O.4) Keep the patient NPO until bowel sounds return.

ANS: 4 Patients who require bowel surgery typically remain NPO until peristalsis returns, helping to prevent paralytic ileus, a complication that can occur after the bowel is surgically manipulated.

Administering morphine promotes comfort but may increase the risk of ileus. Administering IV fluids prevents dehydration but does not directly prevent ileus. Inserting an indwelling urinary catheter prevents urineretention and facilitates monitoring postoperative urine output.

PTS: 1 DIF: Moderate REF: p. 969; not stated directly in text KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application

9. The nurse in a long-term care facility is teaching a group of residents about increasing dietary fiber. Which foods should she explain are high in fiber?

1) White bread, pasta, and white rice2) Oranges, raisins, and strawberries3) Whole milk, eggs, and bacon4) Peaches, orange juice, and bananasANS: 2 Oranges, raisins, and strawberries are high in fiber. White bread, pasta, andwhite rice are carbohydrates. Whole milk, eggs, and bacon are high in cholesterol. Peaches, orange juice, and bananas are sources of potassium.

PTS:1DIF:ModerateREF:p. 969 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Comprehension 10. The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patients abdomen, she notes low-pitched, infrequentbowel sounds.

How should she document this finding? 1) Hyperactive bowel sounds2) Abdominal bruit sounds3) Normal bowel sounds4) Hypoactive bowel soundsANS: 4 Hypoactive bowel sounds are low-pitched, infrequent, and quiet. An abdominalbruit is a hollow, blowing sound found over an artery, such as the iliac artery.

Normal bowel sounds are high pitched with approximately 5 to 35 gurgles occurring every minute. Hyperactive bowel sounds are very high pitched andmore frequent than normal bowel sounds.

PTS:1DIFifficultREF:p. 972 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 11. The healthcare team suspects that a patient has an intestinal infection.Which action should the nurse take to help confirm the diagnosis?

1) Prepare the patient for an abdominal flat plate. 2) Collect a stool specimen that contains 20 to 30 mL of liquid stool.3) Administer a laxative to prepare the patient for a colonoscopy.4) Test the patients stool using a fecal occult test.ANS: 2 To confirm the diagnosis of an infection, the nurse should collect a liquid stool specimen that contains 20 to 30 mL of liquid stool. An abdominal flat plate and afecal occult blood test cannot confirm the diagnosis. Colonoscopy is not necessary to obtain a specimen to confirm the diagnosis.

PTS:1DIF:ModerateREF:pp. 974-975 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 12. The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse can conclude that learning occurs if the patient says, For 3 days prior to testing, I should avoid eating: 1)

Beef. 2) Milk.3) Eggs.4) Oatmeal. ANS: 1 The nurse should instruct the patient to avoid red meat, chicken, fish, horseradish, and certain raw fruits and vegetables for 3 days prior to fecal occultblood testing.

PTS: 1 DIF: Moderate REF: pp. 989-990 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level:Comprehension 13. The nurse is instructing a patient about performing home testing for fecal occult blood.

The nurse should explain that ingestion of which substancemay cause a false- negative fecal occult blood test?

1) Vitamin D2) Iron3) Vitamin C4) ThiamineANS: 3 Ingestion of vitamin C can produce a false-negative fecal occult blood test; ingestion of vitamin D, iron, and thiamine does not. Iron can lead to a false-positive result.

PTS: 1 DIF: Moderate REF: pp. 989-990 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 14. Which action should the nurse take to assess a 2-year-old child forpinworms? 1) Press clear cellophane tape against the anal opening at night to obtain aspecimen. 2) Collect a freshly passed stool from a diaper using a wooden specimen blade.3) Place a smear of stool on a slide and add two drops of reagent.4) Prepare the patient for a flat plate (x-ray) of the abdomen.ANS: 1 To assess for pinworms, the nurse should press cellophane tape against the childs anal opening during the night or as soon as he awakens. Remove the tapeimmediately, and place it on a slide.

Perineal swabs may also be necessary for microscopic study.

Collecting a fresh stool specimen from a diaper describes the method for an infant or toddler.

Placing a smear of stool on a slide and adding a reagent describes fecal occult blood testing. An abdominal flat plate is not a method of assessing for pinworms.

PTS: 1 DIF: Moderate REF: p. 975 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 15. The nurse must irrigate the colostomy of a patient who is unable tomove independently. How should the nurse position the patient for this procedure?

1) Semi-Fowlers position2) Left side-lying position3) Supine with the head of the bed lowered flat4) Supine with the head of bed raised to 30 degreesANS: 2 The nurse should position an immobile patient in a left side-lying position to irrigate his colostomy. Semi-Fowlers, supine with the bed lowered flat, and thesupine position with the

head of bed elevated to 30 are not appropriate positions for colostomy irrigation.

PTS:1DIF:ModerateREF:p. 1008 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 16. A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation shouldthe nurse make to this mother?

1) Consume a diet consisting of bananas, white rice, applesauce, and toast.2) Drink large quantities of water regularly to prevent dehydration.3) Take loperamide (an antidiarrheal) as needed to control diarrhea. 4) Increase the consumption of raw fruits and vegetables.ANS: 1 The nurse should encourage the patient with diarrhea who has an appetite toconsume a diet that consists of bananas, white rice, applesauce, and toast.

These foods are easy to digest, provide calories for energy, and help provide asource of calcium. The patient should sip liquids frequently to prevent dehydration; large quantities might worsen diarrhea. Medication, such as loperamide (Imodium), is usually reserved for chronic diarrhea. Raw fruits and vegetables may worsen diarrhea.

PTS:1DIF:ModerateREF:p. 978 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 17. Which is a key treatment intervention for the patient admitted withdiverticulitis? 1) Antacid2) Antidiarrheal agent3) Antibiotic therapy4) NSAIDsANS: 3 A key treatment for diverticulitis (an infected diverticulum) is antibiotic therapy;if antibiotic therapy is ineffective, surgery may be necessary. Antacids, antidiarrheal agents, and NSAIDs are not indicated for treatment of diverticulitis.

PTS:1DIF:ModerateREF:p. 970 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 18. The nurse assesses a patients abdomen 4 days after abdominal surgeryand notes that bowel sounds are absent. This finding most likely suggest which postoperative complication?

1) Paralytic ileus2) Small bowel obstruction3) Diarrhea4) ConstipationANS: 1 Absent bowel sounds on the fourth postoperative day suggests paralytic ileus, a complication associated with abdominal surgery. A small bowel obstruction and diarrhea produce hyperactive bowel sounds. Constipation might be associated with hypoactive bowel sounds.

PTS:1DIF:ModerateREF:p. 972

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 19. A patient with a colostomy complains to the nurse, I am noticing really bad odors coming from my pouch. To help control odor, which foods should the nurse advise him to consume?

1) White rice and toast2) Tomatoes and dried fruit3) Asparagus and melons4) Yogurt and parsleyANS: 4 Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White riceand toast (also bananas and applesauce) help control diarrhea. Asparagus, peas,melons, and fish are known to cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that might cause blockage in a patient with an ostomy.

PTS:1DIF:ModerateREF:p. 987 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 20. A patient with severe hemorrhoids is incontinent of liquid stool. Which ofthe following interventions is contraindicated?

1) Apply an indwelling fecal drainage device.2) Apply an external fecal collection device.

26 Place an incontinence garment on the patient.4) Place a waterproof pad under the patients buttocks.ANS: 1 An indwelling fecal drainage device is contraindicated for children; for more than 30 consecutive days of use; and for patients who have severe hemorrhoids, recent bowel, rectal, or anal surgery or injury; rectal or anal tumors; or strictureor stenosis. External devices are not typically used for patients who are ambulatory, agitated, or active in bed because the device may be dislodged, causing skin breakdown. External devices cannot be used effectively when the patient has Impaired Skin Integrity because they will not seal tightly. Absorbent products are not contraindicated for this patient unless Impaired Skin Integrity occurs. Even with absorbent products or an external collection device, the nurse should place a waterproof pad under the patient to protect the bed linens.

PTS:1DIFifficultREF:p. 1001 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 21. A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To helpachieve this goal, nurse should teach the patient to: 1) Call the primary care provider if the stoma becomes pale, dusky, or black.2) Limit the intake of gas-forming foods such as cabbage, onions, and fish.3) Irrigate the stoma to produce a bowel movement on a schedule.

Avoid returning to the use of an ostomy appliance if he becomes ill.ANS: 3 Patients

with an ostomy in the descending or sigmoid colon may use colostomy irrigation as a means to control and schedule bowel evacuation and possibly eliminate the need to wear an ostomy pouch. Limiting the intake of gas-forming foods is a good idea from a social perspective; however, it does not help achievethe goal of having regular bowel movements and thus, eliminating the need to wear a pouch. When illness occurs, it may be difficult to control the output, so the patient can use an ostomy appliance. This will not make it more difficult to schedule the bowel movements after the illness passes.

PTS:1DIF:ModerateREF:p. 971 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which factor(s) place(s) the patient at risk for constipation? Choose allthat apply. 1) Sedentary lifestyle2) High-dose calcium therapy3) Lactose intolerance4) Consuming spicy foodsANS: 1, 2 Physical activity stimulates peristalsis and bowel elimination. Therefore, those with a sedentary lifestyle commonly experience constipation. High-dose calciumtherapy also predisposes a patient to constipation. Lactose intolerance and consuming spicy foods are associated with a nursing diagnosis of Diarrhea, not Constipation.

PTS:1DIF:ModerateREF:p. 969 KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level:Comprehension 2. A patient who has been immobile since sustaining injuries in a motor vehicle accident complains of constipation. The nurse encourages him to consume eight to ten 8ounce servings of fluid daily. Which fluid(s) should thepatient avoid because of the diuretic effect? Choose all that apply.

1) Cranberry juice2) Water3) Coffee 4) Ginger ale5) Tea ANS: 3, 5 Coffee, tea, and caffeine-containing sodas should be avoided because caffeinepromotes diuresis, placing the patient at further risk for constipation. Water is the preferred fluid; however, fruit juices and decaffeinated sodas are also acceptable.

PTS:1DIF:ModerateREF:p. 977 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 3. The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance forthe nurse to insert the tubing into the patients rectum? Choose all that apply.

1) 2 in (5.1 cm) 2) 3 in (7.6 cm) 3) 4 in (10.2 cm) 4) 5 in (12.7 cm) ANS: 2, 3 When administering an enema, the nurse should insert the tubing about 3 to 4inches into the patients rectum. Two inches would not be effective because it would not place the fluid high enough in the rectum. Five inches is too much.

PTS:1DIF:ModerateREF:p. 994 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall Completion 1. When performing an abdominal assessment, what sequence of assessmenttechniques should the nurse use? Label the steps from A to D, with A being thefirst step to perform.

A. Auscultation B. Palpation C. Percussion D. Inspection ANS: D, A, C, B When performing an abdominal assessment, the nurse should follow the sequence: inspection, auscultation, percussion, and palpation. Percussion andpalpation may stimulate peristalsis, so the techniques with the least contact should be done first.

PTS:1DIF:ModerateREF:p. 972

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 2. The nurse is collecting a stool specimen. Arrange the following steps in the order in which

the nurse should perform them. Label the steps from A to D, withA being the first step to perform.

A. Have the patient defecate into a special container placed under the toiletseat.

B. Put on gloves and place the specimen in a specimen container.

C. Ask the patient to void to empty the bladder.

D. Place a label on the specimen container.

ANS: C, A, B, D The nurse should ask the patient to void and then have him defecate into a special container placed under the toilet seat. Next, the nurse should put on gloves and, using a tongue blade, place the specimen into the container. Finally,she should label the specimen and send it to the laboratory for analysis.

PTS: 1 DIF: Difficult REF: pp. 989-990 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 3. When administering an enema, list the following steps in the order in whichthey should be

performed. Label the steps from A to F, with A being the first step to perform.

A. Document the results of the procedure.

B. Assess the patient for cramping.

C. Insert the tubing about 3 to 4 inches into the rectum.

D. Lubricate the tip of the enema tubing generously.

E. Raise the container to the correct height and instill the solution at a slow rate.

F. Encourage the patient to hold the solution for 3 to 15 minutes, depending onthe type of enema.

ANS: D, C, E, B, F, A You must lubricate the tip before inserting the tubing. You would then insert thetubing and begin instilling the solution before assessing for cramping that the instillation might produce.

Only after the solution is instilled would you ask the patient to hold the solution. The last action is to document the results of the procedure, after the procedure is finished.

PTS:1DIFifficultREF:pp. 993-995 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

Chapter 27. Sensory Perception

Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The nurse checks a patients pupils using a penlight. Which receptors isthe nurse stimulating?

1) Chemoreceptors2) Photoreceptors3) Proprioceptors4) MechanoreceptorsANS: 2 hotoreceptors located in the retina of the eyes detect visible light. Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an individual to sense the position of the body in space. Chemoreceptors are located in the taste buds and epithelium of the nasalcavity. They play a role in taste and smell.

Thermoreceptors in the skin detect variations in temperature. Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.

PTS:1DIF:EasyREF:p. 1068 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 2. Which structure within the brain is responsible for consciousness andalertness? 1) Reticular activating system2) Cerebellum3) Thalamus4) HypothalamusANS: 1 The reticular activating system, located in the brainstem, controls consciousnessand alertness.

The cerebellum maintains muscle tone, coordinates muscle movement, and controls balance.

The thalamus is a relay system for sensory stimuli. The hypothalamus controls body temperature.

PTS:1DIF:EasyREF:p. 1068 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 3. The nurse has been teaching a parent about stimuli to develop her infants auditory nervous system. Which behavior by a parent toward the childprovides evidence that learning occurred?

1) Cuddling2) Speaking3) Feeding4) SoothingANS: 2 Exposure to voices, music, and ambient sound helps develop the infants auditory nervous system. Cuddling, feeding, and soothing provide comfort andpleasure and teach the infant about his external environment.

PTS:1DIF:EasyREF:p. 1069

KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Recall 4. A patient complains to the nurse that since taking a medication he hassuffered from excessively dry mouth. What term should the nurse use to document this complaint?

1) Exophthalmos2) Anosmia 3) Insomnia4) XerostomiaANS: 4 The nurse should document excessively dry mouth as xerostomia. Exophthalmosis abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis.

Anosmia is losing the sense of smell. Insomnia is inability to sleep.

PTS:1DIF:ModerateREF:p. 1072 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 5. Which nursing diagnosis has the highest priority for a patient withimpaired tactile perception?

1) Self-Care Deficit: Dressing and Grooming2) Impaired Adjustment3) Risk for Injury4) Activity IntoleranceANS: 3 The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing him at risk for injury. Self-Care Deficit, Impaired Adjustment, and Activity Intolerance are also likely to be appropriate for this patient but are not as high a priority as Risk for Injury. Risk for Injury isdirectly related to safety, which must always be a priority.

PTS: 1 DIF: Moderate REF: p. 1072 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 6. A patient with Parkinsons disease is at risk for which complication?1) Impaired kinesthesia2) Macular degeneration3) Seizures4) XerostomiaANS: 1 Patients with Parkinsons disease are at risk for impaired kinesthesia, placing them at risk for falling. Drooling, not excessive dry mouth (xerostomia), is common with Parkinsons disease. Seizures and macular degeneration are notassociated with Parkinsons disease.

PTS:1DIF:ModerateREF:pp. 1074-1075 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 7. The nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient?

1)

Encouraging family members to visit only during the day 2) Applying wrist restraints during periods of agitation3) Playing soft, calming music during the evening4) Administering lorazepam (a tranquilizer)ANS: 3 Soft, calming music is sometimes helpful for patients with dementia. Encouraging a family member to sit with the patient might have a calming effect, but the option does not provide for that during the evening when the patient is symptomatic. Applying bilateral wrist restraints might further agitate the patient. Lorazepam will provide sedation but might cause further confusion.

PTS:1DIF:ModerateREF:p. 1081 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 8. Which intervention is appropriate for the patient with a nursing diagnosisof Disturbed Sensory Perception: Gustatory?

1) Limit oral hygiene to one time a day.2) Teach the patient to combine foods in each bite.3) Assess for sores or open areas in the mouth.4) Instruct the patient to avoid salt substitutes.

ANS: 3 The nurse should assess for sores or open areas in the mouth and provide frequent oral hygiene. The nurse should also teach the patient to eat foods separately to allow the taste of food to be distinguishable. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods, so the patientshould not avoid them.

PTS:1DIF:ModerateREF:p. 1083 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 9. A patient diagnosed with macular degeneration asks the nurse to explainhis condition. Which statement by the nurse best describes macular degeneration?

1) The portion of your eye called the macula, which is responsible for centralvision, is damaged.

2) Your lens became cloudy, causing your blurred vision. This cloudiness willincrease over time.

3) The pressure in the anterior cavity of your eye became elevated, shifting theposition of your lens.

4) Theres an irregular curvature of your cornea, causing your blurred vision.ANS: 1 Macular damage (degeneration) causes diminished central vision. Cataracts are caused by a cloudy lens and result in blurred vision. Glaucoma is pressure in the

anterior cavity of the eye, which shifts the lens position. Astigmatism is irregular curvature of the cornea, resulting in blurred vision.

PTS:1DIF:ModerateREF:p. 1072 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 10. A patient who sustained a head injury in a motor vehicle accident hasdamage to the temporal lobe. This injury places the patient at risk for which type of hearing loss? 1) Otosclerosis2) Conduction deafness3) Presbycusis4) Central deafnessANS: 4 Central deafness results from damage to the auditory areas in the temporal lobes. Otosclerosis is hardening of the bones of the middle ear, especially the stapes.

Conduction deafness results when one of the structures that transmitsvibrations is affected.

Presbycusis is a progressive sensorineural loss associatedwith aging.

PTS:1DIF:ModerateREF:p. 1072 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 11. A patient comes to the clinic complaining of a taste disturbance. Which medication that the patient is currently prescribed is most likely responsible for this disturbance?

1) Furosemide, a diuretic2) Phenytoin, an anticonvulsant3) Glyburide, an antidiabetic4) Heparin, an anticoagulantANS: 2 Phenytoin is a medication that has a high incidence of associated taste disturbance. Furosemide, glyburide, and heparin are not implicated in tastedisturbances.

PTS:1DIF:ModerateREF:p. 1073 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Application 12. Which instruction should the nurse be certain to include when providing discharge teaching for a patient who has a serious visual deficit?

1) Install blinking lights to alert an incoming phone call.2) Have gas appliances inspected regularly to detect gas leaks.3) Wear properly fitting shoes and socks.4) Avoid using throw rugs on the floors.ANS: 4 The nurse should instruct the visually impaired patient to avoid using throw rugson the floors at home. She should instruct the patient with a hearing deficit to install blinking lights to alert him to an incoming phone call. She should instruct the patient with an olfactory deficit to have gas appliances inspected regularly to detect leaks. The patient with a tactile deficit should be instructed to use properly fitting shoes and socks.

PTS:1DIF:ModerateREF:p. 1084 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 13. The nurse must irrigate the ear of a 4-year-old child. How should thenurse pull the

pinna to straighten the childs ear canal?

1) Up and back2) Straight back3) Down and back4) Straight upwardANS: 3 The nurse should straighten the ear canal of a small child by pulling the pinna down and back.

To straighten the ear canal of an adult, the nurse should pull thepinna up and outward.

PTS: 1 DIF: Moderate REF: p. 1086 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 14. Which step should the nurse take first when performing otic irrigation inan adult?

1) Warm the irrigation solution to room temperature.2) Position the patient so she is sitting with her head tilted away from the affectedear. 3) Straighten the ear canal by pulling up and back on the pinna.4) Place the tip of the nozzle into the entrance of the ear canal.ANS: 1 The nurse should warm the irrigation solution to room temperature first. Next, the nurse should assist the patient into a sitting position, with the head tilted away from the affected ear; straighten the ear canal by pulling up and back on the pinna; place the tip of the nozzle into the entrance of the ear canal; and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the patients head. Then continue irrigating until the canal isclean.

PTS: 1 DIF: Easy REF: p. 1086 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 15. Which essential oil might the nurse trained in aromatherapy use touplift and stimulate a patient?

1) Lavender2) Roman chamomile3) Rosemary4) Ylang-ylangANS: 3 Rosemary is very stimulating and uplifting. Lavender, Roman chamomile, andYlang- ylang are used to promote relaxation.

PTS:1DIF:ModerateREF:p. 1073 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 16. Which assessment finding is considered an age-related change?1) Presbycusis2) Hyperopia3) Increased sensitivity to touch4) Increased sensitivity to tasteANS: 1 Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia is the ability to see

distant objects well; it is not an age-related change. The ability to perceive touch and taste diminishes with age; it does notincrease.

PTS:1DIF:ModerateREF:p. 1069, 1072 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 17. After sustaining a stroke, the patient lacks attention to the right side ofhis body. Which nursing diagnosis best describes the patients problem?

1) Disturbed Sensory Perception2) Unilateral Neglect3) Risk for Peripheral Vascular Dysfunction4) Acute ConfusionANS: 2 This patient lacks attention to the right side of his body after sustaining a stroke; therefore, the most appropriate nursing diagnosis is Unilateral Neglect. The patient may also have Disturbed Sensory Perception, Risk for Peripheral Vascular Dysfunction, and Acute Confusion, but they are not the most appropriate for thedefined problem.

PTS:1DIFifficultREF:p. 1079 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 18. A patient is admitted with an exacerbation of asthma. Which factorplaces the patient at highest risk for sensory overload?

1) Administering albuterol (a central nervous stimulant) as needed2) Administering a tranquilizer intravenously every 2 hours as prescribed3) Delivering oxygen at 6 L/min via nasal cannula4) Maintaining complete bedrest in a quiet, dimly lit roomANS: 1 Medications that stimulate the central nervous system, such as albuterol, place the patient at risk for sensory overload. A tranquilizer and a quiet darkened room may help the patient to relax, thus preventing sensory overload. If the patients oxygen needs are met with oxygen at 6 L/min via nasal cannula, the patient should not experience sensory overload related to oxygen therapy alone.

PTS:1DIFifficultREF:p. 1071 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 19. A patient complains of an impaired sense of smell. Which cranial nervemight have been affected?

4) Trigeminal2) Glossopharyngeal3) Olfactory4) VagusANS: 3 The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an impaired sense of smell. The trigeminal nerve transmits stimuli from the face and head. The glossopharyngeal nerve is responsible for taste. The vagus nerve is responsible for sensations

of the throat, larynx, and thoracic andabdominal viscera.

PTS: 1 DIF: Moderate REF: p. 1072 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 20. Which intervention is helpful when caring for a patient with impairedvision? 1) Suggest the patient use bright overhead lighting.2) Advise the patient to avoid wearing sunglasses when outdoors.3) Do not offer large-print books, as this may embarrass the patient.

Place the patients eyeglasses within easy reach.ANS: 4 The nurse should place the patients eyeglasses within easy reach and makesure that they are clean and in good repair. The patient should have sufficientlight but avoid bright light, which might cause glare. The patient should be encouraged to wear sunglasses, visors, or hats with brims when outdoors. Amagnifying lens or large- print books may be helpful.

PTS:1DIF:ModerateREF:p. 1082 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 21. A patient tells the nurse that since taking a medication he has sufferedfrom excessively dry mouth. Which of the following assessments would be needed in order to plan interventions for that symptom?

1) Asking the patient if foods taste different now2) Checking the patients sense of smell3) Having the patient stand to check for balance4) Assessing for a history of seizuresANS: 1 Many medications cause xerostomia (dry mouth), and xerostomia is the most common cause of impaired taste. Impaired sense of smell also affects the senseof taste; however, there is no reason to assume impaired smell in this patient.

Balance is related the inner ear and to kinesthetic sense, not to taste and xerostomia.

Xerostomia would be related to seizures only if a patient experienced dry mouth as an aura; this would be unusual. Even if this were the case, the information would allow the nurse to plan care for seizures, but not forthe symptom of dry mouth.

PTS:1DIFifficultREF:p. 1072 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. For a particular patient, it has become essential to minimize the risk of further damage to the auditory nerve. Which of the following medications mayneed to be discontinued if the patient is taking them? Choose all that are correct.

1) Furosemide, a diuretic2) Digoxin, a cardiotonic3) Famotidine, an antacid4) Aspirin, an

analgesicANS: 1, 4 Aspirin and furosemide may cause ototoxicity, leading to auditory nerve impairment. Digoxin and famotidine do not place the patient at risk for auditorynerve impairment. PTS:1DIFifficultREF:p.

1070 KEY: Nursing process: Planning | Client need: SECE | Cognitive level:Comprehension 2. Which factors in a health history place a patient at risk for hearing loss?Choose all that apply.

1) Being an older adult2) Childhood chickenpox3) Frequent otitis media4) Diabetes mellitusANS: 1, 3 Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. Older adults experience a generalized decrease in the number of nerve conduction fibers andstructural changes in the ear, which cause hearing loss.

Chickenpox and diabetes mellitus do not place the patient at risk for hearing loss.

PTS: 1 DIF: Moderate REF: p. 1072 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 3. The nurse caring in the intensive care unit suspects that one of her patients is experiencing sensory overload. Which findings(s) has/have aroused her suspicion? Choose all that apply.

1) Disorientation2) Restlessness3) Hallucinations4) DepressionANS: 1, 2 The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased ability to perform tasks, anxiety, muscle tension, andmuscle tension. Sensory deprivation causes irritability, confusion, depression,heart palpitations, hallucinations, and delusions.

PTS:1DIF:ModerateREF:p. 1071 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 4. Which action(s) can the nurse take to prevent sensory overload? Chooseall that apply.

1) Leave the television on to block out other noises.2) Minimize unnecessary light in the patients room.3) Plan care to provide uninterrupted periods of sleep.4) Speak calmly with a moderate voice volume.ANS: 2, 3, 4 To prevent sensory overload, minimize unnecessary light, plan care to provide uninterrupted periods of sleep, and speak to the patient in a moderate tone ofvoice using a calm and confident manner. Television can be used to provide sensory stimuli, but not to prevent sensory overload.

When used, it should notbe left on indiscriminately.

PTS:1DIF:ModerateREF:p. 1081

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 5. For an unconscious patient, which of the following interventions arenecessary to provide for patient safety? Choose all that apply.

1) Talk to the patient as you provide care.2) Incorporate more touch in the plan of care.3) Give frequent eye care if blink reflex is absent.4) Keep the side rails up and bed in low position.ANS: 3, 4 Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the side rails up. If the patients blink reflex is absent or her eyes do not close totally, you may need togive frequent eye care to keep secretions from collecting along the lid margins.The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help withreality orientation.

Providing touch will also help prevent sensory deficit; however, it is not a safety measure.

PTS:1DIFifficultREF:p. 1085 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application

Chapter 28. Pain

Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A patient suddenly develops right lower-quadrant pain, nausea, vomiting,and rebound tenderness. How should the nurse classify this patients pain?

1) Acute2) Chronic3) Intractable4) NeuropathicANS: 1 Acute pain typically has a short duration and a rapid onset. Chronic pain lastslonger than 6 months and interferes with daily activities. Intractable pain is chronic and highly resistant to relief. Neuropathic pain is a type of chronic painthat occurs from injury to one or more nerves.

PTS:1DIF:EasyREF:p. 1092 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 2. How should the nurse classify pain that a patient with lung cancer is experiencing?

1) Radiating2) Deep somatic3) Visceral4) ReferredANS: 3 Visceral pain is commonly experienced in the abdominal cavity, cranium, or thorax. Lung cancer produces visceral pain. Radiating pain starts at the sourceand extends to other locations.

Deep somatic pain is typically caused by fracture, sprain, arthritis, and bone cancer. Referred pain occurs in an area distant from the original site.

PTS:1DIF:ModerateREF:p. 1091 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 3. A patient who underwent a left above-the-knee amputation complains ofpain in his left foot. The nurse should document this finding as what type of pain?

1) Psychogenic2) Phantom3) Referred4) RadiatingANS: 2 The nurse should document this finding as phantom pain. Phantom pain is painthat is perceived to originate in an area that has been amputated. Psychogenicpain refers to pain experienced by a person which does not match the symptoms or the apparent source of pain. It is thought to arise from psychological factors and is disproportional to the painful stimuli.

Referred painoccurs in an area distant from the original site.

Radiating pain starts at the source but extends to other locations.

PTS:1DIF:EasyREF:p. 1091 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 4. A patient who sustained a leg laceration in an industrial accident is brought to the emergency department. The area around the laceration is red, swollen, and tender. Which substance is responsible for causing this response?

1) Histamine2) Prostaglandin3) Bradykinin4) SerotoninANS: 3 Tissue damage causes the release of the substances histamine, bradykinin, and prostaglandin.

Bradykinin triggers the release of inflammatory chemicals that cause the injured area to become red, swollen, and tender. Serotonin is a neurotransmitter and is not involved in the inflammatory response.

PTS:1DIFifficultREF:p. 1092 KEY: Nursing process: NA | Client need: PHSI | Cognitive level: Application 5. In which process do peripheral nerves carry the pain message to thedorsal horn of the spinal cord?

1) Transduction2) Transmission3) Perception4) Modulation ANS: 2 Peripheral nerves carry the pain message to the dorsal horn of the spinal cordduring a process known as transmission. In a process called transduction, specialized nociceptors convert potentially damaging mechanical, thermal, and chemical stimuli into electrical activity that leads to the experienceof pain. Perception involves the recognition of pain by the frontal cortex of the brain. During modulation, pain signals can be facilitated or inhibited, and the perception of pain can be changed.

PTS:1DIFifficultREF:p. 1092 KEY:Nursing process: NA | Client need: PHSI | Cognitive level: Recall 6. A patient reports that he uses music therapy to help control his chronicpain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process?

1) Perception2) Transduction3) Transmission4) ModulationANS: 4

Music therapy can prompt the release of endogenous opioids during the modulation stage, which is the stage of the pain process where the perception ofpain changes. It is not during the perception (recognizing the pain sensation), transmission (relaying the pain message), or transduction (converting potentially damaging stimuli into electrical activity leading to pain sensation).

PTS:1DIF:ModerateREF:pp. 1093, 1100; synthesis of information required KEY:Nursing process: Planning | Client need: PHSI | Cognitive level: Recall 7. The nurse is assessing an intubated patient who returned from coronaryartery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain?

1) Blood pressure 160/82 mm Hg2) Temperature 100.6F3) Heart rate 80 beats/min 4) Oxygen saturation 95% ANS: 1 This patient has an elevation in blood pressure which is a physiological finding associated with pain. The patient has a mild temperature elevation, which is acommon response to surgery.

Heart rate and oxygen saturation are within normal limits.

PTS: 1 DIF: Moderate REF: pp. 1095-1096 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 8. A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain controlplaces this patient at risk for which complication?

1) Metabolic alkalosis2) Pneumothorax3) Pneumonia4) HemothoraxANS: 3 Pain associated with rib fractures causes splinting. Splinting often causes the patient to breathe shallowly and avoid deep coughing to expel sputum, which can lead to pneumonia. Rib fractures can also lead to complications such as pneumothorax and hemothorax; however, they do not result from inadequate pain control. Respiratory acidosis, not metabolic alkalosis, may result from theshallow breaths caused by pain and restricted chest wall movement with splinting.

PTS:1DIF:ModerateREF:p. 1096 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 9. When should the nurse assess pain?1) Whenever a full set of vital signs is taken2) During the admission interview3) Every 4 hours for the first 2 days after surgery4) Only when the patient complains of painANS: 1 The nurse should assess pain whenever a full set of vital signs is checked. Moreover, the

nurse should assess pain on admission of a patient to the facility,even when pain is not the chief complaint. Patients may have chronic pain that has no association with their reason for seeking care. Pain should be assessed more frequently than every 4 hours in the immediate postoperative period. Painshould be reassessed after any treatment is given to evaluate effectiveness of the treatment. Some patients may not complain of pain unless they are specifically asked whether they are in pain. Pain rating scales help to quantify the intensity of pain for the nurse providing analgesia.

PTS: 1 DIF: Moderate REF: pp. 1096-1098 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 10. Which nursing diagnosis is most appropriate for the patient who returns from the postanesthesia care unit after undergoing right hemicolectomy surgery for colon cancer?

1) Acute pain secondary to surgery2) Acute pain (abdominal) secondary to surgery for colon cancer3) Chronic pain secondary to cancer diagnosis4) Chronic pain (abdominal) secondary to abdominal surgeryANS: 2 The nurse should identify a diagnosis by specifying the location of the pain and any precipitating or etiological factors. This patient is experiencing acute abdominal pain that is related to his surgery for colon cancer; therefore, a nursing diagnosis that specifies the surgery is the most appropriate diagnosis forthis patient. In addition, options listing chronic pain are incorrect because the pain is acute, not chronic.

PTS: 1 DIF: Moderate REF: p. 1100 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 11. Which drug might the primary care provider prescribe to help facilitatepain management in a client with chronic pain?

1) Selective serotonin reuptake inhibitor2) Selective norepinephrine reuptake inhibitor3) Narcotic analgesic4) Anti-emeticANS: 1 The control of depression greatly facilitates pain management, especially for patients experiencing chronic pain. Therefore, the physician may prescribe a selective serotonin uptake inhibitor (antidepressant), such as paroxetine (Paxil), as part of the treatment plan. Selective norepinephrine reuptake inhibitors, suchas Atomoxetine (Strattera), are commonly used for attention deficit- hyperactivity disorder. If a narcotic, such as oxycodone (OxyContin), is used for a long time, it may become habit forming (causing mental or physical dependence).

Physical dependence may lead to withdrawal side effects when you stop taking the medicine. This is not the first-line therapy for chronic pain. An anti- emetic, such as ondansetron (Zofran), is used to control for nausea andvomiting, which can occur with some analgesic medication. However, the prescriber would more likely change the medication to something the patient tolerates better rather than order an anti- emetic to control the side effect.

PTS:1DIFifficultREF:p. 1103; higher-order item, can be inferred from text KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

12. The nurse administers acetaminophen 325 mg and codeine 30 mg orally to a patient complaining of a severe headache. When should the nursereassess the patients pain?

1) 15 minutes after administration2) 60 minutes after administration3) 90 minutes after administration4) Immediately before the next dose is dueANS: 2 The nurse should reassess pain in the patient who received an oral pain medication 30 to 60 minutes after administration. The nurse should reassess thepatient receiving IV medications 10 to 15 minutes after administration. The nurse should not wait until just before the patient can receive another dose. Thepatient may require additional pain medication before the next dose is due.

PTS:1DIF:ModerateREF:p. 1100 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level:Application 13. After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, thepatient states that his pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take?

1) Use nonpharmacological therapy while waiting 3 more hours before the nextdose. 2) Administer an additional 800 mg oral dose of ibuprofen right away.3) Do nothing because the patients facial expression indicates he is comfortable.4) Notify the prescriber that the current pain management plan is ineffective.ANS: 4 The nurse should notify the prescriber that the current pain management plan is ineffective. The nurse should not delay treatment for 3 hours when the next dose of medication is due. The nurse cannot administer an extra dose of ibuprofen without a prescribers order to do so. Ibuprofen 800 mg is a maximum dose for most individuals. The nurse should not assume that the patient is not inpain simply because he appears comfortable; pain is what the patient states it is.

PTS:1DIF:ModerateREF:pp. 1110-1111 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 14. The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan?

1) Place the cold pack directly on the skin over the ankle.2) Apply the cold pack to the ankle for 30 minutes at a time.3) Check the skin frequently for extreme redness.4) Keep the cold pack in place for at least 24 hours.ANS: 3 The nurse should instruct the patient to cover the cold pack with a washcloth, towel, or fitted sheet before applying it to the ankle to prevent tissue damage. Acold pack should be applied intermittently for the first 24 hours, leaving it in place for no longer than 15 minutes at a time.

The patient should check the skinfrequently and discontinue the treatment immediately if redness or other signs of tissue irritation occur.

PTS:1DIF:ModerateREF:p. 1101

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 15. The nurse plays music for a child with leukemia who is experiencingpain.

Which pain management technique is this nurse using?

1) Distraction2) Guided imagery3) Sequential muscle relaxation4) HypnosisANS: 1 Music is a form of distraction that has been shown to reduce pain and anxiety by allowing the patient to focus on something other than pain. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequentialmuscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscles while breathing out.

This relaxation technique has also beeneffective for relieving pain. Hypnosis involves the induction of a deeply relaxed state.

PTS:1DIF:EasyREF:pp. 1101-1102 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 16. The nurse uses his hands to direct energy fields surrounding the patients body. After this intervention, the patient states that his pain has lessened. How should the nurse document the intervention?

1) Tactile distraction was performed and appeared effective in reducing pain.2) Guided imagery was effective to relax the patient and reduce the pain.3) Therapeutic touch was performed; patient verbalized lessening of pain aftertreatment. 4) Sequential muscle relaxation was performed; patient states pain is less. ANS: 3 Therapeutic touch focuses on the use of hands to direct energy fields surrounding the body.

The nurse should document use of therapeutic touch and its effectiveness in the progress notes after performing the procedure. Tactile distraction involves activities such as massage, hugging a favorite toy, holding aloved one, or stroking a pet. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscle while breathing out. This relaxation technique is often effective for relieving pain.

PTS:1DIF:ModerateREF:p. 1102 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 17. A patient prescribed a nonsteroidal anti-inflammatory drug (NSAID), naproxen (Aleve, Naprosyn), for treatment of arthritis complains of stomach upset. What should the nurse instruct the patient to do?

1) Notify the prescriber immediately.2) Take the medication with food.3) Take the medication with 8 ounces of water.4) Take the medication before bedtime.ANS: 2

The nurse should instruct the patient to take the medication with food to lessen gastric irritation. Taking the medication with 8 ounces of water will not decrease gastric irritation. Taking the medication just before bedtime may cause gastric reflux, increasing gastric irritation. Although indigestion is an unwanted side effect of naproxen, it is not an emergency that requires the prescriber to be notified immediately. However, prior to giving naproxen, be sure the patient hasnot had ulcers, stomach bleeding, or severe kidney or liver problems. If so, the patient is not a candidate for treatment with naproxen.

PTS:1DIF:ModerateREF:p. 1103 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 18. A patient is prescribed morphine sulfate 4 mg intravenously for postoperative pain.

Which action should the nurse take before administering themedication?

1) Monitor the patients respiratory status.2) Auscultate the patients heart sounds.3) Check blood pressure in supine and sitting positions.4) Monitor the patient for psychological drug dependence.ANS: 1 The nurse should assess the patients respiratory status and level of alertness before administering the medication because respiratory depression can be a life-threatening effect. It is not necessary to auscultate heart sounds or to checkblood pressure while the patient lies down (supine position) and sits up.

Psychological dependence occurs rarely even after long-term prescribed use of morphine.

Therefore, it is not necessary to routinely monitor a patient who is receiving morphine for acute postoperative pain for psychological drugdependence. PTS:1DIF:ModerateREF:p.

1104 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Application 19. A client reports taking acetaminophen (Tylenol) to control osteoarthritis.Which instruction should the nurse give the patient requiring long-term acetaminophen use?

1) Caution the patient against combining acetaminophen with alcohol.2) Explain that acetaminophen increases the risk for bleeding.3) Advise taking acetaminophen with meals to prevent gastric irritation.4) Explain that physical dependence may occur with long-term oral use.ANS: 1 Even in recommended doses, acetaminophen can cause hepatotoxicity in thosewho consume alcohol. Therefore, the nurse should caution the patient against combining acetaminophen with alcohol. Aspirin, not acetaminophen, increases the risk for bleeding because it inhibits platelet aggregation. Nonsteroidal anti- inflammatory drugs (NSAIDs), not acetaminophen, cause gastric irritation and should be taken with meals. Opioid analgesics, not acetaminophen, can cause physical dependence.

PTS:1DIF:ModerateREF:p. 1103 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 20. Which side effects associated with opioid use may improve after takinga few doses of the drug?

1)

Constipation2) Drowsiness3) Dry mouth4) Difficulty with urinationANS: 2 Drowsiness as well as nausea are side effects of opioid therapy that commonlyimprove after a few doses are administered. Other side effects include constipation, vomiting, dry mouth, and difficulty with urination. These side effects do not typically lessen with use.

PTS:1DIF:ModerateREF:p. 1104 KEY: Nursing process: Planning | Client need: SECE | Cognitive level:Comprehension 21. A patient develops a respiratory rate 6 breaths/minute after receiving IV hydromorphone (Dilaudid) 2 mg. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect?

1) Physostigmine (Antilirium) 2) Flumazenil (Romazicon)3) Naloxone (Narcan)4) Protamine sulfateANS: 3 The nurse should anticipate administering naloxone to reverse the respiratory depression associated with opioid use. Flumazenil reverses the central nervoussystem depressant effects of benzodiazepines. Physostigmine reverses the effects of anticholinergic drugs. Protamine sulfate is the antidote for heparin.

PTS:1DIF:ModerateREF:p. 1104 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 22. Which pain management task can be safely delegated to nursingassistive personnel?

1) Assessing the quality and intensity of the patients pain2) Evaluating the effectiveness of pain medication3) Providing a therapeutic back massage4) Administering oral dose of acetaminophenANS: 3 The nurse can safely delegate providing a back massage for the patient in pain. However, the nurse should never delegate the responsibility of assessing the patients pain, monitoring the patients response to pain management strategies,administering medications (including over-the-counter preparations), or evaluating the pain management plan.

PTS:1DIF:ModerateREF:p. 1100 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 23. Which expected outcome is best for the patient with a nursing diagnosisof Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia?

1)

The patient will verbalize a reduction in pain after receiving pain medication and repositioning.

2) The patient will rest quietly when undisturbed.3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4during ambulation.

4) The patient will receive pain medication every 2 hours as prescribed.ANS: 3 A low pain rating is the best expected outcome for the patient with a nursing diagnosis of Acute Pain secondary to surgical resection of a ruptured spleen and possible inadequate analgesia because it is specific and measurable. The patientverbalizing reduced pain is not specific enough. The nurse needs to know how much pain relief is achieved. A numeric score gives a clearer indication of the effectiveness of analgesia. The patient might have experienced a reduction in pain, but his pain level might still be intolerable. Saying the patients pain is relieved because he is resting quietly does not address the pain relief while he isawake. Some patients will sleep in an attempt to cope with pain, so this outcome could lead to inaccurate evaluation. Providing pain medication is a nursing intervention, not an expected outcome.

PTS:1DIFifficultREF:p. 1100 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis 24. A patient had a bowel resection 5 days ago. Which request by the patient might alert the nurse that the patient has a history of substance abuse?

1) Oral pain medication once every 6 to 8 hours2) Patient-controlled analgesic3) Oral pain medications instead of the IM form4) Only nonpharmacological pain measuresANS: 2 The patient underwent surgery 5 days ago; if there are no complications, it is unlikely that he would require frequent dosing of analgesic. The nurse should recognize this behavior as a possible indicator of current substance abuse or addiction. Requesting oral pain medications every 6 to 8 hours is a typical behavior for a patient 5 days after surgery. Requesting an oral form of the drugdoes not indicate substance abuse.

PTS:1DIF:EasyREF:pp. 1109-1110 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 25. A patient with Raynauds disease receives no symptomatic relief with diltiazem (Cardizem). Which surgical intervention might be a treatment optionfor this patient to help provide symptomatic relief?

1) Cordotomy2) Rhizotomy3) Neurectomy4) SympathectomyANS: 4 Sympathectomy severs the pathways to the sympathetic nervous system. The procedure improves vascular blood supply and eliminates vasospasm. It is effective for treatment of pain associated with vascular disorders, such as Raynauds disease. Cordotomy interrupts pain and temperature sensation below the tract that is severed.

This procedure is commonly performed to relieve trunkand leg pain. Rhizotomy interrupts the anterior or posterior nerve route located between the ganglion and the cord. It is commonly used to treat head and neck pain. Neurectomy is used to eliminate intractable localized pain.

The pathways of peripheral or cranial nerves are interrupted to block pain transmission.

PTS:1DIF:ModerateREF:p. 1108 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Recall 26. Which action should the nurse take first when the patient has a score of4 on the sedation rating scale?

Stimulate the patient.2) Prepare to administer naloxone (Narcan).3) Administer a dose of pain medication.4) Notify the physician immediately.ANS: 1 If the patients score on the sedation rating scale is equal to or greater than 4, the nurse should first stimulate the patient. He should next notify the physician.The nurse should consider administering naloxone, as prescribed, if the patientsrespiratory rate is less than 8 breaths/minute; if respirations are shallow with marginal or falling oxygen saturation; or if the patient is unresponsive to stimulation. Before the patient receives another dose of pain medication, the dose should most likely be reduced and other potential causes of sedation should be investigated.

PTS:1DIFifficultREF:p. 1106 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 27. A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus inher right leg. Which factor contraindicates the use of epidural analgesia in this patient?

1) Anticoagulant therapy Diabetes mellitus3) Hypertension4) EmbolectomyANS: 1 Patients who undergo mitral valve replacement typically require long-term anticoagulant therapy. Anticoagulant therapy is a contraindication for epiduralanalgesia use because of the risk for spinal hematoma and uncontrolled bleeding. Diabetes and hypertension are not contraindications for epidural analgesia. Epidural analgesia is commonly used after embolectomy because certain anesthetic agents, such as bupivacaine, help prevent vasospasm.

PTS:1DIFifficultREF:p. 1108 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 28. After undergoing dural puncture while receiving epidural pain medication, a patient complains of a headache. Which action can help alleviatethe patients pain?

1) Encourage the client to ambulate to promote flow of spinal fluid.2) Offer

caffeinated beverages to constrict blood vessels in his head.3) Encourage coughing and deep breathing to increase CSF pressure.4) Restrict oral fluid intake to prevent excess spinal pressure.ANS: 2 Treatment for a headache that occurs as a result of dural puncture consists of bedrest, analgesics as prescribed, and liberal hydration. Caffeine and a dark, quiet environment may also be helpful. Headaches will be more severe when thepatient is sitting upright or ambulating.

Fluid volume deficit will also aggravate aspinal headache after epidural anesthesia.

PTS:1DIFifficultREF:p. 1108 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 29. An older adult receiving hospice care has dementia as a result of metastasis to the brain.

His bone cancer has progressed to an advanced stage.Why might the client fail to request pain medication as needed? The client: 1) Experiences less pain than in earlier stages of cancer.2) Cannot communicate the character of his pain effectively.3) Recalls pain at a later time than when it occurs.4) Relies on caregiver to provide pain relief without asking.ANS: 2 There is no evidence to suggest that patients with dementia and other forms of cognitive impairment do not experience pain. It is most likely that they cannot effectively communicate the intensity or quality of pain and are therefore at riskfor underassessment of pain and inadequate pain relief. Be aware of behavioral cues indicating pain rather than relying on verbal report. Failure to request pain medication is not likely a result of hesitation to ask for it out of habit or relianceon others; rather, it is likely due to inability to effectively express to the caregiver that analgesia is needed.

PTS:1DIF:ModerateREF:p. 1095 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis 30. What is typically the most reliable indicator of pain?1) Patients self-report2) Past medical history3) Description by caregiver(s)4) Behavioral cuesANS: 1 The patients self-report is the most reliable indicator of pain. A patients facial expression, vocalization, posture or position, or other behaviors do not always accurately indicate the intensity or quality of a patients experience of pain. Thepatient might be trying to hide signs of pain in order to be brave or strong.

Sociocultural factors can influence a patients nonverbal expression of pain. Caregivers might not appreciate the extent of pain because pain is an individualized experience.

Perception of pain might be heightened if other medical conditions coexist, although this perception is also influenced by otherfactors, such as past experience with pain and the success or failure of the treatment to produce relief. Emotions, cognitive impairment, developmental stage, communication skills, and mental health disorders, such as depression oranxiety, can influence the perception of pain.

PTS:1DIF:ModerateREF:p. 1096 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application

Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. A 73-year-old patient admitted after a stroke has expressive aphasia.Which pain intensity scale(s) would be appropriate to use with this patient? Choose all that apply. 1) Visual analog2) Numerical rating3) Wong-Baker face rating4) Simple descriptorANS: 1, 3 The Wong-Baker face-rating scale uses simple illustrations of faces to depict various levels of pain. The scale was developed for children but has proved effective for adults with communication and cognitive impairments. The visual analog requires patients to point to a location on a line that reflects their pain level. Some patients have difficulty with the abstract nature of this scale. When using the numerical rating scale, the patient must choose a number from 0 to 10to denote his pain level. This scale is sometimes difficult for clients with cognitive impairments, such as expressive aphasia; however, it would be appropriate to try it if the face-rating scale is not available. Patients commonlyfind the simple descriptor scale difficult to understand. This scale uses a list ofadjectives that describe pain intensity.

PTS: 1 DIF: Moderate REF: pp. 1097-1098 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 2. A patient diagnosed with lung cancer who is receiving morphine (MS Contin) complains of constipation. Which instruction(s) by the nurse might helprelieve the patients constipation? Choose all that apply.

1) Be sure the amount of fruit, vegetables, and fiber in your diet is adequate.2) Drink at least eight 8-ounce glasses of water each day.3) Avoid using stool softeners because they may become habit forming.4) Increase your exercise routine to include 1 hour of exercise a day.ANS: 1, 2 The nurse should instruct the patient to be sure the amount of fruit, vegetables,and fiber in his diet is adequate, and increase fluid intake to eight, 8-ounce glasses of water per day. Stool softeners may also be used. The patient should also be encouraged to increase exercise; even walking a short distance may be helpful. It is not necessary to increase exercise to 1 hour of exercise a day. The patient may be physically able to walk only short distances.

PTS:1DIF:ModerateREF:p. 1105 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application

Chapter: 29. Physical Activity & Immobility Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A 15-year-old patient complains of left ankle pain after being tackledwhile playing football. He asks the nurse what tests he needs to have to determine if he has a strain or a fracture. How should the nurse reply?

1) You dont need an x-ray; I can tell by the way your ankle looks and feels whetheryou have a strain or fracture.

2) Sprains, strains, and fractures have similar symptoms at first; you will need anx-ray of the joint to be certain.

3) We will need to get a venous Doppler study to make sure that there is not afracture. 4) First, we need to get an MRI to diagnose your injury as a fracture instead ofstrain or sprain.

ANS: 2 Signs and symptoms associated with a sprain, strain, or fracture are the same. An x-ray allows the medical provider to visually observe for any breaks ina bone. An xray is a more practical than an MRI to diagnose a fracture. A venous or arterial Doppler is used to detect blood flow.

PTS: 1 DIF: Easy REF: p. 1136 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 2. The nurse planning the care for a frail, malnourished, immobile patient recognizes which of the following as the best treatment to protect the patients integument?

1) Offering the patient six small meals a day2) Assisting the patient to sit in a chair three times a day3) Turning the patient at least every 2 hours4) Administering fluid boluses as directed by the healthcare providerANS: 3 External pressure from lying or sitting in one position compresses capillaries and obstructs blood flow to the skin. Immobile patients confined to a bed should be turned at least every 2 hours to protect their skin and relieve pressure.

PTS:1DIF:EasyREF:p. 1137 KEY: Nursing process: Planning | Client need: SECE | Cognitive level:Comprehension 3. What action is most important in limiting the nurses risk of back injuries?

Use good body mechanics at all times.2) Work with another nurse or an aide when lifting and turning patients.3) Avoid manual lifting by using assistive devices as often as possible.4) Develop a lift team at the clinical site.ANS: 3

Back injuries are the leading cause of injury among nurses. Good body mechanics and teamwork limit the risk of injury. However, the American NursesAssociations (ANA) Handle with Care program advocates the regular use of assistive devices as well as avoiding manual lifting.

PTS:1DIFifficultREF:p. 1128 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 4. The nurse is helping the patient to perform leg exercises after surgery toprevent thrombophlebitis. Which type of muscle is the patient using for these exercises?

1) Skeletal2) Smooth3) Cardiac Slow-twitch fibersANS: 1 Skeletal muscle moves the bones with ligaments. Smooth muscle is found in the digestive tract and other hollow structures, such as the blood vessels and bladder. Cardiac muscle contracts spontaneously and is blood ejected out of theheart. Slow- twitch fibers are a subtype of skeletal muscle cell. Slow-twitch fibers(type I), or red muscle, have a rich blood supply and are rich in mitochondria (the powerhouse of the cell) to give the muscle more oxygen and energy to sustain aerobic activity. The fast- twitch fibers (type II skeletal muscle type) are known as white muscle. These fibers increase the speed of muscle contraction.

PTS:1DIF:EasyREF:p. 1120 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 5. A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?

1) Active ROM2) Turning the patient every 2 hours3) Passive ROM4) Administering glucosamine supplementsANS: 3 Passive ROM involves moving the joints through their ROM when the patient isunable to do so for himself. Passive ROM promotes joint mobility. Active ROM would not be possible for a quadriplegic patient. Turning the patient every 2 hours prevents skin breakdown but does not promote mobility or prevent contracture. Glucosamine is a building block for the formation and repair of cartilage. However, there is inconclusive, scientific evidence regarding the benefit of this substance to improve joint function.

PTS:1DIF:Moderate REF: pp. 1122, 1151; higher-order item, answer can be derived from text KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 6. A nurse is assessing a 74-year-old male patient for an exercise programto be offered at the local hospital. During the evaluation, the nurse notes the following vital signs: P = 72, RR = 16, BP = 132/70. After 3 minutes of moderate-intensity running on the treadmill, the

patient becomes short of breath and states, I have to stop. I cant do this anymore. The nurse measures his vital signs again: P = 152, RR = 40, BP = 172/98. She instructs him to rest.Vital signs return to baseline after 15 minutes. The nurse should recognize his symptoms as associated with which of the following?

1) Anxiety2) Orthostatic hypotension3) Limited activity tolerance4) Respiratory distress ANS: 3 To assess for activity tolerance, assess and record vital signs before and after exercise. A rapid change from baseline vital signs or a slow return to baseline indicates limited activity tolerance. Anxiety might primarily exhibit signs of difficulty getting enough air and elevated heart rate and systolic blood pressure.Vitals would resolve when anxiety is reduced and not after exercise. Orthostatic hypotension is a temporary lowering of blood pressure when suddenly standing up. It is not a finding related to exercise.

PTS:1DIF:ModerateREF:p. 1138 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 7. What is the correct method for turning an adult patient who recentlysustained a spinal cord injury?

1) Ask the patient to assist with the turn by holding the side rails of the bed.2) Place a draw sheet under the patient to assist with turning.3) Request help from another nurse to perform the logrolling technique.4) Use a mechanical lift for safe turning and protecting the nurses back.ANS: 3 The patients spine should be maintained in straight alignment. Logrolling movesthe patients body as a unit and maintains the patients spine in straight alignment. Holding on to the side rail or using a draw sheet or mechanical lift will not keep the spine in alignment.

PTS: 1 DIF: Difficult REF: p. 1148 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 8. An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which of the following is the correct description ofosteoporosis?

1) Loss of bone density that increases the risk of fracture2) Degenerative joint disease that produces pain and decreased function3) Chronic inflammatory joint disease that must be treated with steroids4) Acute infection in the bone that must be treated with antibioticsANS: 1 Osteoporosis is a decrease in total bone density. The internal structure of the bone diminishes, and the bone collapses in on itself. Women experience a rapiddecline in bone mass after menopause. Osteoarthritis is a degenerative joint disease. Osteomyelitis is a serious infection in the bone.

PTS:1DIF:EasyREF:p. 1135

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 9. When caring for a patient with osteoporosis, which of the following isthe most important action to take to minimize progression of the disease? 1) Take a calcium supplement twice a day.

2) Start a weight-bearing exercise program.3) Avoid strenuous activity that puts stress on the bones.4) Schedule regular healthcare checkups.ANS: 2 Osteoporosis causes bones to become porous and weak. Starting a weight- bearing exercise program is the most important aid in promoting bone strengthand decreasing the rate of bone loss. Calcium supplementation helps maintain bone density.

PTS:1DIF:ModerateREF:p. 1135 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 10. Which course of action taken by her patient with osteoporosis wouldallow the nurse to know that her teaching was effective?

1) Taking a calcium supplement every day and increasing her phosphorous intake2) Participating in an aerobic barbell strength class at the gym three times a week3) Using a wheelchair to reduce the risk of spontaneous fractures to her legs andfeet 4) Seeking healthcare by scheduling a follow-up examination with bone densitytesting ANS: 2 Active participation in a weight-bearing and weight-lifting program demonstratesnot only understanding of the treatment of osteoporosis but commitment to an action plan to reduce bone loss that comes with osteoporosis. Calcium supplementation is also part of the treatment for osteoporosis. However, high phosphorous intake lowers calcium levels and would not be appropriate for a client with osteoporosis. Restricting weight-bearing activity to a wheelchair will actually lower bone density. Although follow-up care is appropriate for a client with osteoporosis, it does not indicate commitment to a daily treatment plan.

PTS:1DIF:EasyREF:p. 1135 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis 11. Which of the following is true of synarthroses? Joints are: 1) Freely movable.2) Capable of only limited movement.3) Immovable.4) Painful with movement.ANS: 3 Synarthroses joints are immovable joints. The sutures between the cranial bones are considered synarthroses joints. Although these joints have some flexibility in youth to allow for growth, they gradually become rigid and immovable with ag e. There is no pain associated with synarthroses.

PTS:1DIF:ModerateREF:p. 1120 1)

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 12. A man has been admitted to the hospital unit with a medical diagnosis of chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assisthim with his breathing?

1) Fowlers position2) Sims position3) Lateral recumbent position4) Lateral positionANS: 1 Fowlers position is a semi-sitting position in which the head of the bed is elevated 45 to 60 degrees. This position promotes respiratory function by lowering the diaphragm and allowing the greatest chest expansion. Sims position is a side-lying position where the patient is on his left side with left legextended and right leg flexed. This position is commonly used for rectal examination. Lateral recumbent position is another term describing Sims position. Lateral position simply means side lying.

PTS:1DIF:EasyREF:p. 1146 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 13. A nurse has been asked to design an exercise program with the goal of increasing a clients muscular strength and endurance. Which exercise program would specifically focus on meeting that goal?

Flexibility training2) Resistance training3) Aerobic conditioning4) Anaerobic conditioningANS: 2 Resistance training involves movement against resistance, which increases muscular strength and endurance. Most commonly, resistance training refers to weight lifting and isotonic movement. When exercising for strength, the amountof resistance is increased with each exercise. When exercising for endurance, the number of repetitions is increased with each exercise. Flexibility training willnot increase muscular strength.

Aerobic and anaerobic conditioning may havesome benefit on strength and endurance, but their primary focus is cardiovascular conditioning.

PTS:1DIF:ModerateREF:p. 1129 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Analysis 14. In order to achieve balance, body mass must be distributed aroundwhich point? 1) Center of body alignment2) Center of balance Center of gravity4) Base of supportANS: 3 Balance is achieved when the body is in alignment. To be balanced, a persons line of gravity must pass through his center of gravity, and the center of gravitymust be close to his base of support. The center of gravity is the point around which mass is distributed.

PTS:1DIF:EasyREF:p. 1121

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Comprehension 15. A frail 78-year-old man is admitted to the hospital after a fall at homeresulted in a left hip fracture. After surgery, he is to begin ambulating with a walker but must avoid weightbearing on his left lower leg. What is the best intervention to help him use his walker?

1) Aerobic exercise with deep breathing2) Quadriceps and gluteal repetitions3) Isometric toning of lower legs4) Arm resistance trainingANS: 4 Arm strength is necessary for ambulating with a walker and other assistive devices. Upper body resistance training increases muscles strength and tone, which will aid him in using the walker more easily. Toning the lower body throughexercise of the quadriceps and gluteal muscles, although important for regainingstrength in general after surgery, does not aid in using a walker. Aerobic exercisewith deep breathing produces the greatest benefit to cardiovascular health but does little to improve the upper body strength needed for ambulating with an assistive device.

PTS:1DIF:Moderate REF: pp. 1152-1156; synthesis of information required; not a direct response tothe item KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 16. Identify the most appropriate nursing diagnosis for promoting the safetyof a frail, elderly patient after hip replacement surgery who also has a history of emphysema. 1) Impaired Mobility related to weakness2) Ineffective Breathing Pattern related to disease process3) Activity Intolerance related to injury4) Risk for Injury related to medical conditionANS: 4 The patients medical condition places him at an increased Risk for Injury: He isat risk 2) for falls and for further injury to his hip. The patient does have Impaired Mobility; however, his Impaired Mobility puts him at Risk for Injury. A diagnosis of Impaired Mobility would focus the outcomes on improving his mobility rather than protecting him from further injury. We have no data other than a diagnosisof emphysema to indicate that he is experiencing Ineffective Breathing Pattern.He is experiencing Activity Intolerance, but this is not his primary safety risk. A diagnosis of Activity Intolerance would focus the goals on increasing his endurance and conserving his energy.

PTS:1DIF:ModerateREF:p. 1140 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Synthesis 17. What would be the most appropriate goal for a frail, elderly patient witha nursing diagnosis of Risk for Injury after hip surgery?

1) Remain free from injury or falls throughout hospital stay.2) Increase activity tolerance by discharge from hospital.3)

Demonstrate effective breathing when ambulating.4) Increase mobility by discharge from hospital.ANS: 1 Remaining free from injury or falls is a measurable goal, and it is directly related to the patients nursing diagnosis, Risk for Injury. Increasing activity tolerance and mobility by the time of discharge is not specific and measurable.

Additionally, these outcomes do not relate to Risk for Injury. A goal of effectivebreathing for a frail, elderly patient after hip surgery does not relate to Risk forInjury.

PTS:1DIF:EasyREF:p. 1141 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 18. A 16-year-old was hospitalized 3 weeks ago. He has been confined to bed throughout his hospital stay because of a crushed pelvis. His parents tell thenurse, Our son is just staring off into space; he wont talk to us. We are worried because he has not even listened to his iPod, watched television, or played his video games for 2 days. That is so unlike him. What is the best response the nurse can make?

1) I will inform his doctor and see if we can get your son started on anantidepressant medication.

2) He is at a critical time in his life; teens are often moody, and being in thehospital with an 2) injury will only make that worse. 3) Your son had a major injury; and his immobility might be causing him to feelisolated and depressed.

4) He is bored because he has been in the hospital for 3 weeks; Ill try to findsomething new for him to do.

ANS: 3 Being immobile, whether in the hospital or home, leads to isolation and mood changes. Patients who are in bed for long periods can suffer from psychological changes such as depression, anxiety, hostility, sleep disturbances, and changesin their ability to perform self-care activities.

PTS:1DIF:ModerateREF:p. 1137 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 19. A healthy, 32-year-old man wants to start a fitness program to increasehis muscle tone and muscle strength. What advice should the nurse offer him? The United States Department of Health and Human Services recommends: 1) That exercising even once a week is beneficial.2) 30 minutes or more of moderate-intensity physical activity three times a week.3) 1 hour, three times a week of moderate-intensity physical activity.4) 150 to 300 minutes or more of moderate-intensity physical activity per week.ANS: 4 Exercise involves physical activity and increases muscle tone and strength. The

U.S. Department of Health and Human Services recommends 150 to 300 minutes or more of moderate- or vigorous-intensity physical activity per week. PTS:1DIF:ModerateREF:p. 1130 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Comprehension 20. A patient fractured her right ulna 8 weeks ago and has just had her cast removed. The orthopedic surgeon prescribes isometric exercises for the right arm. Which of the following exercises comply with the surgeons orders?

1) Place a 5-pound dumbbell in the right hand and squeeze; hold the squeezeposition for 6 to 8 seconds, and repeat 5 to 10 times.

2) Grasping the right wrist with the left hand, move the right arm up, down, andside to side; hold each position for 6 to 8 seconds, and repeat 5 to 10 times.

3) Grasping the right wrist with the left hand, pull the right arm across thebody; hold this position for 6 to 8 seconds, and repeat 5 to 10 times.

4) Press the right hand against a wall; hold this position for 6 to 8 seconds, andrepeat 5 to 10 times.

ANS: 4 Isometric exercise involves muscle contraction without motion. Isometric exercises are useful for developing strength. This type of exercise is appropriatefor the patient who has had an extremity confined to a cast because muscle atrophy occurs when the muscle is not used.

Performing repetitions light weightincreases strength but this would stress the healing fracture at this point in the rehabilitation. Pulling an arm across the body improves flexibility but does not benefit the ulna while healing.

PTS:1DIFifficultREF:p. 1128 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 21. A woman with a high-risk pregnancy with triplets is in preterm labor; she is on strict bedrest for 5 days. During this time she has not had a bowel movement, although normally, passes stool daily. She describes feeling bloatedand uncomfortable. What information should the nurse give the patient when explaining constipation?

1) Immobility often causes constipation.

A stool softener daily will relieve the problem.3) Use of a bedpan results in bloating and constipation.4) A low-fiber diet will resolve the problem.ANS: 1 Immobility slows peristalsis, which leads to constipation, gas, and difficulty evacuating stools from the rectum. Increasing fiber in the diet often preventsconstipation. A stool softener may be ordered if other measures are unsuccessful. Some people do find use of a bedpan difficult.

PTS:1DIF:EasyREF:p. 1137

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 22. A patient is on strict bedrest for 5 days. During this time she has not had a bowel movement, although she normally passes stool daily. She describesfeeling bloated and uncomfortable. A nursing diagnosis that would best addressa patient who is on bedrest is Constipation related to: 1) Change in previous pattern.2) Immobility.3) Dietary intake.4) Change in environment. ANS: 2 Immobility slows peristalsis, which leads to constipation, gas, and difficulty evacuating stools from the rectum. Based on the scenario, this nursing diagnosiswould specifically address the patients condition.

PTS:1DIF:Moderate REF:p. 1137; higher-order item with implied answer KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 23. A 32-year-old with a high spinal cord injury has been admitted to the hospital for antibiotic therapy to treat pneumonia. He lives independently andhas developed strong upperbody strength to maximize his independence.

Which transfer device should be used when transferring him from the bed to his wheelchair?

1) Mechanical lift2) Transfer belt3) Draw sheet4) Transfer boardANS: 4 A transfer board is used by patients with longstanding mobility problems; it offers them the greatest amount of independence while ensuring safety. Patientsusing a transfer board should have sufficient upper-body strength to perform thetransfer safely. A mechanical lift could be used, but it does not promote independence. A transfer belt is used for clients who are able to stand. A drawsheet is useful for moving a patient in bed rather than from bed to wheelchair.

PTS:1DIF:EasyREF:p. 1149 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level:Comprehension 24. An 82-year-old patient is unsteady on her feet when walking about the room. She reports feeling a little sore but has no complaints of weakness. What is the appropriate piece of equipment to use when helping her ambulate?

1) Crutches2) Transfer belt3) Cane4) WalkerANS: 2

Crutches are commonly used when the patient has an injured lower extremity. Acane or walker is generally used for the patient with a lower extremity injury or weakness. The most appropriate equipment to use would be a transfer belt. A transfer belt allows the patient the greatest amount of independence while ensuring safety.

PTS:1DIF:EasyREF:pp. 1149-1150 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 25. The nurse is helping an 82-year-old patient to ambulate in the hallway.Suddenly she states, I feel so light-headed and weak, as her knees begin to buckle. The nurses best action at this time would be to: 1) Assist the patient to slide down his leg as he guides her to a seated or lyingposition. 2) Grab her under the arms and hold her up as he calls for assistance.3) Immediately release the transfer device and place a wheelchair behind thepatient to prevent a fall.

4) Instruct the patient to grab the rail in the hallway while he calls for assistance.ANS: 1 If a patient becomes weak or begins to fall when walking, do not attempt to holdthe patient up.

Instead, protect the patient as you guide her to a seated or lying position.

Create a wide base of support, and project forward the hip closest to the patient. Assist the patient to slide down your leg as you call for help. Protectthe patients head as her body descends.

PTS:1DIF:ModerateREF:p. 1152 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 26. According to the U.S. Department of Health and Human Services2008 Physical Activity Guidelines for Americans, which of the following statements about the benefits of physical activity is correct?

1) The risks of physical activity outweigh the health benefits.2) Physical activity in excess of recommendations for age is harmful.3) Combining aerobic and muscle-strengthening activities promotes better health.4) Lesser amounts of activity provide little to no health benefits.ANS: 3 The combination of aerobic and bone- and muscle-strengthening physical activities leads to health benefits for people of all ethnic groups and ages. Physical activity is safe for almost everyone, and the health benefits of physicalactivity far outweigh the risks.

Additional health benefits are provided by increasing to 300 minutes a week of moderateintensity aerobic physical activity, or 150 minutes a week of vigorous- intensity physical activity, or an equivalent combination of both. For all individuals, some activity is better than none.

PTS:1DIF:EasyREF:p. 1130 KEY: Nursing process: Planning | Client need: HPM | Cognitive level:Comprehension 27. When encouraging a fitness program for older adults, what must thenurse consider?

1)

Older adults should engage in 75 to 150 minutes of moderate-intensity physicalactivity per week.

2) More than 150 minutes of moderate-intensity physical activity can be harmful tobones. 3) Structured fitness programs achieve greater health benefits for older adults.4) Older adults at risk for falling should do activities that maintain or improvebalance. ANS: 4 Older adults should do exercises that maintain or improve balance if they are atrisk of falling.

Older adults should follow the adult guidelines, which are for 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous- intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in periods of at least 10 minutes, preferably spread throughout the week. If this is not possible because of limiting chronic conditions, older adults should be as physically active as their abilities allow. They should avoid inactivity. Structured calisthenics programs are no more beneficial for achievinghealth benefits than other forms of moderate- and vigorous- intensity physical activity. Structured fitness programs can become boring for some individuals. A varied routine often improves compliance and consistency of exercise.

PTS: 1 DIF: Easy REF: pp. 1131-1132 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which of the following body systems must interact to produce mobilityand locomotion? Choose all that apply.

1) Digestive system2) Muscles3) Skeleton4) Nervous systemANS: 2, 3, 4 Activity and exercise require bodily movement (mobility) and locomotion (self-powered movement from one place to another). Mobility depends on the successful interaction among the skeleton, the muscles, and the nervous system.

PTS:1DIF:EasyREF:p. 1119 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 2. Which of the following patients would you expect to be at risk fordecreased activity? Choose all that apply.

1) Older adult who walks at the mall for physical activity2) Someone living in a skilled nursing facility3) Healthy adult who works as a computer programmer4) Obese child who enjoys video games ANS: 2, 3, 4

The person who lives in a skilled nursing facility might be sedentary because of advancing age and other age-associated medical problems that lead to inactivity. With obesity, movement becomes more difficult and strain on joints increases. A sedentary lifestyle, whether adult or child, contributes to obesity; activities, such as computer work and video games, are sedentary and require little physical activity. Physical activity doesnt have to be a structured fitness class but can also be walking, even walking in a mall or neighborhood, just as long as the intensity is moderately vigorous.

PTS: 1 DIF: Moderate REF: p. 1119 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Comprehension 3. A patient has started a fitness program. What program features illustratethat he has started a well-rounded program?

1) Flexibility2) Isometric exercises3) Resistance training4) Aerobic conditioningANS: 1, 3, 4 Flexibility training helps warm up the muscles and prevents injury during exercise. Resistance training increases muscular strength and endurance. Aerobic conditioning affects fitness and body composition. Isometric exercise isan active form of physical activity using opposing resistance where the joints dont move and muscles dont lengthen. Isometrics are done in static positions,rather than moving through a range of motion.

PTS:1DIF:ModerateREF:pp. 1129-1130 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level:Comprehension 4. The nurse is instructing a patient about the need to replace fluid before,during, and after exercise in order to avoid dehydration. She should teach the patient to determine the amount of fluid to consume on the basis of: 1) Duration of exercise.2) Environmental temperature.3) Level of fitness.4) Degree of thirst.ANS: 1, 2 Lost fluids must be replaced to decrease the risk of dehydration, regardless of level of fitness.

During intense exercise, the body can lose 2 liters of fluid for every hour of exercise. Elevated environmental temperatures also increase the amount of fluid lost through sweating. When athletes drink according to thirst, the risk that they will over- drink and so develop exerciseassociated hyponatremia is minimized (Noakes, 2007).

On the other hand, exercise can suppress thirst, making it an unreliable signal to replace fluids lost with exercise.

PTS:1DIF:Easy REF:p. 1133; answer can be derived from the text KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 5. Which of the following actions represent proper body mechanics for nurses providing care as well as teaching patients about safe body movements?Choose all that apply.

1) Stand with the body in alignment and erect posture.2) Bend at the waist to lift heavy objects from the floor.3) Use a wide base of support with your feet at shoulder width.4) Keep objects close to your body when carrying them.ANS: 1, 3, 4 Proper body mechanics involves good body alignment, erect posture, and a widebase of support. To prevent back injury resulting from reaching and straining muscles, carry objects close to the trunk. Bending at the waist to lift objects uses the back muscles and increases the risk of injury. Instead, squat to lower your center of gravity, and use your leg muscles for lifting.

PTS:1DIF:ModerateREF:pp. 1121-1122 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

Chapter 30. Sexual Health Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which of the following is the most important information to collect at women’s health examination for a 52-year-old woman?

1)Age at first sexual encounter 2) History of PMS 3)Birth control method used 4)Date of last menstrual period ANS: 4 A 52-year-old woman may be experiencing erratic periods of perimenopause. The date of her last menstrual period will help determine her perimenopausal status and guide the discussion of physical, emotional, and sexual changes that commonly occur during a period of declining estrogen production. The nurse will need to determine her menstrual status, which also includes the length and heaviness of flow, the regularity of her cycle, and any change in symptoms associated with menstruation. The nurse will also need to assess for birth controlrequirements in a heterosexual or bisexual woman.

PTS: 1 DIF: Moderate REF: pp. 1186-1187; application item, not directly stated intext KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Application 2. An 18-year-old high school senior comes to the local family planning clinic requesting birth control pills. When discussing sexual health with the adolescent girl, your first nursing priority would be to do which of the following?

1) Urge the teen to practice healthful sexual behaviors.2) Inform her about the risk of pregnancy and STIs.3) Assess the teens knowledge of sexuality and reproduction.4) Provide detailed information about birth control pills.ANS: 3 You cannot assume that adolescents or young adults have adequate sexual knowledge, and it is difficult for most people to admit a lack of knowledge to a professional. Therefore, when discussing sexual health with a client, the nurse must first assess the clients knowledge and understanding of reproduction andsexuality.

PTS: 1 DIF: Difficult REF: p. 1177 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis 3. Which is the first stage of sexual arousal?1) Desire2) Excitement3) Stimulation4) OrgasmANS: 1 The sexual response cycle is the sequence of physiological events that occurs when a person becomes sexually aroused. A theorist named Basson identified five stages of physiological events that occur when a person becomes sexuallyaroused: desire, excitement, plateau, orgasm, and resolution. Desire precedes all other stages of the cycle, but sexual response

does not necessarily proceedbeyond desire.

PTS:1DIF:ModerateREF:pp. 1178-1179 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall 4. A 65-year-old widow is being given an annual physical exam. She states she has been dating a widowed man for 9 months and that the relationship isfulfilling in most areas.

However, she is unable to have sexual relations becauseshe feels she is cheating on her husband, who died 5 years ago. Her partner is very understanding, although her inability to have sexual relations is becoming a strain on their relationship. What is an appropriate nursing diagnosis for thiswoman?

1) Sexual Dysfunction related to conflicted sexual orientation2) Ineffective Sexuality Patterns related to values conflicts3) Ineffective Sexuality Patterns related to impaired relationship with partner4) Sexual Dysfunction related to fear of the unknownANS: 2 The nursing diagnosis Ineffective Sexuality Patterns is used when the patient expresses concerns about her own sexuality, whereas Sexual Dysfunction is used when there is an actual change in sexual function that the patient views asunsatisfying, unrewarding, or inadequate. In this situation, the patient still viewsherself as being committed to her deceased husband, causing a conflict in values.

PTS:1DIFifficultREF:p. 1188 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 5. You are caring for a 35-year-old man who tells you that he feels distress about being a male, and ever since he was a young child has thought of himselfas a female. He describes the isolation he feels and concern about fitting in socially and at work because of these recurrent thoughts. How would you respond to your patient?

1) Provide information about support groups and other community resources for transsexual people.

2) Reassure him that he is normal, saying there are more people than we knowwho feel this way.

3) Share with him that you personally have had thoughts like this but have copedwith these thoughts.

4) Suggest your patient seek mental healthcare for medication to help him dealwith his anxiety.

Those experiencing a sexual identity disorder, such as transsexualism, typicallyfeel overwhelming cultural disapproval and isolation. The lifelong stresses associated with being transsexual penetrate nearly every aspect of life: medically, socially, and emotionally.

Competent and responsive healthcare is essential, and nurses can be an especially valuable source of information andsupport during a time of isolation and emotional inner conflict.

Reassuring the patient he is normal discounts his feelings and conveys insensitivity on the partof the nurse as well as a lack of willingness to listen openly. Genuine support and active

listening are important for the transsexual person who is struggling with his gender identity.

Interjecting your own experiences trivializes the patients experience. The nurses first action is to offer information rather than imply that the patient has a mental health issue requiring antianxiety agents.

PTS:1DIF:ModerateREF:p. 1174 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 6. Based on a nursing diagnosis of Ineffective Sexuality Patterns related tovalues conflicts, what would be the most effective nursing intervention for a patient?

1) Educate the patient about sexual orientation and function.2) Encourage the patient to discuss relationship problems with her partner.3) Advise the patient to discuss her value conflict with a counselor.4) Instruct the patient on effective methods to identify fears.

Effective nursing interventions address the etiology of the identified nursing diagnoses. This patient is experiencing a values conflict. Therefore, interventions must address this concern rather than issues, such as fears and relationship problems. The partner might not be the most suitable person for thepatient to talk to because she would be too close to the matter; a counselor is trained to discuss sexuality and values conflicts in a professional and objective manner.

PTS:1DIF:ModerateREF:p. 1189 KEY: Nursing process: Interventions | Client need: Health Promotion | Cognitivelevel: Application 7. What do shared touching, celibacy, masturbation, and developingintimate relationships have in common? They are all: 1) Forms of sexuality or sexual orientation.2) Cues to use in formulating a nursing diagnosis.3) Important in the development of sexual identity.4) Forms of sexual expression.ANS: 4 People express their sexuality and gain satisfaction in many ways. Developingintimate relationships, fantasies and erotic dreams, masturbation, shared touching, oralgenital stimulation, anal stimulation or intercourse, sexual intercourse, and celibacy are all forms of sexual expressioneven a lack of activity is an expression of sexuality.

PTS:1DIF:ModerateREF:pp. 1181-1182 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Analysis 8. In order to discuss a clients sexual health needs in a comfortable andcompetent manner, it is most important for a nurse to be able to: 1) Recognize and set aside personal biases or experiences related to sexuality.2) Perform an accurate and comprehensive physical assessment.3) Collect an accurate and comprehensive sexual history.4) Acquire theoretical knowledge of sexual health concerns.ANS: 1

In many cultures, people have been socialized to avoid talking openly about sexuality. As a nurse, you will find that you must discuss a variety of issues thatare vital for a clients optimal wellness. Some of these discussions may include sexual concerns, dysfunctions, infections, or behaviors. As you reflect on the issues of human sexuality, you will be challenged to confront your own biases related to sexuality and to set those aside as you work with your clients.

Although theoretical knowledge is important, you will be able to use it fully only if you can identify and set aside your own biases.

PTS:1DIF:EasyREF:p. 1172 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Comprehension 9. Which of the following statements by a teenage client would indicate thatyour teaching about detection of STIs has been effective?

A healthcare provider can tell if you have an STI just by looking at your genitals.2) The doctor has to do surgery to biopsy the tissue to find out if a person has anSTI. 3) A healthcare provider can tell if you have an STI by getting a detailed sexualhistory. 4) A genital swab culture can be done at the office or clinic to determine if a personhas an STI. ANS: 4 Many STIs have few or no symptoms. To find out if a patient has an STI, you must obtain a swab culture of secretions. For a man, a culture is obtained fromthe urethra. For a woman, secretions are swabbed near the cervix.

PTS:1DIF:ModerateREF:p. 1183 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 10. When evaluating the treatment plan for a patient with erectile dysfunction (ED), you would deem the treatment successful if the patient madethe following statement: 1) I feel very good about the treatment; I am now comfortable with my sexualorientation. 2) I am happy with the treatment as I can now maintain an erection throughorgasm.

Now I can communicate my sexual needs to my partner without embarrassment.4) I now know how to prevent further sexually transmitted infections.ANS: 2 Men with erectile dysfunction have persistent or recurring inability to achieve or maintain an erection sufficient for satisfactory sexual performance. When the patient is maintaining penile erection through orgasm, this is an indication the interventions were successful. ED is not related to sexual orientation or exposure to STIs. Comfort with communicating about sexual needs is helpful forsexual satisfaction but is not the cause of ED. PTS:1DIF:ModerateREF:p. 1185 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 11. When providing care for a client with concerns about his sexual orientation, you use the PLISSIT model. You recognize that the first step youmust take is to: 1) Provide information about sexual orientation and common alterations.2) Plan time to discuss concerns with the client in a private, comfortable setting.3) Permit the client to speak openly by communicating an open, accepting attitude.4) Provide referrals to the client so he can identify resources to assist him in thefuture.

ANS: 3 The PLISSIT model was developed as a guideline for sex therapy. Although basic nursing education does not prepare you to provide sex therapy, the first three PLISSIT steps have been adapted to address sexual knowledge deficits that you are qualified to treat. The first step, P, is to provide permission. Permission means that you communicate an open, accepting attitude so the client feels freeto ask questions and express concerns and feelings.

PTS:1DIFifficultREF:p. 1196 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Comprehension 12. A 24-year-old woman comes to the clinic to be evaluated for sexually transmitted infections. She states she has no symptoms, but her boyfriend is complaining of a thin, clear discharge and mild discomfort with urination. His doctor advised him that his partner should be treated because this problem mayaffect her future fertility. What disorder should be assessed for?

1) Chlamydia2) Trichomoniasis3) Genital herpes4) Human papillomavirusANS: 1 The male partner exhibits symptoms of chlamydia. Women are frequently asymptomatic for chlamydia. As a result, the infection may go untreated andaffect future fertility.

Trichomoniasis is asymptomatic in men, but women experience a frothy, odorous vaginal discharge. Small blisters on the genitals may be seen with genital herpes. Human papillomavirus produces genital warts.

PTS:1DIFifficultREF:p. 1183 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 13. When in the reproductive cycle is there marked growth of ovarian material and regrowth of the endometrium, ending with the release of theovum?

1) Menstrual phase2) Follicular phase3) Luteal phase4) FertilizationANS: 2 The luteal phase occurs after the menstrual phase. At this time, the endometrial lining builds back up after being shed with menstruation. Ovarian follicles mature until the ovum is released.

The luteal phase occurs after ovulation. In this phase, if fertilization does not occur, progesterone drops and menses beginsagain. Fertilization occurs at the time of ovulation at which a sperm joins with the mature egg and the endometrium is ripe to support the embryo.

PTS:1DIF:ModerateREF:p. 1172 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall Multiple Response

Identify one or more choices that best complete the statement or answer thequestion.

1. Normal physiological changes in womens sexual responses that occurwith aging include which of the following? Choose all that apply.

1) Delayed nipple erection2) Increased vaginal expansion3) Reduced vaginal lubrication4) Reduced labial separation and swellingANS: 1, 3, 4 As women age, normal physiological responses in sexual behavior include delayed nipple erection, reduced vaginal lubrication, and reduced labial separation and swelling. Vaginal expansion is reduced rather than increasedbecause of decreased estrogen and progesterone levels.

PTS:1DIF:ModerateREF:p. 1179 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis 2. A 2-year-old boy has come to the well-child clinic with his mother for a checkup. When the nurse asks his mother if she has any concerns, she says, I dont know why he wont quit touching his privates all the time. I have tried sitting him in a chair, smacking his hand, and telling him no, but he continues todo this. I just dont know how to make him stop. How would you best respond to her concerns? Choose all that apply.

Give him a little time, and hell grow out of it. Hes just too young to understandright now. 2) How often do you punish him by giving him a time-out or by using physical discipline?

3) Physical punishment is not the best way to modify a childs behavior.4) It isnt unusual for him to fondle his genitals, as this is part of his exploration ofhis body. ANS: 2, 3, 4 The first two years of life are highly sensual as infants are nursed, stroked, bathed, and massaged, and they develop their first attachment experience through bonding with the mother.

It is not unusual for infants and preschoolers to fondle their genitals and enjoy being nude.

This is part of their exploration of their bodies, and parents should not overreact. Although health teaching about normal sexual development of toddlers is important, this mothers comments area red flag to appropriate discipline. Her exaggerated response using physical reprimands to a 2-year-old child bears further exploration about other potential for physical harm or abuse within the home. The nurse has a responsibility to assess risk to the child for an abusive situation and counsel the mother about alternate methods of dealing with the behavior.

PTS:1DIF:ModerateREF:p. 1175 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application 3. What are common reasons victims of abuse might not report an incidentof sexual assault? Choose all that apply.

Fear that her abuser would be angry if she reported it and would hurt her again2) Belief that she was to blame for starting a fight with the abuser3) Idea that the legal system couldnt prosecute the abuser for the crime4) Desire to have the incident behind her, as if it never happened in the first placeANS: 1, 2, 3, 4

Reasons for not reporting rape include fear of the assailant, fear of consequences to the assailant, knowledge of the low conviction rate for rapists,the desire to avoid a trial, shame and embarrassment, past sexual history, self- blame, and wanting to move on and not face possible consequences involving pregnancy and sexually transmitted infection.

PTS:1DIF:ModerateREF:p. 1184 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 4. Which of the following are considered sexual response cycle disorders?Choose all that apply.

1) Arousal disorder2) Date rape3) Orgasmic disorder4) Low libido ANS: 1, 3, 4 Low libido, arousal disorder, and orgasmic disorder all affect the sexual responsecycle. These disorders affect desire, arousal, excitement, and orgasm. Rape occurs when there is nonconsensual vaginal, anal, or oral penetration. It occurs through force, by the threat of bodily harm, or when the victim is incapable of giving consent. Date rape is forced, unwanted sexual intercourse by an acquaintance when the assault occurs during an agreed-upon social encounter.

PTS:1DIF:EasyREF:pp. 1184-1185 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level:Comprehension 5. When caring for a woman who was sexually assaulted, what is your best approach for collecting information surrounding the event? Choose all that apply. 1) Use a calm, reassuring voice when asking questions of your patient.2) Ask only close family members to describe events related to the incident.3) Provide privacy by asking questions behind a closed curtain.4) Document the details using the patients own words.ANS: 1, 4 Use a calm, professional approach as you collect sexual data from your patients.This will not only help them to feel more comfortable and confident, but will alsoyield more honest and complete information. Your patient might have difficulty discussing the events relating to the assault; however, this is a private matter and not a topic to discuss with family members, regardless of the apparent closeness of the relationship. When asking personal questions, provide privacyand be sensitive to your clients cues. A curtain is not secure enough because conversation easily could be overheard. Clear, unambiguous documentation is extremely important because of the criminal nature of sexual crime. Using the patients own words is a way for the nurse to avoid misinterpreting the facts aswell as keep from introducing bias or drawing conclusions about the event.

PTS:1DIF:ModerateREF:p. 1184; not directly stated in text KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 6. You are caring for a 32-year-old woman who has been sexually assaulted.What nursing interventions are initially most important for this client?

1) Help her to communicate effectively with police about the attack.2) Obtain

permission from your client to test for pregnancy and STIs.3) Refer your client to a sexual assault support group.4) Promote and model empathy and support for her family members.ANS: 2, 3 A victim of rape has experienced psychological and physiological trauma. Sexual assault is a risk factor for sexually transmitted infection (STI). Testing for STIs and pregnancy is a necessary component of the physical care of a victim of sexual violence. Referral to a local sexual assault support group is critical when planning care.

A sexual assault nurse examiner (SANE), who is a registered nurse, can assist the client through the physical examination, police interview,and disclosure to family members, all of which are important activities.

PTS: 1 DIF: Moderate REF: p. 1184 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application Completion Complete each statement.

1. includes how we perceive ourselves, how we relate toothers, and how we express ourselves as sexual beings.

ANS: SexualityDefinition.

PTS: 1 DIF: Moderate REF: p. 1172 KEY:Nursing process: Interventions | Client need: PSI | Cognitive level: Recall

Chapter 31: Sleep and Rest

Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A person who is deprived of REM sleep for several nights in succession will usually experience: 1)Extended NREM sleep.

2) Paradoxical sleep.

3)REM rebound.

4)Insomnia.

ANS: 3 A person who is deprived of REM sleep for several nights will usually experience REM rebound. The person will spend a greater amount of time in REM sleep on successive nights, generally keeping the total amount of REM sleep constant over time.

PTS:1DIF:ModerateREF:p. 1205 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 2. A patient states that many of his friends told him to ask for Valium or Ativan to help him sleep while hospitalized. The nurse knows that nonbenzodiazepines (such as Ambien) are often preferred over benzodiazepines(Ativan or Valium). Why is this?

1)Benzodiazepines are eliminated from the body faster than are nonbenzodiazepines, so they do not provide a full night of sleep.

2)Nonbenzodiazepines cause daytime sleepiness, allowing people to rest throughout the day.

3)Benzodiazepines produce daytime sleepiness and alter the sleep cycle.

4) Nonbenzodiazepines remain in the body longer than do benzodiazepines .ANS: 3 Nonbenzodiazepines (such as Ambien) have a short half-life, which means that they are eliminated from the body quickly and do not cause daytime sleepiness. Ativan is a long-acting benzodiazepine and remains in the body longer than Ambien, often causing daytime sleepiness.

PTS: 1 DIF: Moderate REF: p. 1215 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 3. Which of the following factors has the greatest positive effect on sleep quality?

1)Sleeping hours in synchrony with the persons circadian rhythm 2) Sleeping in a quiet environment 3)Spending additional time in stage IV of the sleep cycle 4) Napping frequently during the day hours ANS: 1 A circadian rhythm is a biorhythm based on the day night pattern in a 24-hour cycle.

Sleep quality is best when the time at which the person goes to sleep and awakens is in synchrony with his circadian rhythm. Not all people require a quiet environment for sleep. Time spent in stage IV of the sleep cycle is affected by the total time spent asleep. Napping on and off throughout the day might disrupt the natural circadian rhythm with uninterrupted periods of

sleep that cycle through the various stages of the sleep cycle.

PTS:1DIF:ModerateREF:p. 1204 KEY: Nursing process: N/A| Client need: HPM | Cognitive level: Analysis 4. Which is a major factor regulating sleep?1) Electrical impulses transmitted to the cerebellum2) Level of sympathetic nervous system stimulation3) Amount of sleep a person has become accustomed to4) Amount of light received through the eyesANS: 4 The circadian rhythm is a biorhythm based on the daynight pattern in a 24-hourcycle. A persons circadian rhythm is regulated by a cluster of cells in the hypothalamus of the brainstem that respond to changing levels of light. A majorfactor in regulating sleep is the amount of light received through the eyesnot the typical amount of sleep the person has within a 24-hour period. The autonomic nervous system (rather than central nervous system) controls the involuntary processes of the body, such as sleep, digestion, immune function, and so on.

PTS:1DIF:ModerateREF:p. 1204 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 5. Which of the following is the main difference between sleep and rest?1) In sleep, the body may respond to external stimuli.2) Short periods of sleep do not restore the body as much as do short periods ofrest. 3) Sleep is characterized by an altered level of consciousness.4) The metabolism slows less during sleep than during rest.ANS: 3 During rest, the mind remains active and conscious; sleep is characterized by altered consciousness. Sleep is a cyclic state of decreased motor activity and perception. A sleeping person is unaware of the environment and does respond selectively to certain external stimuli.

However, at rest, the body is disturbed byall external stimuli; sleep restores the body more than does rest. The metabolism decreases more during sleep than during rest.

PTS:1DIF:EasyREF:p. 1202 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Analysis 6. A patient tells you that she has trouble falling asleep at night, even though she is very tired. A review of symptoms reveals no physical problems and she takes no medication. She has recently quit smoking, is trying to eat healthier foods, and has started a moderateintensity exercise program. Her sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosiswould be Disturbed Sleep Pattern related to: 1) Increased exercise.2) Nicotine withdrawal. 3) Caffeine intake.4) Environmental changes.ANS: 2 Based on the information given, the patient is not experiencing significant stress or change in sleep routine or environment, which commonly lead to insomnia.

People who use nicotine tend to have more difficulty falling asleep and are more easily aroused

than those who are nicotine free. People who stop smoking often experience temporary sleep disturbances during the withdrawal period.

PTS:1DIF:ModerateREF:p. 1208 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 7. Which patient teaching would be most therapeutic for someone withsleep disturbance?

1) Give yourself at least 60 minutes to fall asleep.2) Avoid eating carbohydrates before going to sleep.3) Catch up on sleep by napping or sleeping in when possible.4) Do not go to bed feeling upset about a conflict.ANS: 4 Intense emotion before bedtime can interfere with rest and sleep. Lying awakelonger than 30 minutes is counterproductive. Eating a small amount of a complex carbohydrate can aid in falling asleep. Avoid simple sugars because sucrose can lead to a short-term energy boost instead of relaxation. Taking naps during the day and sleeping late on some mornings can actually exacerbate a sleep disturbance. Its better to establish a consistent routine for wake and sleep.The extra sleep during the day can interfere with the bodys readiness for sleep at night.

PTS:1DIF:EasyREF:pp. 1207-1208 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 8. The expected outcome (goal) for a patient with Disturbed Sleep Pattern isthat she will: 1) Limit exercise to 1 hour per day early in the day.2) Consume only one caffeinated beverage per day.3) Demonstrate effective guided imagery to aid relaxation.4) Verbalize that she is sleeping better and feels less fatigued.ANS: 4 The patient would verbalize that she is sleeping better and feels less fatigued. The expected outcome (goal) is based on the nursing diagnosis, and its achievement should reflect resolution of the problem. The other options are outcomes that demonstrate only that the patient took certain actions. They would not, if achieved, demonstrate that the problem of Disturbed Sleep Patternhad been resolved.

PTS:1DIF:ModerateREF:p. 1213 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis 9. When making rounds on the night shift, the nurse observes her patient tobe in deep sleep. His muscles are very relaxed. When he arouses as the nurse changes the IV tubing, he is confused. What stage of sleep was the patient mostlikely experiencing?

1) Stage V2) Stage IV3) Stage III4) REM ANS: 2 Stage IV is the deepest sleep. In this stage, the delta waves are highest in amplitude, slowest in

frequency, and highly synchronized. The body, mind, and muscles are very relaxed. It is difficult to awaken someone in stage IV sleep; if awakened, the person may appear confused and react slowly. During this stage,the body releases human growth hormone, which is essential for repair and renewal of brain and other cells.

PTS:1DIF:EasyREF:p. 1206 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 10. What is the purpose of using a sleep diary?1) Identify sleeprest patterns over a 1-year period.

2) Note the trend in sleepwakefulness patterns over a 2-week period.3) Note typical sleep habits and most common daily routines.4) Examine the patterns of sleep during the night and naps during the day.ANS: 2 A sleep diary provides specific information about the patients sleepwakefulnesspatterns over a certain period of time. It allows identification of trends in sleepwakefulness patterns and associates specific behaviors interfering with sleep. The diary is typically kept for 14 days.

PTS: 1 DIF: Moderate REF: p. 1212 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 11. Patterns of waking behavior that appear during sleep are known as:1) Parasomnias.2) Dyssomnias.3) Insomnia.4) Hypersomnia.ANS: 1 Parasomnias are patterns of waking behavior that appear during sleep.Sleepwalking, sleep talking, and bruxism are parasomnias.

PTS: 1 DIF: Easy REF: p. 1208 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension 12. A 6-year-old boy is admitted to the hospital for a surgical procedure associated with a hospital stay. When the nurse asks his mother about the boyssleep patterns, she says, Sometimes he will get out of bed, walk into the kitchen, and get the cereal out of the cabinet.

Then he just turns around and goes back to bed. The nurse explains that he is sleepwalking.

The best nursing diagnosis for Tad would be: 1) Risk for Insomnia related to sleepwalking.2) Risk for Fatigue related to sleepwalking.3) Disturbed Sleep Pattern related to dyssomnia.4) Risk for Injury related to sleepwalking.ANS: 4 Sleepwalking occurs during stages III and IV of NREM sleep. The sleeper leavesthe bed and walks about with little awareness of surroundings. He may perform what appear to be conscious motor activities but does not wake up and has no memory of the event on awakening. The boy is at high risk for injury when sleepwalking because of his lack of awareness of his surroundings. Insomnia is amedical diagnosis rather than a nursing diagnosis.

Certainly his sleep pattern is disturbed; however, there is little in the way of independent actions that the nurse could take for either the problem or etiology of this diagnosis, so it would not be useful. The boy does not awaken while sleepwalking and is not likely to experience

fatigue from the event.

PTS:1DIF:ModerateREF:p. 1213 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 13. The primary focus of your interventions for a 6-year-old child whosleepwalks would be to: 1) Maintain patient safety during episodes of somnambulation.2) Administer and teach about medications to suppress stage IV sleep.3) Encourage the child to verbalize feelings regarding sleep pattern.4) Provide a quiet environment for nighttime sleep.ANS: 1 Sleepwalking places the patient at Risk for Injury because of his lack of awareness of the surroundings. The nurses primary intervention would be to protect the patient from injury (e.g., falls) while sleepwalking, also called somnambulation. Because the child is only 6 years old, administering and teaching about medications and having him verbalize feelings would not be useful. Providing a quiet environment would likely be ineffective and certainlynot the focus of interventions.

PTS:1DIF:ModerateREF:p. 1211 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 14. From what stage of sleep are people typically most difficult to arouse?

1) NREM, alpha waves2) NREM, sleep spindles3) NREM, delta waves4) REM ANS: 3 Contrary to previous beliefs, stages III and IV of NREM (delta wave) are the deepest stages of sleepnot REM. It is difficult to awaken someone in stage IVslow wave NREM sleep, and if she is awakened, the person may appear confused and react slowly. Stage I NREM is a light sleep from which the sleeper can easily be awakened.

Stage II (sleep spindles) is also light sleep; the sleeperin this stage is easily roused. REM sleep is the stage at which most dream activity occurs, as well as more spontaneous awakenings.

PTS:1DIF:ModerateREF:p. 1205 KEY:Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 15. During which of the following developmental stages does a person tendto need the most hours of sleep?

1) Toddler2) Adolescence Middle adulthood4) Older adulthoodANS: 1 Toddlers (ages 1 to 3 years) require 12 to 14 hours of sleep in a 24-hour period. Adolescents (ages 12 to 18 years) usually need 8 to 9 hours in a 24-hour period. Middle-aged adults

(ages 40 to 65 years) typically require 7 hours in a 24-hour period. Older adults (age 65 years and older) often need 5 to 7 hours of sleep ina 24- hour period.

PTS:1DIF:EasyREF:p. 1204 KEY:Nursing process: Planning | Client need: HPM | Cognitive level:Comprehension Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Select the factors known to affect sleep. Choose all that apply.1) Age2) Environment3) Lifestyle4)State of health 5) Ethnicity ANS: 1, 2, 3, 4 Age, environment, lifestyle, and state of health are factors affecting sleep. Manyolder adults sleep less but require more rest. Alcohol, caffeine, nicotine use, anddiet are examples of lifestyle factors that affect sleep. When a person is ill, she may sleep more or find that she cannot sleep because of pain or other factors associated with illness.

Changes in environment also affect sleep.

PTS:1DIF:EasyREF:pp. 1207-1208 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level:Comprehension 2. A mother expresses concern that her 7-year-old has episodes of nocturnal enuresis approximately 3 to 4 times per week. The nurses bestresponse would be which of the following? Choose all that apply.

1) Your daughters bladder is still developing at this point in her life.2) Be patient; most children outgrow enuresis.3) Wake your daughter every 4 hours to use the bathroom.4) You might consider purchasing protective pads for the bed.5) Try a bed alarm to wake her when she starts wetting the bed at night.ANS: 2, 4 Enuresis is nighttime incontinence past the stage at which toilet training has been well established. Most incidents occur during NREM sleep when the child isdifficult to arouse. As the great majority of children outgrow enuresis, the best strategy is patience. In the meantime, protecting the mattress from moisture and odor will help reduce frustration and embarrassment. A bed alarm can be used for older children (typically older than age 10 or 12) who are resistant to other behavioral strategies.

PTS:1DIF:ModerateREF:p. 1211 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 3. The patient is diagnosed with obstructive sleep apnea. Identify thesymptoms you would expect the client to exhibit. Choose all that apply.

1)

Bruxism2) Enuresis3) Daytime fatigue4) Snoring5) Drooling ANS: 3, 4 Obstructive sleep apnea is caused by partial airway occlusion (usually by thetongue or palate) during sleep. The patient experiences interrupted sleep as he arouses frequently to clear the airway. As a result, the patient has episodes ofsnoring and daytime fatigue.

PTS:1DIF:ModerateREF:p. 1210 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension Completion Complete each statement.

1. disorders are those that occur when signs and symptomsof a disease appear or become worse during sleep.

ANS: Sleep-provoked PTS:1DIF:ModerateREF:p. 1211 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Comprehension

Chapter 32. Skin Integrity and Wound Healing Multiple Choice Identify the choice that best completes the statement or answers the question.

1. What is the function of the stratum corneum?1) Provides insulation for temperature regulation2) Provides strength and elasticity to the skin 3) Protects the body against the entry of pathogens4) Continually produces new skin cellsANS: 3 The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection, and an energy reserve (adipose). The dermis is composedof irregular fibrous connective tissue that provides strength and elasticity to the skin. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface.

PTS:1DIF:ModerateREF:p. 1223 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 2. Skin integrity and wound healing are compromised in the client whotakes blood pressure medications because antihypertensives: 1) Can cause cellular toxicity.2) Increase the risk of ischemia.3) Delay wound healing.4) 4) Predispose to hematoma formation.ANS: 2 Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia. Chemotherapeutic agents delay wound healing because of their cellular toxicity. Anticoagulants canlead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formation with minimal pressure or injury.

PTS:1DIFifficultREF:p. 1224 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 3. What is the primary difference between acute and chronic wounds?Chronic wounds: 1) Are full-thickness wounds, but acute wounds are superficial.2) Result from pressure, but acute wounds result from surgery.3) Are usually infected, whereas acute wounds are contaminated.4) Exceed the typical healing time, but acute wounds heal readily.ANS: 4 The length of time for healing is the determining factor when classifying a wound as acute or

chronic. Acute wounds are expected to be of short duration. Wounds that exceed the anticipated length of recovery are classified as chronicwounds.

PTS:1DIF:EasyREF:p. 1225 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 4. A patient with quadriplegia presents to the outpatient clinic with anischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?

1) Partial-thickness wound2) Penetrating wound3) Superficial wound4) Full-thickness woundANS: 1 Partial-thickness wounds extend through the epidermis into the dermis. Superficial wounds involve only the epidermal layer of skin. Full-thickness wounds extend into the subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to indicate that the wound includes internal organs.

PTS:1DIF:EasyREF:pp. 1226-1227 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 5. A patient underwent abdominal surgery for a ruptured appendix. Thesurgeon did not surgically close the wound. The wound healing process described in this situation is: 1) Primary intention healing.

4) Secondary intention healing.3) Tertiary intention healing.4) Approximation healing.ANS: 2 Secondary intention healing occurs when a wound is left open, and it heals fromthe inner layer to the surface by filling in with beefy red granulation tissue.

Primary intention healing occurs when a wound is surgically closed. Tertiary intention healing occurs when a wound that was previously left open to heal bysecondary intention is closed by joining the margins of granulation tissue. Approximation is another word for the joining of wound edges.

PTS:1DIF:ModerateREF:p. 1227 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 6. When teaching a patient about the healing process of an open woundafter surgery, which of the following points would the nurse make?

1) The patient will need to take antibiotics until the wound is completely healed.2) Because the patients wound was left open, the wound will likely becomeinfected. 3) The patient will have more scar tissue formation than for a wound closed atsurgery.

The patient should expect to remain hospitalized until complete wound healingoccurs. ANS: 3 Because the wound edges are not approximated, more scar tissue will form. Although open

wounds are more prone to infection, this is not an expected outcome, and antibiotics would not necessarily be needed. A patient with an open wound should not expect an extended hospital stay if wound care can beprovided in the home or an outpatient setting.

PTS:1DIFifficultREF:p. 1227 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 7. What is the primary goal that the nurse should establish for a patientwith an open wound?

1) The wound will remain free of infection throughout the healing process.2) Client completes antibiotic treatment as ordered.3) The wound will remain free of scar tissue at healing.4) Client increases caloric intake throughout the healing process.ANS: 1 Wounds healing by secondary intention are more prone to infection; therefore,the primary goal would be to prevent infection. Antibiotics may not be necessary, and the nurse can expect the formation of scar tissue in this particular situation. There is no evidence presented that the patient needs toincrease caloric intake.

PTS:1DIF:ModerateREF:p. 1227 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Synthesis 8. While assessing a new wound, the nurse notes red, watery drainage.What type of drainage will the nurse document this as?

1) Sanguineous2) Serosanguineous3) Serous4) PurosanguineousANS: 2 Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds. Serous drainage is straw colored, andsanguineous drainage is bloody.

Purosanguineous drainage is pus that is redtinged.

PTS:1DIF:EasyREF:p. 1229 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 9. Three days after a patient had abdominal surgery, the nurse notes a 4- cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and thereis no obvious drainage. Heart rate is 96 beats/min and oral temperature is 100.8F (38.2C). The nurse would suspect that the patient has what kind ofcomplication? 1) Infection at the incisional site2) Dehiscence of the wound3) Hematoma under the skin4) Formation of granulation tissueANS: 1 Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevatedpulse and temperature).

Dehiscence is the rupture of a suture line, whereas evisceration is the protrusionof internal

organs through the rupture. A hematoma is a collection of blood that forms under the skin. It is usually tender or painful to the touch and is usually swollen.

Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. It is beefy red in appearance but would not be warm or tender to the touch.

PTS:1DIF:ModerateREF:p. 1229 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 10. Which of the following describes the difference between dehiscence and evisceration?

With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. 2) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent.

3) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue.

4) Dehiscence involves rupture of subcutaneous tissue; evisceration involvesdamage to dermal tissue.

ANS: 1 With dehiscence there is a separation of one or more layers of wound tissue, whereas evisceration involves the protrusion of internal viscera from the incisionsite.

Evisceration is an urgent complication usually requiring immediate surgical intervention.

PTS:1DIF:ModerateREF:pp. 1229-1230 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 11. The nurse will know that the plan of care for the diabetic client withsevere peripheral neuropathy is effective if the client: 1) begins an aggressive exercise program.2) follows a diet plan of 1,200 calories per day. is fitted for deep-depth diabetic footwear.4) remains free of foot wounds.ANS: 4 Diabetic clients experiencing difficulty with blood sugar control are prone to the development of peripheral neuropathy, which results in decreased sensation in the feet and lower extremities.

Decreased sensation in the feet places the clientat increased risk for development of wounds or pressure ulcers in the feet. The nurse will know his plan of care is effective when the clients feet remain free of wounds. An aggressive exercise program would not be appropriate for a client with severely diminished sensation in the feet. Similarly, a 1,200-calorie diet would be inadequate for most clients. Being fitted for diabetic footwear is an intervention rather than a goal.

PTS:1DIFifficultREF:p. 1232; higher-order item implied from text KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Synthesis

12. Pressure ulcers are directly caused by which of the following conditionsat the site?

1) Compromised blood flow2) Edema3) Shearing forces4) Inadequate venous returnANS: 1 Pressure ulcers are caused by unrelieved pressure that compromises blood flowto an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and shear are extrinsic factors affecting skin integrity, which increases the risk of a client developing a pressure ulcer but is not the direct cause. Inadequate arterial blood flow to an area due to pressure causes the development of a pressure ulcer. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury.

PTS: 1 DIF: Difficult REF: p. 1230 KEY: Nursing process: Planning | Client need: HPM | Cognitive level:Comprehension 13. A patient hospitalized in a long-term rehabilitation facility is immobileand requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?

1) Stage II pressure ulcer2) Stage III pressure ulcer3) Stage IV pressure ulcer4) Unstageable pressure ulcerANS: 4 An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth.

PTS: 1 DIF: Moderate REF: p. 1234 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 14. A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as?

1) Stage I pressure ulcer, healing2) Stage II pressure ulcer, healing3) Stage III pressure ulcer, healing4) Stage IV pressure ulcer, healingANS: 4 Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are notreplaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing.

PTS: 1 DIF: Moderate REF: p. 1232 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 15. A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his

wound drainage would be most appropriatefor assessing fluid loss?

1) Draw a circle around the area of drainage on a dressing.

Classify drainage as less or more than the previous drainage.3) Weigh the patient at the same time each day on the same scale.4) Weigh dressings before they are applied and after they are removed.ANS: 4 By weighing the dressing before it is applied and after it is removed, the nurse can accurately determine the amount of drainage. Weighing the patient daily would evaluate his overall fluid balance but is not sensitive to fluid loss throughthe wound. Marking a circle around the wound is useful for determining the extent of drainage seeping out of a wound, but it does not provide information how much fluid is draining.

PTS:1DIF:ModerateREF:p. 1238 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Synthesis 16. A patient had a CVA (stroke) 2 days ago, resulting in decreased mobilityto her left side. During the assessment, the nurse discovers a stage I pressurearea on the patients left heel. What is the initial treatment for this pressure ulcer?

1) Antibiotic therapy for 2 weeks2) Normal saline irrigation of the ulcer daily3) Dbridement to the left heel Elevation of the left heel off the bedANS: 4 Pressure ulcers are caused by pressure to an area that restricts blood flow, causing ischemia to underlying tissue. The primary treatment is to relieve the pressure, thus improving blood flow. Elevating the patients left heel off the bedwould relieve pressure to this area.

PTS:1DIF:ModerateREF:p. 1231 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 17. Why is the information obtained from a swab culture of a woundlimited? 1) A positive culture does not necessarily indicate infection, because chronicwounds are often colonized with bacteria.

2) A negative culture may not indicate infection, because chronic wounds are often colonized with bacteria.

3) Most wound infections are viral, so the swab culture would not be indicative of awound infection.

4) A swab culture result does not include bacterial sensitivity informationnecessary to

provide treatment.

ANS: 1 The information obtained from a swab culture is limited because a positive culture may not indicate infection. Chronic wounds are often colonized with bacteria, but this does not require antibiotic treatment. A needle aspiration of the wound would provide more definitive information about whether the woundis infected or not and can be performed by a registered nurse. However, the most accurate wound information is obtained by tissue biopsy performed by a specially trained provider.

PTS:1DIF:ModerateREF:p. 1242 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 18. For the client with a stage IV pressure ulcer, what would an applicablepatient goal/outcome be?

1) Client will maintain intact skin throughout hospitalization.2) Client will limit pressure to wound site throughout treatment course.3) Wound will close with no evidence of infection within 6 weeks.4) Wound will improve prior to discharge as evidenced by a decrease in drainage.ANS: 3 The goal for any wound is for healing to take place with no complications (such as infection). Intact skin throughout hospitalization is not realistic with a stage IVpressure ulcer. Limiting pressure to a wound site is incorrect because total pressure relief must be provided to the area. Improved wound drainage before discharge is not a realistic expectation for a stage IV pressure ulcer.

PTS:1DIFifficultREF:p. 1234 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Synthesis 19. A man was involved in a motor vehicle accident yesterday. He is to be sedated for over 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis forhim at this time?

1) Risk for Infection related to subcutaneous injuries2) Risk for Impaired Skin Integrity related to immobility3) Impaired Tissue Integrity related to ventilator dependency4) Impaired Skin Integrity related to ventilator dependencyANS: 2 This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state.

Thus, he is unable to turn himself to relieve pressure. There is nomention of subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries.

Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses.

PTS:1DIF:ModerateREF:pp. 1235-1237 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 20. What intervention would be most appropriate for a wound with a beefyred wound bed?

1) Mechanical dbridement

2) Autolytic dbridement3) Dressing to keep the wound moist and clean4) Removal of devitalized tissue and a sterile dressingANS: 3 A red wound indicates active healing, and the best treatment is gentle cleansingand a dressing that will ensure a clean, moist wound environment. Dbridement is not necessary in this situation because there is no devitalized tissue present.

PTS: 1 DIF: Moderate REF: p. 1228 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 21. A patient has a stage II pressure ulcer on her right buttock. The ulcer iscovered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound?

1) Dry gauze dressing changed twice daily2) Nonadherent dressing with daily wound care3) Hydrocolloid dressing changed as needed4) Wet-todry dressings changed three times a day ANS: 3 A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion. It would also promote autolytic dbridement of the slough and absorb the exudate from the autolysis. Dry gauze and nonadherent dressing (e.g., Telfa) would cover the wound but would not aid in removing the slough. A wet-to-dry dressing is a form of mechanical dbridement. It would aid in removing the slough but is nonselective; therefore, itcould cause damage to healthy tissue as well.

PTS:1DIFifficultREF:pp. 1233, 1251, 1277; synthesis required KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 22. The nurse would know care for a stage II pressure ulcer is achieving thedesired goal when: 1) The ulcer is completely healed with minimal scarring.2) The patient reports no pain at the site.3) A minimal amount of drainage is noted.4) The wound bed contains 100% granulated tissue.ANS: 4 A healing wound contains granulating tissue. Although pain and drainage are indicators of inflammation, infection, and bleeding, no pain or drainage at thewound site does not indicate proper healing is occurring. A wound can heal leaving a scar.

PTS:1DIFifficult REF: p. 1227; higher-order item, answer can be derived from text KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 23. Your patient has a deep wound on the right hip, with tunneling at the 8 oclock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid

and contains 100% red beefy tissue in the wound bed. Ofthe following, which would be an appropriate dressing choice?

1) Alginate dressing2) Dry gauze dressing3) Hydrogel4) Hydrocolloid dressingANS: 1 Alginates are highly absorbent and are appropriate for wounds with moderate to large amounts of drainage. They are ideal for wounds with tunneling, as they willconform to fill the tunnel.

Gauze and hydrocolloids have limited absorptive ability. Gauze could adhere to the wound bed and cause trauma when removed. A hydrogel would increase the drainage, with the potential of macerating surrounding skin.

PTS:1DIF:ModerateREF:p. 1250 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 24. Of the following, which is the best choice for performing woundirrigation? 1) Water jet irrigation2) 35-cc syringe with a 19-gauge angiocatheter3) 5-cc syringe with a 23-gauge needle4) Bulb syringeANS: 2 A 35-cc syringe with a 19-gauge angiocatheter is the best choice for irrigation because it will deliver the irrigation solution at approximately 8 psi. The water jet irrigation unit and 5-cc syringe with a 23-gauge needle would deliver the solution above the recommended pressure range of 4 to 15 psi. A bulb syringe isnot an appropriate choice because there is an increased risk of aspirating drainage from the wound.

PTS: 1 DIF: Moderate REF: p. 1246 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 25. Your patient has multiple open wounds that require treatment. Whenperforming dressing changes, you should: 1) Remove all of the soiled dressings before beginning wound treatment.2) Cleanse wounds from most contaminated to least contaminated.3) Treat wounds on the patients side first, then the front and back of the patient.4) Irrigate wounds from least contaminated to most contaminated.ANS: 4 To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination.

PTS:1DIF:ModerateREF:p. 1249 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Synthesis 26. A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to theincision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? 1) Steri-Strips2) Abdominal binder3) T-

binder4) Paper tapeANS: 2 An abdominal binder provides added support to an incision site and decreases the risk of wound dehiscence. A T-binder is used in the perineal area. Steri-Stripsand paper tape would not be needed for an approximated incision that has intact staples, sutures, or surgical glue.

PTS:1DIF:EasyREF:p. 1253 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 27. A patient has an area of nonblanchable erythema on his coccyx. Thenurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient?1) Transparent film dressing2) Sheet hydrogel3) Frequent turn schedule4) Enzymatic dbridementANS: 3 The patient should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. A stage I wound is not open, soa dressing is not warranted.

Enzymatic dbridement is used to remove slough oreschar in an open wound. A transparent film dressing would protect the area.

However, the primary treatment is to relieve the source of pressure.

PTS:1DIF:ModerateREF:p. 1244 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 28. When applying heat or cold therapy to a wound, what should the nursedo? 1) Leave the therapy on each area no longer than 15 minutes.2) Leave the therapy on each area no longer than 30 minutes.3) When using heat, ensure the temperature is at least 135F (57.2C) beforeapplying it. 4) When using cold, ensure the temperature is less than 32F (0C) before applyingit. ANS: 1 Apply heat or cold therapies intermittently, leaving them on for no more than 15minutes at a time in an area. This helps prevent tissue injury and also makes thetherapy more effective by preventing rebound phenomenon. Temperatures should be kept between 59F and 113F (15C and 45C), depending on the type of therapy chosen and what is comfortable to the patient.

Temperatures colder or warmer than those recommended can damage tissue.

PTS:1DIF:EasyREF:p. 1254 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 29. A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound heals a little more he will suture it closed. The nurse recognizes that the surgeon isusing which form of wound healing?

1) Primary intention2) Regenerative healing3) Secondary intention4) Tertiary intentionANS: 4 Tertiary intention is a technique used when a wound is clean contaminated or dirty (potentially

infected). Initially, the wound is allowed to heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter,granulating tissue is brought together and the wound edges are sutured closed.

PTS:1DIF:ModerateREF:p. 1227 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 30. What is a common characteristic of aging skin?1) Increased permeability to moisture2) Diminished sweat gland activity3) Reduced oxygen-free radicals4) Overproduction of elastinANS: 2 Aging skin tends to be drier. Sweat gland activity is diminished. The skins connective tissue, collagen, and elastin are reduced, which means the skin losesfirmness and so wrinkles. Skin aging also occurs with exposure to oxygen-free radicals that are waste products from chemical reactions in the body as well as with exposure to certain food and environmental sources. An infants skin is thinner and more permeable to moisture in the environment.

PTS:1DIF:ModerateREF:p. 1224 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 31. Which client does the nurse recognize as being at greatest risk forpressure ulcers?

1) Infant with skin excoriations in the diaper region2) Young adult with diabetes in skeletal traction3) Middleaged adult with quadriplegia4) Older adult requiring use of assistive device for ambulationANS: 3 The client at greatest risk for pressure sores is the one with a lack of sensory perception at the site (e.g., quadriplegia). The infant with disruption to the skin from diaper rash is at risk for skin infection but not for a pressure sore. The young adult with diabetes is at increased risk for delayed wound healing but notlikely for a pressure sore because he would shift weight in bed and respond to discomfort of pressure on a bony site. The older adult is normally at risk for pressure injury, but when mobile, even with an assistive device, the risk is minimal.

PTS:1DIF:ModerateREF:p. 1224 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 32. The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be?Choose all that apply.

1) Is actively bleeding2) Has swollen, tender insect bite3) Has just sprained her ankle4) Has lower back painANS: 4 Heat therapy is used to relieve stiffness and discomfort commonly associated with musculoskeletal soreness. Heat causes dilation of the blood vessels and improves delivery of oxygen and nutrients to the tissues. It promotes relaxationand is used to aid in the healing process. Applying heat promotes vasodilation and reduces blood thickness (viscosity) and

leaky capillaries, all of which would be harmful to the patient who is actively bleeding. It can lead to a drop in bloodpressure. Heat should not be applied to a site with inflammation (insect bite or acute joint injury with swelling) because it can increase edema to the site. A good application for heat therapy is to promote comfort and relaxation to the patient experiencing back pain.

PTS:1DIF:ModerateREF:p. 1254 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Select the process(es) that occur(s) during the inflammatory phase ofwound healing. Choose all that apply.

1) Granulation2) Hemostasis3) Epithelialization4) InflammationANS: 2, 4 During the inflammatory phase of wound healing, hemostasis and inflammationoccur. After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site and aggregate to stop bleeding. Together, this results in hemostasis. Inflammation follows as a defense against infection at the wound site.

PTS: 1 DIF: Moderate REF: p. 1228 KEY:Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 2. What are two risk assessment tools used in the United States to evaluatea patients risk for pressure ulcers? Choose all that apply.

1) Pressure ulcer healing chart2) PUSH tool3) Braden scale4) Norton scaleANS: 3, 4 The Braden scale is a tool used to predict the risk of developing a pressure sore. Evaluation is based on six areas (indicators): sensory perception, moisture, activity, mobility, nutrition, and friction or shear. The Norton scale is another toolused to assess the risk for pressure ulcers based on the patients physical condition, mental state, activity, mobility, and incontinence.

These are the two most used risk assessment tools in the United States. Both of these tools are used to identify persons at high risk of pressure ulcer development. The PUSH tool provides a comprehensive means of reporting the progression of a pressure ulcer. Surface area, exudate, and type of wound tissue are scored and totaled.

The Pressure Ulcer Healing Chart is part of the PUSH tool, which is used tomonitor the progression of a pressure ulcer.

PTS: 1 DIF: Moderate REF: p. 1235 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

3. Which of the following are examples of nonselective mechanicaldbridement methods? Choose all that apply.

1) Wet-to-dry dressings2) Sharp dbridement3) Whirlpool4) Pulsed lavageANS: 1, 3, 4 Wet-to-dry dressings, sharp dbridement, and pulsed lavage are all forms of mechanical dbridement. They are nonselective forms, which means that healthytissue as well as devitalized tissue can be removed with their use. Sharp dbridement is a selective form of dbridement. With sharp dbridement, only devitalized tissue is removed.

PTS:1DIF:ModerateREF:p. 1248 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 4. Why is an accurate description of the location of a wound important?Choose all that apply.

1) Influences the rate of healing2) Determines the appropriate treatment choice 3)Will affect the frequency of dressing changes4) Affects patient movement and mobilityANS: 1, 4 Wounds in highly vascular areas heal more rapidly than wounds in less vascular regions.

Wounds that can be stabilized also heal more readily than those in areas of stress. Treatment choices and frequency of dressing changes will be dependent on the condition of the wound, not the location.

PTS:1DIF:ModerateREF:p. 1235 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis Completion Complete each statement.

1. Exposure to moisture leads to

of the skin, which increasesthe

likelihood of skin breakdown.

ANS: maceration By definition, maceration is the softening of a solid (e.g., the skin) by soaking itin a liquid.

PTS: 1 DIF: Easy REF: p. 1225 KEY:Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 2.

is total separation of the layers of a wound with internalviscera protruding through the incision.

ANS: Evisceration PTS:1DIF:ModerateREF:p. 1230 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

Chapter 33. Oxygenation Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The nurse is providing care to a pregnant woman in preterm labor. The patient is 32 weeks pregnant. Initially, the patient states, I’ve gained 30 pounds. That should be enough for the baby. Everything will be OK if I deliver now. After teaching the patient about fetal development, the nurse will know her teaching is effective if the patient makes which of the following statements?

1)The baby’s lungs are well developed now, but he will be at increased risk for SIDS if I deliver early.

2)We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early.

3)If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening.

4)Thanks for reassuring me; I was pretty sure there isnt much risk to the baby this far along in my pregnancy.

ANS: 3 Premature infants (younger than 33 weeks gestation) are born before the alveolar surfactant system is fully developed. Therefore, they are at high risk forrespiratory distress syndrome (RDS). RDS is characterized by widespread atelectasis (collapse of alveoli), usually related to a deficiency of surfactant thatkeeps air sacs open.

PTS:1DIF:ModerateREF:p. 1297 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 2. The nurse is caring for a patient who is experiencing dyspnea. Which of the following positions would be most effective if incorporated into the patientscare?

1) Supine2) Head of bed elevated 803) Head of bed elevated 304) Lying on left sideANS: 2 Position affects ventilation. An upright or elevated position pulls abdominal organs down, thus allowing maximum diaphragm excursion and lung expansion.

PTS:1DIF:EasyREF:p. 1303 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 3. While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which actionshould the nurse take immediately?

Clamp the chest tube close to the insertion site.2) Set up a new drainage system, and connect it to the chest tube.3) Have the patient take and hold a deep breath while the nurse reconnects thetube to the CDU. 4)

Place the disconnected end nearest the patient into a bottle of sterile water.ANS: 4 Recollapse of the lung can occur because of loss of negative pressure within the system. This is commonly caused by air leaks, disconnections, or cracks in the bottles or chambers. If any of these occur, the nurse should immediately place the disconnected end nearest the patient into a bottle of sterile water or saline to a depth of 2 cm to serve as an emergency water seal until a new system can be connected. Do not clamp the chest tube because this can rapidly lead to a tension pneumothorax. A new drainage system should be set up to decrease therisk of infection, but the immediate action is to place the disconnected end into a bottle of sterile water.

PTS:1DIF:ModerateREF:p. 1322 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 4. The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?

1) The amount of sputum the patient expectorates decreases with each doseadministered. Cough is completely suppressed, and she is able to sleep through the night.3) Dry, unproductive cough is reduced, but her voluntary coughing is moreproductive. 4) Involuntary coughing produces large amounts of thick yellow sputum.ANS: 3 Antitussives are cough suppressants that reduce the frequency of an involuntary, dry, nonproductive cough.

Antitussives are useful for adults when coughing is unproductive and frequent, leading to throat irritation or interruptedsleep. Expectorants help make coughing more productive. The goal of an antitussive/expectorant combination is to reduce the frequency of dry, unproductive coughing while making voluntary coughing more productive.

PTS:1DIFifficultREF:p. 1310 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 5. The nurse is admitting to the medical-surgical unit an older adult womanwith a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea.

What is the first action the nurse should take? 1) Review and implement the primary care providers prescriptions for treatments.2) Perform a quick physical examination of breathing, circulation, and oxygenation.3) Gather a thorough medical history, including current symptoms, from the family.

Administer oxygen to the patient through a nasal cannula.ANS: 2 The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation in order to determine the type of immediate intervention required. The nurses assessment should include simple questions about current symptoms. A more thorough medical history canbe gathered once the patients oxygenation needs are addressed. Following a quick assessment, the nurse should then review and implement physicians orders. Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed.

PTS:1DIF:ModerateREF:pp. 1301-1302

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 6. You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patients respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?

1) Biots breathing2) Kussmauls respirations3) Sleep apnea4) Cheyne-Stokes respirationsANS: 4 This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranialpressure due to brain injury.

PTS:1DIF:EasyREF:p. 1303 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 7. You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient?

1) Nonrebreather mask2) Nasal cannula3) Partial rebreather mask4) Venturi maskANS: 4 The Venturi mask is capable of delivering 24% to 50% FIO2. The cone-shaped adapter at the base of the mask allows a precise FIO2 to be delivered. This is very useful for patients with chronic lung disease. Rebreather masks are used when high concentrations of oxygen are required. A nasal cannula administers oxygen in liters per minute and does not allow administration of a precise FIO2.

PTS:1DIFifficultREF:p. 1335 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 8. Which of the following provide the most reliable data about theeffectiveness of airway suctioning?

1) The amount, color, consistency, and odor of secretions2) The patients tolerance for the procedure3) Breath sounds, vital signs, and pulse oximetry before and after suctioning4) The number of suctioning passes required to clear secretionsANS: 3 Breath sounds, vital signs, and oxygen saturation levels before and after suctioning provide data about the effectiveness of suctioning. Information aboutthe amount and appearance of secretions provides data about the likelihood of airway infection and/or inflammation. Data about the patients tolerance of suctioning provide information about the patients overall condition. The numberof suctioning passes required to clear the secretions provides information about the amount of secretions present.

PTS: 1 DIF: Moderate REF: p. 1351

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 9. What is the rationale for wrapping petroleum gauze around a chest tubeinsertion site?

1) Prevents air from leaking around the site Prevents infection at the insertion site3) Absorbs drainage from the insertion site4) Protects the tube from becoming dislodgedANS: 1 Petroleum gauze creates a seal around the insertion site. Collapse of the lung can occur if there is a leak around the insertion site that causes loss of negativepressure within the system. Air leaks are one common cause of loss of negative pressure.

PTS:1DIF:EasyREF:p. 1322 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 10. You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113,and respiratory rate is 30.

The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi inboth lungs. What is the most appropriate action to take?

1) Call the respiratory therapist to check the ventilator settings.2) Provide endotracheal suctioning.3) Provide tracheostomy care.

Notify the physician of the patients signs of fluid overload.ANS: 2 Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds during respiration, auscultation of adventitious breath sounds, and restlessness are signs that indicate the need for suctioning. Airways are suctioned to remove secretions and maintain patency. The patients symptomsshould subside once the airway is cleared. PTS: 1 DIF: Moderate REF: p. 1318, 1342 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 11. Chest percussion and postural drainage would be an appropriateintervention for which of the following conditions?

1) Congestive heart failure2) Pulmonary edema3) Pneumonia4) Pulmonary embolusANS: 3 Chest physiotherapy moves secretions to the large, central airways for expectoration or suctioning. This treatment is not effective for conditions that donot involve the development of airway secretions, including congestive heart failure, pulmonary edema, and pulmonary embolus.

PTS:1DIF:ModerateREF:p. 1313 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 12. Which of the following blood levels normally provides the primarystimulus for breathing?

1)

pH2) Oxygen3) Bicarbonate4) Carbon dioxideANS: 4 Carbon dioxide (CO2) level provides the primary stimulus to breathe. High CO 2 levels stimulate breathing to eliminate the excess CO2. A secondary, although important, drive to breathe is hypoxemia. Low blood O2 levels stimulate breathing to bring more oxygen into the lungs.

PTS:1DIF:ModerateREF:p. 1296 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 13. A 62-year-old man with emphysema says, My doctor wants me to quit smoking. Its too late now, though; I already have lung problems. Which of the following would be the best response to his statement?

1) You should quit so your family does not get sick from exposure to secondhandsmoke.

2) You will need to use oxygen, but remember it is a fire hazard to smoke withoxygen in your home.

3) Once you stop smoking, your body will begin to repair some of the damage toyour lungs.

4) You should ask your primary care provider for a prescription for a nicotine patchto help you quit.

ANS: 3 The nurses response should focus on correcting the patients misinformation rather than on convincing him to stop smoking. Once a person stops smoking, the body begins to repair the damage. During the first few days, the person will cough more as the cilia begin to clear the airways. Then the coughing subsides, and breathing becomes easier. Even long-time smokers can benefit from smoking cessation. The suggestions that the patients family will become ill and that oxygen is a fire hazard appear to be scare tactics, which can be seen as coercive, and would not be effective in motivating the patient to stop smoking. Although asking the primary care provider for a prescription may help the patient to stop smoking, it does not address his incorrect belief that it is too latefor him to do so.

PTS:1DIF:ModerateREF:p. 1299 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 14. The nurse administers intravenous morphine sulfate to a patient forpain control. She will need to monitor her patient for which of the following adverse effects?1) Decreased heart rate2) Muscle weakness3) Decreased urine output4) Respiratory depressionANS: 4

Opioids are potent respiratory depressants. Patients receiving opioids should be monitored for decreased rate and depth of respirations.

PTS:1DIF:ModerateREF:pp. 1299, 1305; critical-thinking and synthesis required KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level:Comprehension 15. When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct?

1) You will need a single pair of sterile gloves.2) Place the patient in semi-Fowlers position, if possible.3) Clean the stoma under the faceplate with hydrogen peroxide.4) Cut a slit in sterile 4 4 gauze halfway through to make a dressing.ANS: 2 Semi-Fowlers position promotes lung expansion and prevents back strain for thenurse. You will need two pairs of sterile gloves: one pair for dressing removal, and a clean pair for the rest of the procedure. You should clean the stoma underthe faceplate with sterile saline. Never cut a 4 4 gauze for the dressing because lint and fibers from the cut edge could enter the trachea and cause respiratory distress.

PTS: 1 DIF: Easy REF: p. 1338 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 16. A patient has just had a chest tube inserted to dry-seal suctiondrainage. Which of the following is a correct nursing intervention for maintenance?

1) Keep the head of the bed flat for 6 hours.2) Immobilize the patients arm on the affected side.3) Keep the drainage system lower than the insertion site.4) Drain condensation into the humidifier when it collects in the tubing.ANS: 3 The drainage system must be below the insertion site to prevent fluid flowingback into the pleural cavity and compromising the patients respiratory status. Maintain patient in semirecumbent position (head of bed elevated 30 to45 degrees), not flat. This is extremely important to promote lung expansion, reduce gastric reflux, and prevent ventilator-associated pneumonia (VAP), if theperson is being mechanically ventilated. Patients being mechanically ventilated are at high risk for developing VAP, which is associated with high mortality rates. Mouth rinses and mouthwashes are a part of the recommended routine for preventing VAP. They also provide comfort and preserve integrity of the mucous membranes.

Encourage the patient to move the arm on the affected side; if he cannot, perform passive range-of-motion. You should check the ventilator tubing frequently for condensation, and drain the fluid into a collection device or waste receptacle because condensation in the ventilator tubing can cause resistance to airflow. Moreover, the patient can aspirate it if it backflows down into the endotracheal tube. The fluid should not be drained into the humidifier because the patients secretions may have contaminated it.

PTS: 1 DIF: Difficult REF: p. 1353 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Multiple Response

Identify one or more choices that best complete the statement or answer thequestion.

1. The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Chooseall that apply.

1) Keep healthy snacks or gum available to chew instead of smoking a cigarette.2) Dont tell your friends and family you are trying to quit, until you feel confidentthat youll be successful.

3) Plan a time to quit when you will not have many other demands or stressors inyour life. 4) Reward yourself with an activity you enjoy when you quit smoking.ANS: 1, 3, 4 People who are trying to quit smoking often are more successful when they are accountable to other people who are encouraging and supportive. Having something to chew (e.g., carrot sticks, gum, nuts, or seeds) can distract from thedesire to smoke a cigarette. Setting a date to stop smoking and choosing a time of low stress are two strategies that help people be more successful with smoking cessation. Self-reward for meeting goals is a form of positive reinforcement.

PTS:1DIF:ModerateREF:p. 1311, ESG Self-Care: Smoking Cessation Tips KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Comprehension 2. A patient has a history of COPD. His pulse oximetry reading is 97%. Whatother findings would indicate adequate tissue and organ oxygenation? Chooseall that apply.

1) Normal urine output2) Strong peripheral pulses3) Clear breath sounds bilaterally4) Normal muscle strengthANS: 1, 2, 4 To determine adequacy of tissue oxygenation, assess respiration, circulation, and tissue/organ function. Good peripheral circulation is characterized by strong peripheral pulses. Impaired tissue oxygenation to the kidneys would result in abnormal kidney function (e.g., poor urine output). Hypoxic limb tissue would result in abnormal muscle functioning (e.g., muscle weakness and pain with exercise). Adequacy of tissue oxygenation cannot be determined by assessingpulmonary ventilation alone; circulation must also be assessed.

PTS:1DIFifficult REF: p. 1300; higher-order item, some of answer implied in text KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 3. The nurse is teaching a patient about her chest drainage system. Which of the following should the nurse include in the teaching? Choose all that apply.

1) Perform frequent coughing and deep-breathing exercises.2) Sit up in a chair but do not walk while the drainage system is in place.3) Get out of bed without assistance as much as possible.4) Immediately notify the nurse if she experiences increased shortness of breath.ANS: 1, 4

Patients should regularly perform coughing and deep-breathing exercises to promote lung reexpansion. Also to promote lung reexpansion, the nurse shouldencourage the patient to be as active as her condition permits, rather than telling her not to walk. Chest drainage systems are bulky, but patients with disposable systems can still get out of bed and ambulate. However, the patientwill need assistance from one or two staff members to protect and monitor the system and to monitor her responses to activity; she should not get out of bed on her own. If a patient with a chest drainage system becomes acutely short of breath, the patient should immediately notify the nurse so the nurse can check for occlusion of the system, which can result in a tension pneumothorax.

PTS:1DIF:ModerateREF:pp. 1313, 1358 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 4. When providing safety education to the mother of a toddler, you would inform the mother that, based on the childs developmental stage, he is at high risk for which of the following factors that influence oxygenation? Choose all thatapply.

1) Frequent, serious respiratory infections2) Airway obstruction from aspiration of small objects3) Drowning in small amounts of water around the home4) Development of asthmaANS: 2, 3 As a toddlers respiratory and immune systems mature, the risk for frequent and serious infections is less than in infanthood. Most children recover from upper respiratory infections without difficulty. Toddlers airways are relatively short andsmall and may be easily obstructed, and they often put objects in their mouth aspart of exploring their environment, thus increasing their risk for aspiration and airway obstruction. In addition, toddlers are at high risk for drowning in very small amounts of water around the home (e.g., in a bucket of water or toilet bowl). The risk for developing asthma is not significantly influenced by the childs developmental stage.

PTS:1DIF:ModerateREF:p. 1297 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Comprehension 5. Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Choose allthat apply.

1) Reduced alveolar-capillary gas exchange2) Lower respiratory tract infections3) Sleep apnea4) HypertensionANS: 2, 3, 4 Obesity causes multiple health problems, many of which affect the lungs, heart,and circulation.

Large abdominal fat stores press upward on the diaphragm, preventing full chest expansion and leading to hypoventilation and dyspnea on exertion. The risk for respiratory infection increases because lower lung segments are poorly ventilated, and secretions are not removed effectively.

When an obese person lies down, chest expansion is limited even more. Excessneck girth and fat stores in the upper airway often lead to obstructive sleep apnea. Obesity also increases the risk of developing atherosclerosis and hypertension. Obesity does not cause reduced alveolarcapillary gas exchange.

PTS: 1 DIF: Easy REF: p. 1299 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Comprehension 6. Which of the following is/are accurate about nasotracheal suctioning?Choose all that apply.

1) Apply suction for no longer than 10-15 sec during a single pass.2) Apply suction while inserting and removing the catheter.3) Reapply oxygen between suctioning passes for ventilator patients.4) Gently rotate the suction catheter as you remove it.ANS: 1, 4 Limiting suctioning to 10 seconds or less and reapplying oxygen between suctioning passes prevent hypoxia. Suction should be applied only while withdrawing the catheter, using a continuous rotating motion to prevent traumato the airway. Endotracheal suctioning is used when the patient is being mechanically ventilated, and most ventilator patients have in-line suctioning, sothere is no need to reapply oxygen.

PTS: 1 DIF: Moderate REF: p. 1347 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 7. Which of the following factors influence normal lung volumes andcapacities?

Choose all that apply.

1) Age 2) Race3) Body size4) Activity levelANS: 1, 3, 4 Normal lung volumes and capacities vary with body size, age, and exercise level. Volumes and capacities are higher in men, in large people, and in athletes.Race does not influence normal lung volumes and capacities.

PTS:1DIF:EasyREF:p. 1305 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 8. Of the following interventions, which is/are likely to reduce the risk of postoperative atelectasis? Choose all that apply.

1) Administer bronchodilators.2) Apply low-flow oxygen.3) Encourage coughing and deep breathing.4) Administer pain medication.ANS: 3, 4 Pain alters the rate and depth of respirations. Often, patients in pain breathe shallowly, which puts them at risk for atelectasis. Regularly assess all patientsfor pain. Once you have medicated the patient, reassess breath sounds, and encourage the patient to cough and breathe deeply. This will help to open air sacs and mobilize secretions in the airways.

PTS: 1 DIF: Moderate REF: pp. 1303, 1313 ; critical-thinking item that requires synthesis of

information KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Synthesis Completion Complete each statement.

1. is the movement of air into and out of the lungs throughthe act of breathing. refers to the exchange of gases (oxygen and carbon dioxide) in the lungs.

ANS: Ventilation; Respiration Pulmonary ventilation (breathing) is the movement of air into and out of the lungs.

Oxygenation of the blood, and ultimately of organs and tissues, depends on adequate ventilation. Respiration refers to gas exchangethat is, the oxygenation of blood and elimination of carbon dioxide in the lungs. Although the plural form respirations is used to mean breaths when taking vital signs, thisis a misnomer: You cannot measure gas exchange by counting breaths per minute.

PTS:1DIF:EasyREF:p. 1295 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 2.Prolonged use of high oxygen concentrations reduces production, which leads to alveolar collapse and reduced lung elasticity.ANS: surfactant Oxygen toxicity can develop when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours.

PTS:1DIF:ModerateREF:p. 1314 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall 3.The amount of air moved into and out of the lungs with each normal breath isknown as the . Normally, this volume is around mL. ANS: tidal volume; 500 PTS:1DIF:EasyREF:p. 1306 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Comprehension True or False 1. A positive TB skin test indicates that a patient has active tuberculosis.

ANS: F Patients with positive TB skin tests must undergo further testing (chest x-ray and sputum cultures) to determine whether they have merely been exposed tothe tuberculosis bacillus or whether they have active disease.

PTS:1DIF:EasyREF:p. 1305 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Recall

Chapter 38. Circulation and Perfusion

Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A patient diagnosed with hypertension is taking an angiotensin- converting enzyme (ACE) inhibitor. When planning care, which of the followingoutcomes would be appropriate for the patient?

1) BP will be lower than 135/85 mm Hg on all occasions.2) BP will be normal after 2 to 3 weeks on medication.3) Patient will not experience dizziness on rising.4) Urine output will increase to at least 50 mL/hrANS: 1 Goals must be clearly stated so that it is easy to evaluate if they have been met.BP . . . lower than 135/85 mm Hg . . . is clearly stated and easily evaluated. In contrast, BP will be normal . . . does not clearly state the desired endpoint.

Freedom from dizziness on rising is probably not achievable because ACE inhibitors are vasodilating agents, which may cause vessel dilation and hypotension, especially when the patient arises from a seated or lying position. Patients should be warned of this effect. The expected/desired effect of the ACEinhibitor is to lower the blood pressure; the urine output is minimally relevant indetermining that outcome, if at all.

PTS: 1 DIF: Difficult REF: pp. 1372-1373 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 2. You are preparing the nursing care plan for a middle-aged patient admitted to the intensive care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is mostappropriate? 1) Decreased Cardiac Output2) Impaired Tissue Perfusion3) Impaired Cardiac Contractility4) Impaired Activity ToleranceANS: 1 The patients symptoms reflect altered cardiac preload, a component of cardiac output. Acute myocardial infarction is often associated with decreased cardiac output as a result of altered cardiac pumping ability. Although the other nursing diagnoses might be associated with Decreased Cardiac Output, these diagnosescannot be determined from the symptoms presented.

Additionally, Impaired Cardiac Contractility is not a NANDA- I nursing diagnosis.

PTS: 1 DIF: Difficult REF: p. 1372 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 3. You are to connect a patient to a cardiac monitor. Which of the followingactions should you take to ensure an accurate electrocardiogram tracing?

1) Select electrode placement sites over bony prominences.2)

Apply the electrodes immediately after cleansing the skin, before the alcoholevaporates. 3) Before applying the electrodes, rub the placement sites with gauze until the skinreddens. 4) Ensure that the gel on the back of the electrodes is dry.ANS: 3 Electrodes should be placed over soft tissues or close to bone in order to obtain accurate waveforms. Sites over bony prominences, thick muscles, and skinfolds can produce artifact; therefore, they should not be used. Alcohol removes skin oils that may prevent the electrodes from adhering. However, the alcohol shouldbe allowed to dry before the electrodes are placed.

Rubbing the skin with gauze or a washcloth removes dead skin cells and promotes better electrical contact. Adry electrode will not conduct electrical activity; gel should not be dry.

PTS: 1 DIF: Moderate REF: p. 1377 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 4. Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?

1) Histamine2) Catecholamines3) Cortisol 4) ProteaseANS: 2 The stress response stimulates release of catecholamines from the sympatheticnervous system.

This results in increased heart rate and contractility, vasoconstriction, and increased tendency of blood to clot. Cortisol is also released in the stress response, but it is more indirectly related to developmentof cardiovascular disease through altered glucose, fat, and protein metabolism.

PTS: 1 DIF: Moderate REF: p. 1365 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 5. The nurse is teaching a pregnant woman about the increased oxygendemand that develops during pregnancy. The nurse knows the patient comprehends the teaching when she makes the following statement: 1) I may need to drink more fluids in order to make more oxygen.2) I may need to take an iron supplement so that I am not anemic.3) I will need a multivitamin supplement for several months.4) I will need to eat more fruits and vegetables.ANS: 2 During pregnancy, oxygen demand increases dramatically. To compensate, the mothers blood volume increases by 30%. The woman requires additional iron toproduce this blood as well as to meet fetal requirements. Failure to meet these iron demands can result in maternal anemia, reducing tissue oxygenation of themother. PTS: 1 DIF: Moderate REF: p. 1365-1366 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application

6. Which part of the ECG tracing represents ventricular repolarization?1) P wave2) QRS complex3) T wave4) U waveANS: 2 The QRS complex represents ventricular depolarization and leads to ventricular contraction.

The P wave represents the firing of the SA node and conduction of the impulse through the atria. In the healthy heart, this leads to atrial contraction. The T wave represents the return of the ventricles to an electrical resting state so they can be stimulated again (ventricular repolarization). The atria also repolarize, but they do so during the time of ventricular depolarization;thus, they are obscured by the QRS complex and cannot be seen on the ECG complex. The U wave is not always seen on the ECG but may be detected with electrolyte imbalance, such as hypokalemia or hypercalcemia. U waves sometimes occur in response to certain medication (e.g., digitalis, epinephrine). Inverted U wave may occur with ischemia to the cardiac muscle.

1.

1) KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 7. Three days ago a patient had cardiac surgery to bypass three occlusions of his coronary arteries. Veins for the bypass were harvested from his right leg. He informs the nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound erythema and swelling at the distal end of the incision.Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the patient has what kind of complication?

1) Deep vein thrombosis2) Dehiscence of the wound3) Internal bleeding4) Infection at the incisional siteANS: 1 Deep vein thrombosis (DVT) is a clot in the veins that are deep under the muscles of the leg.

DVT can occur after surgery, after lengthy bedrest, or aftertrauma. Symptoms include pain, warmth, redness, and swelling of the leg.

Dorsiflexion of the foot (pulling toes forward) and Pratts sign (squeezing calf to trigger pain) have not been found to be reliable in diagnosing DVT. Dehiscence isthe rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. Internal bleeding is a wound-healing complication associated with hematoma formation, pain, hypotension, and tachycardia.

Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevatedpulse and temperature).

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Nursing interventions to reduce the risk of clot formation in the legsinclude which of the following activities? Choose all that apply.

1)

Keep the patients hips and knees flexed while the patient is in bed.2) Apply compression devices (e.g., sequential compression devices).3) Turn the patient frequently or encourage frequent position changes.4) Promote adequate hydration by encouraging oral intake.ANS: 2, 3, 4 A Antiembolism stockings and SCDs are frequently used in perioperative patientsto promote venous return and prevent clot formation. Turn patients frequently;teach patients to change positions frequently. This prevents vessel injury from prolonged pressure in one position.

Promote adequate hydration to keep the blood from becoming viscous (thick). Viscous blood clots more readily.

PTS: 1 DIF: Difficult REF: p. 1373 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 2. Which of the following medications would you expect to be included in the treatment of a patient with congestive heart failure? Choose all that apply.

1) Nitrates2) Beta-adrenergic agents3) Diuretics4) AnticoagulantsANS: 2, 3 Beta-adrenergic agents block stimulation of beta receptors in the heart, lungs, and blood vessels and decrease heart rate, slow conduction through the AV node, and decrease myocardial oxygen demand by reducing myocardial contractility. Diuretics increase removal of sodium and water from the body through increased urine output. Diuretics reduce the volume of circulating bloodand prevent accumulation of fluid in the pulmonary circulation.

PTS: 1 DIF: Moderate REF: pp. 1373-1374 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 3. As the nurse caring for a patient who has suffered a myocardial infarction that has damaged the sinoatrial (SA) node, you should plan to monitor for which of the following potential complications? Choose all that apply.

1) Decreased heart rate2) Increased heart rate3) Decreased cardiac output4) Decreased strength of ventricular contractionsANS: 1, 3 Normally, the SA node is the primary pacemaker for the heart and initiates a rate of 60 to 100 beats per minute. If the SA node fails, the atrioventricular nodecan take over as the pacemaker, but it generally triggers a slower heart rate.

Cardiac output will decrease as a result of the decrease in heart rate. Damage tothe SA node interferes with the electrical activity of the heart but does not directly affect the pumping action of the heart.

PTS: 1 DIF: Difficult REF: pp. 1362-1363 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 4. Which outcome statement is related to Decreased Cardiac Output?Choose all that apply.

1) No dyspnea or shortness of breath with exertion2) Normal skin color3) Respiratory rate less than 16 breaths/min 4) Brisk capillary refill ANS: 1, 2, 4 Individualized goals/outcome statements depend on nursing diagnoses you identify for the patient. However, for a patient with compromised cardiac output,you might plan goals, such as no shortness of breath with exertion, brisk capillary refill in nailbeds, and normal skin color with no pallor. Respiratory rate of less than 16 breaths/min is hypoventilation and can lead to poor oxygenation and tissue acidosis. (See Chapter 39 for more information about acidbase balance.)

PTS: 1 DIF: Moderate REF: p. 1367 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 5. Your client is a healthy, older adult who has come to the health clinic because she reports not feeling like herself. When you are gathering data in yourclients health history, she tells you that she is feeling more fatigue when walkingup stairs and doing her normal household activities. What normal physiologic changes in the cardiovascular system occur with aging?

Choose all that apply.

1) Cardiac contractile strength is reduced.2) Heart valves become more rigid.3) Peripheral vessels lose elasticity.4) Heart responds to increased oxygen demands.ANS: 1, 2, 3 Cardiac efficiency gradually declines as the heart muscle loses contractile strength and heart valves become thicker and more rigid. The peripheral vesselsbecome less elastic, which creates more resistance to ejection of blood from the heart. As a result of these changes, the heart becomes less able to respond toincreased oxygen demands, and it needs longer recovery times after responding.

PTS: 1 DIF: Moderate REF: p. 1365 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension True or False Complete each statement.

1. Nicotine increases the risk for thrombus (blood clot) formation.ANS: T Nicotine increases the risk for thrombus formation because of its constrictingeffects on blood vessel walls.

PTS: 1 DIF: Easy REF: p. 1373 1)

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Comprehension 2. A troponin level is a laboratory test performed to determine how well the cells,tissues, and organs are supplied with oxygen.

ANS: F Troponin is a serum evaluation used to detect myocardial infarction (MI). Levelsof these contractile proteins remain elevated for up to 7 days after MI. Organ function indirectly evaluates the extent to which oxygen demands have been met in the cells, organs, and tissues.

PTS: 1 DIF: Difficult REF: p. 1370 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 3. Heat causes vasodilation, which decreases cardiac output and oxygenation. ANS: F Heat causes vasodilation, which increases cardiac output and oxygenation.PTS: 1 DIF: Easy REF: p. 1365 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension

Chapter 35. Hydration & Homeostasis Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which body fluid lies in the spaces between the body cells?1) Interstitial2) Intracellular3) Intravascular4) TranscellularANS: 1 Extracellular fluid lies outside the cells. It is composed of three types of fluid: interstitial, intravascular, and transcellular. Interstitial fluid lies in the spaces between the body cells. Intracellular fluid is contained within the cells.

Intravascular fluid is the plasma within the blood. Transcellular fluid includes specialized fluids, such as cerebrospinal, pleural, peritoneal, and synovial; anddigestive juices.

PTS:1DIF:EasyREF:p. 1383 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 2. Chloride, bicarbonate, phosphate, and sulfate are examples of what typeof charged particles and why?

1) 1) Cations, because they carry a positive charge2) Cations, because they carry a negative charge3) Anions, because they carry a positive charge4) Anions, because they carry a negative chargeANS: 4 Anions are electrolytes that carry a negative charge; they include chloride, bicarbonate, phosphate, and sulfate. Electrolytes that carry a positive charge are called cations.

Cations include sodium, potassium, calcium, and magnesium.

PTS:1DIF:ModerateREF:p. 1383 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension 3. A patient is brought to the emergency department (ED) by paramedics after a person standing on the sidewalk saw him fall on a crowded street. He has a history of alcoholism and is frequently brought to the ED. The nurse finds thepatient to be disoriented; he has periods of being calm mixed with episodes of being disruptive and loud.

His vital signs are the following: BP 138/84 mm Hg; pulse 135 beats/min, regular and strong; respiratory rate 22 breaths/min; temperature 37.1C (98.1F). What electrolyte imbalance might the nurse suspect?

1) Hypomagnesemia2) Hypocalcemia3) Hyperkalemia4)

HypernatremiaANS: 1 Hypomagnesemia is a frequent consequence of alcoholism. Signs and symptoms include disorientation, mood changes, and tachycardia. Hypocalcemia, a low calcium level, is associated with muscle spasms and tetany. Hyperkalemia, a high potassium level, manifests as weakness, fatigue, and cardiac dysrhythmias.Hypernatremia, a high sodium level, produces extreme thirst and agitation.

PTS:1DIFifficultREF:p. 1392 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 4. The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following?

1) Osmosis2) Filtration3) Hydrostatic pressure4) DiffusionANS: 4 Diffusion is a passive process by which molecules move from an area of higher concentration to an area of lower concentration. Osmosis is the movement of water across a membrane from an area of a less-concentrated solution to an area of more- concentrated solution. Filtration is the movement of water and smaller particles from an area of high pressure to low pressure.

Hydrostatic pressure is the force created by fluid within a closed system.

PTS: 1 DIF: Moderate REF: p. 1384 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 5. A client is admitted to the emergency department (ED) in respiratory distress. The results of his arterial blood gases are the following: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse interprets the findings as which of the following?

1) Respiratory acidosis with normal oxygen levels2) Respiratory alkalosis with hypoxia Metabolic acidosis with normal oxygen levels4) Metabolic alkalosis with hypoxiaANS: 3 The pH is acidotic. The HCO3 of 19 mEq/L is low and has moved in the same direction as the pH, indicating a metabolic disorder. The PCO2 is within normal range with no signs of compensation. The PO2 level is normal.

PTS: 1 DIF: Difficult REF: pp. 1393-1395 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 6. A patient is admitted to the emergency department (ED) in respiratory distress. The results of his first arterial blood gases were: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse evaluates the patients treatment plan by examining repeat arterial blood gases (ABGs). The results are: pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/L. The nurse

concludes which of the following?

1) Respiratory acidosis; the treatment plan is ineffective.2) Metabolic alkalosis; the treatment plan is effective.3) Partial compensation; the treatment plan is ineffective.4) Full compensation; the treatment plan is effective.ANS: 4 Full compensation has occurred as the P CO2 has returned the pH to the normal range. This change indicates that the treatment plan is effective. Partial compensation would be indicated by changes in the P CO2, but the pH would still be outside the normal range. The ABG is now complete compensation metabolicacidosis. PTS: 1 DIF: Difficult REF: pp. 1393-1395 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis 7. When a patient has metabolic acidosis, which body system influences the acidbase imbalance to produce the compensatory changes in the arterial bloodgases? 1) Respiratory system2) Renal system3) Vascular system4) Neurological systemANS: 1 In a metabolic problem, the respiratory system compensates. In a respiratoryproblem, the renal system must compensate. The respiratory system compensates early in the disorder, but it may take up to 3 days for the renal system to compensate fully.

PTS:1DIF:ModerateREF:p. 1394 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis 8. A patients arterial blood gas results are as follows: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. An appropriate nursing diagnosis for the patient is which of the following?

1) Impaired Gas Exchange2) Metabolic Acidosis3) Risk for Impaired Gas Exchange4) Risk for Acid-Base ImbalanceANS: 1 An appropriate diagnosis is Impaired Gas Exchange. The arterial blood gas (ABG) results provide the defining characteristics for Impaired Gas Exchange. The ABG results demonstrate metabolic acidosis; however, this is not a nursing diagnosis. The patient has an actual problem; therefore, the risk for nursing diagnoses are incorrect. Additionally, there is no nursing diagnosis of AcidBase Imbalance or Risk for AcidBase Imbalance.

PTS:1DIF:ModerateREF:p. 1401 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 9. The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the clients electronichealth record. Which one should the

nurse question?

1) Administer an IV of D5W at 125 mL/hr. 2) Strict I&O monitoring.3) Restrict oral intake to 900 mL every 24 hr.4) Monitor serum electrolytes every 4 hr.ANS: 3 Restricting the oral intake of a patient with hypernatremia (Na+ greater than 145 mEq/L) would lead to further elevation in the serum sodium level. Infusing D5W IV fluid is appropriate, as this solution does not contain sodium. Hydrating the patient with D5W would reduce the serum sodium level. Strict I&O monitoring and laboratory evaluation of electrolytes every 4 hr would ensure that the patient is safely rehydrated. PTS:1DIFifficultREF:p. 1391 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 10. Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?

1) Diffusion2) Osmosis3) Filtration4) Active transportANS: 4 Active transport occurs when molecules move across cell membranes from an area of low concentration to an area of high concentration. Active transport requires energy expenditure for the movement to occur against a concentrationgradient. In the presence of ATP, the sodiumpotassium pump actively moves sodium from the cell into the extracellular fluid.

Active transport is vital for maintaining the unique composition of both the extracellular and intracellular compartments. Diffusion, osmosis, and filtration are passive processes.

PTS: 1 DIF: Difficult REF: p. 1385 KEY:Nursing process: N/A | Client need: PHSI| Cognitive level: Comprehension 11. The nurse records a patients hourly urine output from an indwellingcatheter as follows: 0700: 36 mL 0800: 45 mL 0900: 85 mL 1000: 62 mL 1100: 50 mL 1200: 48 mL 1300: 94 mL 1400: 78 mL 1500: 60 mL The nurse can conclude that the patients urine output should be described aswhich of the following?

1)

Low2) Within normal limits3) High 4) InconclusiveANS: 2 Urine accounts for the greatest amount of fluid loss. Normal urine output for an average- sized adult is approximately 1,500 mL in 24 hr. Urine output varies according to intake and activity but should remain at least 30 to 50 mL per hour.The patients urine output is within the normal range. This patient has an indwelling catheter, which will result in continual flow of urine.

PTS:1DIF:ModerateREF:p. 1385 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis 12. Which of the following is the principal site for regulation of fluid andelectrolyte balance?

1) Cardiac system2) Vascular system3) Pulmonary system4) Renal systemANS: 4 A balance of fluid and electrolytes is essential to maintain homeostasis. Excesses or deficits can lead to severe disorders. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the bodys fluid and electrolyte balance.

The heart and vascular system are involved in fluid balance but not in electrolyte balance and not as dramatically in fluid balance as are the kidneysthat is, they do not actually regulate electrolytes. The pulmonary system plays a major role in regulation ofacidbase balance.

PTS:1DIF:EasyREF:p. 1386 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Comprehension 13. Which electrolyte is the primary regulator of fluid volume?1) Potassium2) Calcium3) Sodium4) MagnesiumANS: 3 Sodium is the major cation in the extracellular fluid (ECF). Its primary function is to regulate fluid volume. When sodium is reabsorbed in the kidney, water and potassium are also reabsorbed, thereby maintaining ECF volume. Potassium is akey electrolyte in cellular metabolism. Calcium is responsible for bone health and neuromuscular and cardiac functions. It is also an essential factor in blood clotting. Magnesium is a mineral used in more than 300 biochemical reactions inthe body.

PTS:1DIF:EasyREF:p. 1386 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 14. An 82-year-old woman was brought to the emergency department byher granddaughter. She is a widow and lives alone, although her granddaughterchecks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours.

Physical examination reveals the following: T = 99.6F (37.6C) orally; P = 110 beats/min weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states thatshe feels very weak. The following are her laboratory results: Sodium

138 mEq/L

Potassium

3.7 mEq/L

Calcium

9.2 mg/dL

Magnesium

1.8 mg/dL

Chloride

99 mEq/L

BUN

29 mg/dL

The nurse recognizes that the patient is displaying symptoms associated withwhich of the following?

1) Hypovolemia2) Hypervolemia3) Hypernatremia4) HyponatremiaANS: 1 Hypovolemia may occur as a result of insufficient intake of fluid; bleeding; excessive loss through urine, skin, or the gastrointestinal tract; insensible losses;or loss of fluid into a third space. The first symptom of hypovolemia is thirst.

Other symptoms are a rapid weak pulse, a low blood pressure (although initially the blood pressure may rise), dry skin and mucous membranes, decreased skin turgor, and decreased urine output. Temperature increases because the body is less able to cool itself through perspiration. The person with fluid volume deficit usually has elevated BUN (blood urea nitrogen) and hematocrit levels.

Hypervolemia involves excessive retention of sodium and water in the extracellular fluid, and the vital sign changes are opposite those of a patient with hypovolemia. Hypernatremia and hyponatremia are not applicable becausethe patients sodium level is within normal range.

PTS:1DIFifficultREF:p. 1390 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 15. A patient has been vomiting for 2 days and has not been able to eat ordrink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6F (37.6C) orally; P = 110 beats/min weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium

138 mEq/L

Potassium

3.7 mEq/L

Calcium

9.2 mg/dL

Magnesium

1.8 mg/dL

Chloride

99 mEq/L

BUN

29 mg/dL

Which of the following is an appropriate nursing diagnosis for this patient?1) Impaired Gas Exchange related to ineffective breathing2) Excess Fluid Volume related to limited fluid output3) Deficient Fluid Volume related to abnormal fluid loss4) Electrolyte Imbalance related to decreased oral intakeANS: 3 Vomiting has made this patient hypovolemic; therefore, she has deficient fluid volume. There is no information to indicate that she has respiratory problems orImpaired Gas Exchange. Her symptoms are not consistent with Excess Fluid Volume. Electrolyte Imbalance is not a nursing diagnosis.

PTS:1DIFifficultREF:p. 1400 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 16. Which of the following is the most appropriate goal for a patient withthe nursing diagnosis of Deficient Fluid Volume?

1) Electrolyte balance restored, as evidenced by improved levels of alertness andcognitive orientation 2) Electrolyte balance restored, as evidenced by sodium returning to normal range3) Patient demonstrates effective coughing and deep breathing techniques.4) Maintains fluid balance, as evidenced by moist mucous membranes andurinating every 4 hours ANS: 4 Moist mucous membranes and urinating every 4 hours would demonstrate restoration of fluid balance. Electrolyte imbalance does not necessarily occur with Deficient Fluid Volume; if electrolyte imbalance were present, the nursingdiagnosis would be different. There is no evidence that this patient has a respiratory problem, so coughing and deep breathing are irrelevant.

PTS:1DIF:ModerateREF:p. 1401 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

17. Which laboratory results on a clients health record should alert thenurse to a potential problem?

1) Na+ = 137 mEq/L 2) K+ = 5.2 mEq/L 3) Ca2+ = 9.2 mg/dL 4) Mg2+ = 1.8 mg/dL ANS: 2 A potassium level of 5.2 mEq/L indicates hyperkalemia. The other results are allwithin normal ranges.

PTS:1DIF:ModerateREF:p. 1386 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level:Comprehension 18. A patients vital signs prior to a blood transfusion were: T = 97.6F (36.4C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complainingof feeling itchy and hot. The nurse discovered a rash on the patients trunk. Vitalsigns were: T = 100.8F (38.2C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention?

1) Administer an antihistamine (anti-allergenic) medication.2) Flush the blood tubing with D5W immediately. 3) Prepare for emergency resuscitation.4) Stop the blood transfusion immediately.ANS: 4 The nurse should suspect a transfusion reaction. When a transfusion reaction is suspected, the infusion should be stopped immediately. The blood bag and tubing must be sent to the laboratory for analysis. A new IV line of normal salineshould be hung.

Diphenhydramine (an antihistamine) may be ordered once the physician has been notified of the patients condition. There is no information indicating that the patient is in danger of cardiovascular collapse or requires resuscitation.

PTS: 1 DIF: Moderate REF: p. 1417 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 19. A patient is receiving an IV infusion of lactated Ringers solution and 40 mEq of KCl at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth.

There is a palpable cord along the vein, and the infusionis sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following?

1) Infiltration2) Extravasation3) Hematoma4) PhlebitisANS: 4

Phlebitis is an inflammation of the vein. It may be caused by the infusion of solutions that are irritating to the vein. Patients receiving IV solutions with potassium chloride are at a higher risk for phlebitis, as it is irritating to the vein.The symptom of a palpable cord along the vein distinguishes this as phlebitis.

Infiltration presents as erythema, pain, and swelling. However, there is no palpable cord with inflammation. Extravasation is infiltration of a vesicant substance into the tissues. Differentiating symptoms include blanching and coolness of the surrounding skin; the formation of blisters and subsequent tissue sloughing and necrosis are later signs. A hematoma is a localized mass of bloodoutside the blood vessel. This is generally seen when a vein is nicked during an unsuccessful insertion of an IV line or when an IV line is discontinued without pressure applied over the site.

PTS:1DIFifficultREF:p. 1412 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 20. The nurse assesses that her patients intravenous solution has infiltratedinto the tissues. What action should she take first?

1) Aspirate, then inject 0.5 mL normal saline.2) Restart the IV line in a different vein.3) Stop the infusion immediately.4) Notify the primary care provider.ANS: 3 The nurse should first stop the infusion to avoid further tissue trauma. Because the IV has infiltrated, you must assume that the nurse has already checked thepatency of the line by aspirating. There is no point in injecting saline because doing so puts even more fluid in the tissues. Injecting fluid to try to clear a clot from the catheter is not recommended because of the possibility of causing an embolism. Once the infusion is stopped, the nurse must assess whether the patient needs additional IV therapy. If so, a new IV line must be restarted abovethe site of infiltration or in the opposite arm. The nurse may need to inform theprimary care provider if she is unable to find a new IV site or if she believes the patient no longer needs an IV. PTS:1DIF:ModerateREF:p. 1411 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 21. The physician has ordered a complete blood count for a 6-year-old child.When the nurse enters the room, she finds the child sobbing uncontrollably. His mother tells him to shut up and act your age. How should the nurse proceed?

1) Request that the mother leave the room immediately.2) Request the help of a coworker to hold the child down.3) Inform the child that this wont hurt a bit.4) Calmly approach the child and tell him what is going to happen.ANS: 4 Having blood drawn may be uncomfortable and frightening for a 6-year-old child. A calm approach can alleviate some of the fear. Explain to the childs mother that the boys behavior is normal. Informing the child that the blood drawwill not hurt is wrong and will make him distrustful of future interventions. The nurse may need the help of a coworker, but she should first try a calm approach.

PTS: 1 DIF: Moderate REF: p. 1399; not found in text; critical thinking required

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 22. A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A microdrip infusion set is being used. What is the drip rate (drops/min) that the nurse should monitor?

1) 60 2) 75 3) 125 4) 250 ANS: 3 Calculate the drip rate by multiplying the number of milliliters to be infused perhour (hourly rate) by the drop factor in drops/mL, divided by 60 minutes. An infusion of 250 mL in 2 hours results in an hourly rate of 125 mL/hr.

125 (mL/hr) 60 (drops/mL) = 125 drops/min 60 min PTS:1DIF:ModerateREF:p. 1410 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 23. The nurse examines the electrocardiogram (ECG) tracing of a client andnotes tall T waves. What electrolyte imbalance should the nurse suspect?

1) Hypokalemia2) Hypophosphatemia3) Hyperkalemia4) HypercalcemiaANS: 3 Potassium levels affect the heart. A tall, peaked T wave on an ECG is associatedwith hyperkalemia. A flat T wave is associated with hypokalemia. Phosphorous levels do not trigger ECG changes.

PTS:1DIF:ModerateREF:p. 1391 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension 24. The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T =

37C (98.6F). What disorder should the nurse suspect? 1) Hypovolemia2) Hypercalcemia3) Hyperkalemia4) HypervolemiaANS: 4 Hypervolemia results from retention of sodium and water. Blood pressure rises,the pulse is bounding, and neck veins become distended due to increased intravascular volume.

PTS:1DIF:ModerateREF:p. 1390 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 25. A patient has a continuous IV infusion at 60 mL/hr. The right hand IV has infiltrated and the nurse has started a new IV on the left forearm. Which of the following interventions should the nurse also perform?

1) Elevate the patients left forearm.2) Schedule daily dressing changes to the new IV site.3) Change the administration set.4) Place the patient in Fowlers position.ANS: 3 Reusing an IV set from a previous site increases the risk of contamination. IV dressings are usually changed every 72 to 96 hours when the IV site is rotated. There is no reason to elevate the patients left forearm or to place him in Fowlersposition.

PTS:1DIF:EasyREF:p. 1414 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 26. When performing a central venous catheter dressing change, which ofthe following steps is/are correct?

1) Wear sterile gloves while removing and discarding the soiled dressing. 2) Apply pressure on the catheter-hub junction when removing the soiled dressing.3) Place a sterile transparent dressing over the site and the catheter-hub junction.4) Have the patient wear a mask or turn his head away from the site.ANS: 4 Aseptic technique should be used with approaching the insertion site. Therefore,both nurse and patient should wear a mask. If the patient cannot wear a mask, have him turn his head away from the insertion site during the procedure.

Sterile gloves should be worn when placing the new sterile dressing; however, procedure gloves are used to remove the soiled dressing. The nurse should stabilize the catheter while removing the soiled dressing but not apply pressureto the catheter-hub junction. The transparent dressing should cover the hub of the catheter, but not the catheter-hub junction; this makes it too difficult to remove without disturbing the integrity of the IV line or the site. PTS: 1 DIF: Difficult REF: p. 1432 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application

Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. In a healthy adult, which of the following regulate(s) body fluids? Chooseall that apply.

1) Hormone levels2) Fluid intake3) Oxygen saturation4) Kidney functionANS: 1, 2, 4 A balance between fluid intake and output is essential to maintain homeostasis. Excesses or deficits of intake can lead to severe disorders. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source offluid output.

Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the bodys fluid and electrolyte balance. Oxygen saturation does not regulate fluids. It measures the saturation of oxygen on hemoglobin and is influenced by the partial pressure of oxygen, alveolararterial gradient lung disease, and the amount and type of hemoglobin (such as sickle cell anemia).

PTS:1DIF:ModerateREF:pp. 1385-1386 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension 2. A patient has been admitted to the nursing unit with a diagnosis of chronic renal failure. She will be dialyzed for the first time the following morning.Which of the following are appropriate nursing interventions for the patient?

Choose all that apply.1) Encourage oral fluid intake as desired.2) Place the patient on strict I&O.3) Weigh the patient before and after dialysis. 4) Maintain a total fluid restriction of 1,000 mL as prescribed.ANS: 2, 3, 4 Fluids are restricted in patients with chronic renal failure because of decreasedrenal function.

Therefore, encouraging oral fluids would not be appropriate.

Appropriate nursing interventions for this patient include monitoring the intakeand output, weighing the patient before and after dialysis, following a strict renal diet, and monitoring laboratory values.

PTS:1DIF:ModerateREF:p. 1391-1393, 1402; critical thinking required KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 3. Identify the mechanism(s) involved in acidbase balance. Choose all thatapply.

1) Respiratory mechanisms2) Active transport mechanisms3) Renal mechanisms4) Buffer systemsANS: 1, 3, 4 Acidbase balance is regulated by respiratory mechanisms, renal mechanisms, and buffer systems. Acidbase regulation can be monitored by examining arterialblood gases, especially blood pH. Buffer systems prevent wide swings in pH by absorbing or releasing free hydrogen ions. The lungs (respiratory mechanisms)

control the carbonic acid supply via carbon dioxide. Conditions that cause retention of carbon dioxide, such as chronic obstruction pulmonary disease, lower the pH, whereas tachypneic conditions, such as hyperventilation syndrome, blow off carbon dioxide and increase the pH. The kidneys (renal mechanisms) regulate the concentration of plasma bicarbonate. By reabsorbingor excreting bicarbonate, the kidneys affect acidbase balance. Active transport involves the movement of fluids and electrolytes in the body. PTS:1DIF:ModerateREF:p. 1389 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension 4. Identify the appropriate intervention(s) for a patient with hypovolemia.Choose all that apply.

1) Teach deep-breathing techniques.2) Monitor I&O daily.3) Encourage fluid intake.4) Monitor electrolyte balance.ANS: 2, 3, 4 Hypovolemia occurs when more fluid is lost than is taken into the body. Monitoring I&O provides information to evaluate the status of the problem. Encouraging fluid intake helps to correct the problem. It is good to monitor electrolytes because electrolyte imbalance can occur with hypovolemia (although it may not occur at first). Deep- breathing techniques do not addressfluid balance; there is no evidence that the patient has a respiratory disorder.

PTS:1DIF:EasyREF:p. 1390 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application 5. A patients blood group is B. The nurse knows the patient can receiveblood only from donors with what group(s) of blood? Choose all that apply.

1) A 2) B 3) O 4) AB ANS: 2, 3 Persons with blood group B can receive blood only from the blood groups B and O. Those with blood group AB may receive AB, A, B, and O blood. Blood group A persons may receive blood from A and O donors. Persons with blood group O may receive blood only from O donors. Blood group AB persons are considereduniversal recipients, and blood group O persons are considered universal donors. PTS:1DIF:ModerateREF:p. 1416 KEY: Nursing process: Analysis/Diagnosis | Client need: SECE | Cognitive level: Analysis 6. A nurse is caring for a patient with a peripheral IV line located in the right forearm.

The patient informs the nurse that the IV site is burning. Upon assessment the nurse determines that the IV solution has infiltrated. What site(s) is/are appropriate to consider when restarting the IV line? Choose all that apply.

Left hand2) Right wrist3) Right antecubital area4) Right saphenous veinANS: 1, 3 When restarting an IV line after an infiltration, you must restart above the site of infiltration. As a result, the right antecubital area is correct. The opposite extremity (e.g., left hand) may also be used. The right saphenous vein is incorrect because that vein is located in the leg. The leg should be used as a lastresort for an IV site. The primary care provider should be notified if a leg is beingconsidered as an IV site.

PTS:1DIFifficultREF:p. 1414 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 7. A patient has been diagnosed with hypovolemia. Which order(s) for hydration should the nurse question? Choose all prescriptions that should bequestioned.

1) 0.9% (normal) saline at 100 mL/hr 2) Lactated Ringers solution at 100 mL/hr Total parenteral nutrition solution at 100 mL/hr4) D5W solution at 100 mL/hr ANS: 3, 4 Hypovolemia occurs when there is a proportional loss of water and electrolytes from the ECF. Lactated Ringers and 0.9% (normal) saline are isotonic fluids that remain inside the intravascular space, thus increasing volume. The D5W is a hypotonic solution that would pull body water from the intravascular compartment into the interstitial fluid compartment. Total parenteral nutrition isa hypertonic fluid used to provide nutrition for the patient who cannot meet caloric needs by eating or enteral nutrition.

PTS: 1 DIF: Difficult REF: p. 1390 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 8. When assisting with bedside central venous catheter (CVC) placement,which nursing intervention is appropriate? Choose all that apply.

1) Don sterile gloves and mask (and possibly gown).2) Scrub the insertion site with antibacterial soap for 1 min.3) Verify that informed consent has been obtained.4) Place the patient in low Fowlers position. ANS: 1, 3 Maximum barrier sterile technique is used for CVC insertion (sterile gloves, mask, and gown), although some agency policies do not include sterile gown forthe nurse. This is an invasive procedure, so informed consent is required. The nurse should confirm that this has been obtained. The scrub is not done with antibacterial soap. The scrub is done with chlorhexidinealcohol solution or, alternatively, first with 70% alcohol and then with povidone detergent. The patient is placed in Trendelenburg position with a rolled towel between the shoulders for best site access.

PTS: 1 DIF: Difficult REF: p. 1441 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Completion Complete each statement.

1.

are substances that develop an electrical charge whendissolved in

water.

ANS: Electrolytes PTS:1DIF:EasyREF:p. 1382 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 2.A(n) is any compound that contains hydrogen ions thatcan be released.

ANS: acid PTS:1DIF:EasyREF:p. 1389 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 3.A(n) is a compound that combines with (accepts)hydrogen ions in a solution.

ANS:base alkali PTS:1DIF:ModerateREF:p. 1389 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall

Chapter 36. Care of the Surgical Patient

Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The preoperative phase encompasses which period of time?1) Entry to the operating suite until admission to postanesthesia care2) Entry into the operating suite until discharge from the hospital3) The decision to have surgery until admission to postanesthesia care4) The decision to have surgery until entry to the operating suiteANS: 4 The preoperative phase begins with the decision to have surgery and ends whenthe patient enters the operating room. The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit.

PTS:1DIF:EasyREF:p 1448 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 2. A 2-year-old child is scheduled for a tonsillectomy. When determining theplan of care, the nurse should: 1) Include the parents or caregivers in the plan of care.2) Explain to the child that she will have a sore throat after surgery.3) Tell the child that she can have her favorite foods for the first 24 hours aftersurgery. 4) Prepare the child for discharge from the hospital as soon as she is alert.ANS: 1 It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Be sure to include these people in the plan of care.

Developmentally, a 2-year-old lives in the here and now and wouldnt grasp an intangible concept, such as pain in the future. The toddler would take liquids andsoft foods within the first 24 hours when her throat is sore during swallowing.

She should not eat foods that are rough and crunchy because they may scratchher throat and cause bleeding. After a tonsillectomy, the child will need to be monitored for bleeding and stable vital signs; therefore, she will not be discharged as soon as she is alert.

PTS: 1 DIF: Moderate REF: pp. 1449, 1455 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Synthesis 3. Which of the following is the most appropriate nursing goal for a 2-year-old who is to have a tonsillectomy?

1) Separation anxiety will be minimal.2) The child will verbalize understanding of expected pain.3) The child will tolerate a normal diet 24 hours after surgery.4) The parent will indicate readiness to assume the childs care.ANS: 1 The only concrete information in this question is that the child is 2 years old. Therefore, the

only problem the nurse can reasonably predict from this would bedevelopmental in nature. It is developmentally normal for toddlers to experienceanxiety with separation from parents or caregivers. Minimizing anxiety by involving the parents or caregivers would be the appropriate goal for separation anxiety. A 2-year-old child would not be expected to verbalize understanding of expected pain. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding.Nurses should encourage parental involvement, but parents should not be expected to assume the childs care.

PTS:1DIFifficult REF: p. 1449; critical-thinking question requiring synthesis of previously learned knowledge KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 4. The focus of nursing activities in the preoperative phase is to:1) Admit the patient to the surgical suite.2) Prepare the patient mentally and physically for surgery.3) Set up the sterile field in the operating room.4) Perform the primary surgical scrub to the surgical site.ANS: 2 The nursing focus in the preoperative phase is to prepare the patient mentally and physically for surgery. The patient is in the intraoperative phase when admitted to the surgical suite. The sterile field and the surgical scrub would beperformed in the surgery suite during the intraoperative phase.

PTS:1DIF:EasyREF:p. 1451 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 5. A patient is scheduled for abdominal surgery tomorrow. While gathering preoperative data, the nurse learns that the patient takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. Thepatient reports that he stopped taking the anticoagulant 4 days ago as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, the nurse notifies the surgeon because she: 1) Needs an order to restart the anticoagulant.2) Is concerned about continued use of the multivitamin.3) Has canceled the surgery so more lab tests can be done.ANS: 3 Both prescribed and over-the-counter medications may increase surgical risk. Many herbs can cause potassium loss and increase the risk for cardiac arrhythmias. High doses of vitamin E may increase the risk for bleeding. This patients use of 1,500 IU of vitamin E daily exceeds the recommended dosage, sothe nurse should inform the surgeon of the vitamin E intake. Generally, the surgeon or anesthesiologist instructs patients to continue or discontinue takingtheir prescribed medicines. However, it is important to assess use of supplements and over-the-counter medicines. The nurse cannot cancel surgery without an order from the surgeon, who determines whether the surgery should be delayed or whether it is so urgent that it needs to continue as scheduled, even with the additional risk factor of the vitamin E dosage.

PTS:1DIFifficultREF:p. 1450

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 6. A patient is admitted for hip surgery. The patient usually takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. He stopped taking his anticoagulant 4 days ago as instructed by his surgeon, but has continued to take the multivitamin and vitamin E. An importantproblem for this patient is which of the following?

1) Potential complication: anemia2) Risk for infection related to inadequate anticoagulant dosage3) Risk for bleedingANS: 4 The patient is at an increased risk for bleeding due to his intake of vitamin E. Hemay be at risk for anemia if he experiences a large blood loss in surgery; however, this problem is not appropriate before he experiences the blood loss. This patient does not have a higher-thanaverage risk for infection because he isnot having surgery involving a contaminated system (e.g., the gastrointestinal system). There is no evidence to suggest that this patient is noncompliant simply because he stopped taking his anticoagulant as ordered.

PTS:1DIFifficultREF:p. 1450 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 7. A patient is admitted from a local skilled nursing facility to the outpatientsurgery center for surgical dbridement of a stage IV sacral pressure ulcer. The perioperative nurse discovers that the patient does not have a signed consent form for the surgery on the chart or in the surgery center. The patient says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the patient sign the informed consent form, and he will review it prior to the surgery.What should the nurse do?

1) Follow the surgeons orders, and ask the patient to sign the surgical consentform. 2) Inform the surgeon that she will have the patient sign after he discusses thesurgery with the patient.

3) Ensure that the signed surgical consent is witnessed by two nurses, because thesurgeon is not available.

4) Cancel the surgery and transfer the patient back to the long-term care facility.ANS: 2 Informed surgical consent requires that the surgeon present information about the surgery to the patient, that the patient understands the information and agrees to the surgery, and that the patient has not been coerced to give consent. As a patient advocate, the nurse should verify with the patient that thesurgeon has explained the procedure and answered all her questions. The surgeon is responsible for giving the patient the necessary information and determining the patients competence to make an informed decision about the surgery. If the patient has further questions, the nurse should notify the surgeonand delay sending the patient to surgery until an

informed consent is obtained.

PTS:1DIFifficultREF:p. 1455, 1458 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 8. Identify the type of surgery a terminally ill patient will undergo if thepurpose is removal of tissue to relieve pain.

1) Procurement2) Ablative3) Palliative4) DiagnosticANS: 3 Palliative surgery alleviates discomfort or other disease symptoms without producing a cure.

Procurement surgery occurs when an organ or tissue is harvested for transplantation into another. Ablative surgery involves removal ofa body part.

Diagnostic surgery confirms or negates a diagnosis.

PTS:1DIF:EasyREF:p. 1449 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 9. A patient had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the patient is in the PACU rather than back in his room on the postsurgical unit. The nurse shouldinform the family that: 1) Patients who have had surgical complications are observed in the PACU untilthey are stable enough to return to the floor.

2) Patients recover from the effects of anesthesia in the PACU and then return tothe postsurgical unit for further care.

3) The PACU is a holding area for patients awaiting a surgical unit bed or awaiting adequate staff to provide care on the postsurgical unit.

4) The nurse will ask the surgeon explain to them why the patient is not on thepostsurgical unit, as is the usual procedure.

ANS: 2 A client remains in the PACU until he has recovered from the effects of anesthesia. In the PACU, the client is assessed every 5 to 15 minutes in order to quickly identify surgical or anesthesia-related problems. Most surgical units routinely admit patients to the PACU for a period of observation. Admission to the PACU does not indicate surgical complications or imply that a holding area isrequired. There is no reason the surgeon would need to explain this to the family, as the nurse could communicate the procedure. It is not usual procedurefor a patient to be transferred directly from surgery to the postsurgical unit.

PTS:1DIF:ModerateREF:p. 1471

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level:Application 10. The focus of nursing care in the intraoperative phase is to:1) Prepare the patient for surgery.2) Maintain the sterile field.3) Ensure patient safety during the surgery.4) Obtain a signed informed consent.ANS: 3 The intraoperative phase begins when the patient enters the operating suite andends when the patient is admitted to the postanesthesia care unit. The nursing focus is to ensure patient safety during the surgical procedure by functioning as an advocate when clients cannot advocate for themselves and by monitoring the client and surgical environment throughout the procedure. Although the sterile field must be maintained in this phase and sterility contributes to patient safety, the focus of care is broader than the maintenance of sterility. Obtaining informed consent and preparing the patient for surgery are activities associatedwith the preoperative phase.

PTS:1DIF:EasyREF:p. 1463 KEY: Nursing process: Planning | Client need: SECE | Cognitive level:Comprehension 11. The nurse has a prescription to give a series of medications on an oncall basis. The nurse realizes that these medications will be given: 1) In the postanesthesia recovery unit.2) At the time specified in the order.3) On the patients arrival in the surgery suite.4) When the OR staff notify the nurse to do so.ANS: 4 The anesthesia team may order medications to be given on call if the surgery time is likely to vary. The nurse will give on call medications when he is notifiedto do so by the OR staff.

PTS:1DIF:EasyREF:p. 1460 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 12. A patient has chronic confusion secondary to dementia. As a result, heis unable to sign an informed consent for surgery. In this situation: 4) An informed consent is not needed.2) Two nurses may sign the informed consent for the patient.3) The surgeon must sign the informed consent.4) A family member will be asked to sign the informed consent.ANS: 4 In most states, a family member, conservator, or legal guardian may give consent for a procedure if a patient is not capable of giving an informed consentor if the patient is a minor.

PTS:1DIF:ModerateREF:p. 1458 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 13. The patient tells the nurse, Im so nervous. I want to be knocked out for the surgery so that I dont know what is going on. When the nurse communicateswith the surgeon and anesthetist, she tells them that the patient desires which type of anesthesia? 1) Conscious sedation2)

General anesthesia3) Local anesthesia Regional anesthesiaANS: 2 General anesthesia produces rapid unconsciousness and loss of sensation. During conscious sedation, the client feels sleepy but is easily aroused by touch or speech. Regional anesthesia interrupts nerve impulses to and from the affected area, but the patient remains alert. Local anesthesia produces loss of pain sensation at the desired site and is typically used for minor procedures. Theclient remains alert during local anesthesia.

PTS:1DIF:EasyREF:p. 1464 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 14. A patient is to have a sequential compression device (SCD) applied on the postoperative unit.

The patient is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do?

1) Remove the antiembolism stockings and not replace them.2) Replace the knee-high stockings with thigh-high stockings.3) Notify the surgeon that the patient is wearing antiembolism stockings.4) Apply the SCD over the knee-high antiembolism stockings.ANS: 4 If elastic stockings have been ordered with the sequential compression device, leave them in place; if the patient is not yet wearing them, obtain them and put them on the patient. Knee-high stockings do not need to be replaced with thigh-high stockings. Some research has shown knee-high stockings to be equally effective. There is no need to notify the surgeon, as patients commonly return from surgery wearing antiembolism stockings, as prescribed.

PTS: 1 DIF: Moderate REF: p. 1490 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Surgeries are commonly classified by which of the following? Choose allthat apply.

1) Acuity2) Level of urgency3) Length of surgery4) Organ involvedANS: 1, 2 Surgeries can be classified by body systems, purpose, level of urgency, and degree of seriousness (acuity). The length of surgery and organ involved are notused for classifying surgeries.

PTS:1DIF:ModerateREF:p. 1449 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis 2. Which of the following describes the Perioperative Nursing Data Set?Choose all that

apply.

1) A standardized tool for assessing high-risk surgical patients2) A standardized vocabulary encompassing all surgical patient outcomes3) The first specialized nursing language recognized by the ANA4) A standardized language designed to describe the care of perioperative patientsANS: 3, 4 The Perioperative Nursing Data Set (PNDS) is a standardized vocabulary specifically designed to describe the care of perioperative clients. It consists of 74 nursing diagnoses, 133 nursing interventions, and 28 nurse-sensitive patientoutcomes appropriate for use in any surgical setting. It was the first specialty language recognized by the ANA. PTS:1DIFifficultREF:p. 1451 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 3. The nurse is caring for a patient who had abdominal surgery 3 days agoand will be discharged home later today. The nurse will know that teaching is effective if the patient does which of the following? Choose all that apply.

1) Describes clinical findings associated with infection2) Performs the dressing change as prescribed3) Demonstrates absence of surgical incision pain4) Completes the regimen of prescribed antibioticsANS: 1, 2, 4 The nurse would know that patient teaching was effective if the patient verbalizes signs and symptoms of infection, can perform the ordered dressing change, and completes the regimen of ordered antibiotics. Nurses cannot teacha patient to be free of pain. Pain is subjective. The nurse can teach the patient strategies to assist with pain, but they may not remove the pain completely.

PTS:1DIF:ModerateREF:p. 1481 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 4. Which of the following members of the operative team use steriletechnique during the surgical procedure? Choose all that apply.

1) Surgeon2) Anesthetist3) Scrub nurse4) Registered nurse first assistantANS: 1, 3, 4 The anesthetist is a member of the clean team and remains outside the sterile field. Members of the sterile team include the surgeon, the scrub nurse, and theregistered first nurse assistant.

PTS:1DIF:ModerateREF:p. 1463 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 5. A young adult woman is scheduled for a bilateral breast reduction undergeneral anesthesia. She is normally healthy and takes no daily medications.

Identify the preoperative screening tests appropriate for this patient. Choose allthat apply.

1) Urinalysis2) EKG3) Creatinine clearance4) CBC ANS:1, 4 Preoperative screening tests are ordered to determine if the client has undetected underlying health concerns. Most institutions require a complete blood count (CBC) and urinalysis prior to all surgical procedures. Generally, an electrocardiograph (ECG) is ordered for clients over the age of 50 years or withknown cardiac disease. A creatinine clearance is not a routine presurgical screening test.

PTS: 1 DIF: Moderate REF: pp. 1451, 1454 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 6. Identify the desired effects of general anesthesia. Choose all that apply.1) Reduction of risk2) Analgesia3) Amnesia4) Muscle relaxationANS: 2, 3, 4 General anesthesia is used to control pain (analgesia), relax muscles, and promote amnesia.

Anesthesia is not used for the purpose of obtaining a reduction in risk potential; however, surgical risk is influenced by the type ofanesthesia used.

PTS: 1 DIF: Moderate REF: p. 1464 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension 7. The preoperative nurse is preparing a patient for surgery. Identify the interventions the nurse will perform. Choose all that apply.

1) Inform the family to wait in the surgical waiting room.2) Prepare the surgical suite for the operation.

3) Remove the patients dentures and contact lenses.4) Assist the patient to complete a living will.ANS: 1, 3 Before being transported to the operating suite, the patient must remove all artificial body parts, such as dentures, artificial limbs, or contact lenses. Wigs, eyeglasses, makeup, and jewelry must also be removed. The nurse will also inform the patients relatives where they may wait during the surgery. The surgical suite will be prepared by the surgical team. It is not necessary to have aliving will prior to surgery. However, the nurse will ask the patient if there is onewhen obtaining the nursing history.

PTS:1DIF:ModerateREF:p. 1459 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 8. A patient had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor which of the following activities would thenurse perform for the purpose of decreasing the risk of postoperative complications? Choose all that apply.

1)

Assist the patient to turn, breathe deeply, and cough every 2 hours.2) Teach the patient about the type of tumor removed.3) Assess the drainage from the surgical site.4) Monitor vital signs on a regular basis.ANS: 1, 3, 4 The nurse assists the patient to turn, breathe deeply, and cough every 2 hours in order to decrease the risk of postoperative atelectasis or pneumonia. The nurse assesses the wound drainage to monitor for signs of bleeding, infection, orwound complications.

Vital signs are monitored to detect the potential for infection or hemorrhage, not to prevent them. The nurse may teach the patient about cancerous tumors; however, this intervention will not decrease the risk of postoperative complications.

PTS:1DIF:ModerateREF:p. 1472 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Comprehension 9. A patient returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Choose allthat apply. 1) Wear nonsterile procedure gloves when emptying the drainage container.2) When irrigating the nasogastric tube, use sterile water.3) Wear sterile gloves when irrigating the nasogastric tube.4) Apply water-soluble lubricant if the patients lips are dry.ANS: 1, 4 Nonsterile procedure gloves are to protect the nurse and other patients against microorganisms that might be present in body fluids; wearing them is in observance of standard precautions.

For patients with an NG tube, frequent oralcare, including water- soluble lubricant for dry lips, is important. Sterile gloves are not needed for irrigating the NG tube because the nasal passages, esophagus, and stomach are not sterile. Sterile normal saline and a sterile syringe are used for irrigation, however. Sterile water is not used; saline compensates for electrolytes lost through NG drainage.

PTS:1DIF:ModerateREF:pp. 1492-1493 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Completion Complete each statement.

1.

surgery is the type of surgery that replaces amalfunctioning body part,

tissue, or organ.

ANS: TransplantNot applicable PTS:1DIF:EasyREF:p. 1449 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 2.

surgery is a surgery that is scheduled within 24 to 48hours to alleviate symptoms, repair a body part, or restore function.

ANS: Urgent Not applicable PTS:1DIF:EasyREF:p. 1449 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall

3. The

registered nurse is responsible for preventingpositioning

injuries to the patient.

ANS: circulatingNot applicable PTS:1DIF:ModerateREF:p. 1463 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

Chapter 37. Community & Home Health Nursing

Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The inhabitants of Yulupa, California, form which of the following?1) Aggregate2) Community3) Population4) Vulnerable populationANS: 3 A population is all of the people inhabiting a specified area. In contrast, a community is a group of like-minded individuals or one whose members have acommon purpose, and an aggregate has shared characteristics. A vulnerable population is an aggregate with increased risk for poor health outcomes.

PTS: 1 DIF: Moderate REF: p. 1499 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Application 2. A community health nurse prepares for a new assignment. She has been assigned census tracts 131 and 132. This large area crosses the border of two towns and includes 4,000 people. What components of the community must thecommunity health nurse assess prior to beginning her new assignment?

1) Income levels, health status, and relationships among groups2) Structure of the tracts, effectiveness of the community, and current status3) Number of clients with health problems compared to the number of healthcareproviders 4) Community organizations and beliefs about their role in the communityANS: 2 To understand a community and its needs, the nurse must assess the communitys structure, status (the biological, social, and emotional outcome components of the community), and process (overall effectiveness of the community). Income level and demographic data, such as community organizations and healthcare providers, are included in the assessment of the community structure. The number of clients with health problems is only a partof the assessment of the community status.

PTS:1DIFifficultREF:p. 1500 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Analysis 3. A community health nurse is evaluating the current health programs in the community. Which of these outcomes would indicate a healthy community?

1) Ninety percent of members report adequate access to primary care services.2) Immunization services are available at hospitals and clinics.3) Affordable housing in the community is under construction.4) Mortality rates have been stable over the past 5 years.ANS: 1 Evidence of health in a community can be judged by examining progress in thefocus areas delineated in Healthy People 2020. Access to primary care servicesis a measurable outcome

that provides evidence of effectiveness of health programs. The availability of immunization services at the hospital or at many offices does not provide evidence that these services are being utilized.

Similarly, the fact that affordable housing is under construction does not mean that it is being accepted and used or that enough is being built. Mortality rates may be stable but could be quite high and within unacceptable parameters.

PTS:1DIFifficultREF:p. 1500 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis 4. What is the type of nursing with a focus on the community as a wholeand the health status of individuals as an aggregate?

1) School nursing Community health nursing3) Community-oriented nursing4) Public health nursingANS: 4 Public health nursing focuses on the community at large and the eventual effectof the communitys health status on the health of individuals, families, and groups. Community health nursing focuses on the health of individuals, families,and groups and on how their health affects the health of the community.

Community-oriented care combines elements of community health nursing andpublic health.

School nursing focuses on optimizing health for a community of students in a school setting.

PTS: 1 DIF: Moderate REF: p. 1501 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 5. The community health nurse is working with the residents of governmentsubsidized senior housing. She meets with them regularly to discuss concerns and evaluate whether they receive healthcare that meets theirneeds. Which of the following nursing roles best describes these actions?

1) Case manager2) Client advocate3) Collaborator Counselor5) EducatorANS: 3 As a collaborator, the nurse forges partnerships and coalitions that can effectively address common concerns among different communities. In this role,the nurse facilitates discussion to work toward problem resolution. As a case manager, the nurse makes referrals to or collaborates with other health and social agencies. In the client advocate role, the nurse supports the identified or voiced concerns of the client or community. As an educator, the nurse focuses on wellness and disease prevention through patient teaching. A counselor offerspractical solutions to resolve problems.

PTS:1DIF:ModerateREF:p. 1502 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application

6. A community health nurse gathers information about how individuals in a low- income neighborhood perceive the community and its state of health. Which of the following assessment strategies would be appropriate?

1) Conducting a windshield survey while driving2) Reviewing a multitude of community databases3) Interviewing residents living on every fifth block4) Analyzing demographic data on the community ANS: 3 To assess community perceptions, the nurse will need to interact with a cross-section of the community. Interviewing residents is one way to find out about community concerns and opinions. The other methods are assessment strategies that will provide data about the community but do not offer information on how community members view the community.

PTS:1DIF:ModerateREF:pp. 1506-1507 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Application 7. The community health nurse has gathered data about the community. She identifies many weaknesses in the community health system that contributeto poor health outcomes. What should be her next step?

1) Prioritize the list of problems.2) Validate the data.3) Evaluate the effectiveness of the interventions.4) Plan the care.ANS: 1 After a thorough assessment, the nurse compiles a list of community strengthsand weaknesses. Once this list is in place, the nurse must prioritize the list considering the client needs, funding, and political feasibility.

PTS:1DIF:ModerateREF:p. 1507 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 8. The similarities between the Omaha System and the NANDA-I taxonomyare that both contain which of the following?

1) Evaluation tools expressed in standardized language2) Nursing diagnoses expressed in standardized language3) Diagnoses, outcomes, and interventions4) Labels that are intended for use in any healthcare settingANS: 2 NANDA-I and the Omaha System both contain nursing diagnoses expressed in standardized language. The Omaha System also contains outcomes and interventions.

The Omaha System was developed for use in community settings, whereas NANDA-I may be used in all settings.

PTS:1DIF:ModerateREF:p. 1507 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 9. A nurse serving the community in a public health role would likelyperform which of the following functions within a particular community?

1) Tracking the prevalence of gonorrhea between January and June2) Screening for scoliosis among 12- to 14-year-old girls in middle school3) Weighing premature infants receiving phototherapy at home4) Giving the H1N1 vaccine to fire and police personnelANS: 1 Public health nursing focuses on the community at large and the eventual effectof the communitys health status on the health of individuals, families, and groups. The goal of public health is to prevent individual disease and disability, in addition to promoting and protecting the health of the community as a whole,such as tracking the prevalence of disease. Activities, such as scoliosis screening, home care, and vaccination program, are examples of community health nursing.

PTS:1DIF:ModerateREF:p. 1501 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application 10. A community health nurse planning a new program for teen pregnancy prevention designs a community assessment covering the structure of her target. Which of the following areas would she include?

1) Number of residential and commercial buildings2) Demographic data of the residents3) Morbidity and mortality rates of the population4) Common strategies for conflict resolutionANS: 2 1) Structure refers to the general characteristics of a community. These include demographic data, such as gender, age, ethnicity, and educational and income levels, as well as data about healthcare services, such as the number of primarycare providers or emergency departments in the area.

PTS:1DIF:ModerateREF:p. 1500 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level:Application 11. A patient was involved in a motor vehicle accident that resulted in multiple traumatic injuries. He was hospitalized for 8 days in the intensive careunit and 3 days on the surgical floor. He has been discharged home with home health support. Identify the primary goal of his home care: 1) Provide comprehensive direct care.2) Promote sleep and rest for healing.3) Teach the patient and family how to provide care.4) Explain how home care differs from hospital care.ANS: 3 The primary goal in home healthcare is to promote self-care. Nursing activitiesare directed at fostering independence or teaching the family or other caregivers to assist the client with ongoing needs. Care continues to be comprehensive; however, rather than providing direct care for all needs, the emphasis shifts toward fostering independence.

PTS:1DIF:ModerateREF:p. 1510 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

12. Today is the last day of work on the medical-surgical unit for a nurse who has decided to work in home care. A patient asks her why she is going to home care. Select a response that best illustrates the advantages of home care.

1) Care is much more comprehensive and unhurried in the home; it is moreenjoyable for nurses to work in home care.

2) Home care is much more organized than hospital care; you have access to thewhole team, and there is less interference from others.

3) A home health nurse has more autonomy and skills than a hospital nurse; Ill getto do more.

4) In home care I can see my patients in their personal environment; this will helpme understand them more and allow me to give personalized care.

ANS: 4 1) The home is the clients personal environment: a window into the patients life. The nurse is able to see how the patient lives, interacts, and negotiates the world. Care, in the home and hospital, is comprehensive. In both locations, the nurse has obligations to other patients and will need to watch her schedule. Thelevel of enjoyment a nurse has with her job is dependent on many factors. A disadvantage to home care is the lack of immediate assistance from other members of the health team. Home care nurses may be more autonomous thanhospital nurses; however, their scope of practice is identical.

PTS:1DIF:ModerateREF:p. 1511 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 13. A 56-year-old man is hospitalized because of poorly controlled diabetes and a leg ulcer that developed as a complication of diabetes. He is awake, alert,and oriented but fatigued and in need of wound care. In the hospital, he was placed on insulin and started on a variety of oral medications. He is learning how to check his blood sugar and administer insulin. He has never given himselfinsulin, and he does not understand how to interpret his blood sugar readings.

The physician has prescribed discharge from the hospital with home healthfollow-up. Is this an appropriate referral?

1) Yes; the patient is in need of skilled services and, therefore, is eligible for homecare services.

2) Yes; the patient has been unable to control his diabetes, is noncompliant, andneeds to be monitored.

3) No; the patient should remain hospitalized; he has too many needs for homecare services.

4) No; the patient is relatively young and oriented; he should be able to provide hisown care.

ANS: 1 A client must require skilled services in order to be eligible for home care services. This patient needs wound care, to be taught about diabetes care, andto be monitored. These are all skilled

services. All of these needs can be met with home care services. He is alert and oriented, which is important for planning teaching sessions.

PTS:1DIFifficultREF:p. 1511 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Synthesis 14. A home health nurse is working with a physical therapist and home health aides to work out a schedule for their visits that will best address the patients needs. Which nursing role does this demonstrate?

1) Direct care provider2) Client and family educator3) Client advocate4) 1) Care coordinatorANS: 4 A care coordinator manages and coordinates the services of members of the healthcare team and develops a plan of care that addresses the clients needs. Direct care involves hands-on tasks, such as dressing wounds and administering medications. The educator role involves communicating with clients and familiesto help them develop the skills involved to administer self-care. A client advocate supports the clients right to make decisions and protects the client from harm if he is unable to make decisions.

PTS:1DIF:EasyREF:p. 1512 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 15. A home health nurse has called his patient to arrange an initial homevisit and has driven to the home. What is the nurses objective in the first few minutes of the visit?

1) Develop rapport and trust with the patient and family.

2) Gather demographic data and complete the referral form.

3) Assess the patients most important health needs.

4)Determine the patients needs for ongoing care.

ANS: 1 All of these objectives are appropriate for the home health visit. However, the first few minutes of the initial visit set the tone for the relationship among client,nurse, family, and agency. In that time, the nurse focuses on developing rapportand trust. Once rapport and trust have been developed, the nurse can gather data, assess the client, and determine the need for ongoing care.

PTS: 1 DIF: Moderate REF: p. 1516 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Synthesis 16. Documentation in home healthcare may take many forms. Some nursesuse NANDA-I terminology for diagnoses, whereas others use the Clinical Care Classification (CCC) system. The chief benefit of the CCC system is that it: 1) Contains diagnoses specific to home care, whereas NANDA-I does not.

2) Is simpler to use and more readily understood by other disciplines.3) Is linked to the OASIS reporting forms required by Medicare.4) Uses standardized terminology, whereas NANDA-I does not.ANS: 3 Home care nurses more commonly use the CCC because it is linked to the OASIS reporting forms required by Medicare. The CCC was developed for use in homecare; however, the

diagnoses themselves are not specific to home care. They can be used in any setting.

NANDA-I, NIC, and NOC all use standardized language that may be used in any setting, including home healthcare. NIC andNOC have some interventions and outcomes that are specific to home care use.

PTS:1DIF:ModerateREF:p. 1517 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 17. A 56-year-old woman provides care to her 91-year-old widowed father.She says 1) she is frequently fatigued and that she no longer socializes with her friends. Im so busy taking care of my dad. Its really hard work because he is bedridden. Sometimes it breaks my heart when I have to feed and bathe him. He always seemed so strong when I was a child. The most appropriate nursing diagnosis for this woman is: 1) Caregiver Role Strain2) Impaired Home Maintenance3) Interrupted Family Processes 4) Risk for Caregiver Role StrainANS: 1 This caregiver is experiencing fatigue, isolation, and difficulty adjusting to role changes. These are signs of Caregiver Role Strain. Because symptoms exist, thisis an actual problem as opposed to a potential problem. There is no evidence of Impaired Home Maintenance.

Although family processes have been altered, this is not the best nursing diagnosis based on the defining characteristics given.

PTS: 1 DIF: Moderate REF: p. 1517 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application 18. The nurse is visiting a patient who lives in a single-room occupancy hotel. The patient requires wound care and medication management. There is no running water in the room, and the bathroom down the hall is in disrepair andfilthy. The patients room is not clean. What supplies would be essential for the nurse to bring with him when visiting this client?

1) All wound care supplies needed for the duration of the care2) Reclosable plastic bags for disposal of old dressings3) Small, biohazard sharps container to be left in the room4) Waterless, antibacterial hand sanitizer solutionANS: 4 The nurse should use a waterless antibacterial hand sanitizer in place of soapand water because there is no sink and conditions are filthy. The nurse should limit the supplies brought into the home if the conditions are not clean. Woundcare supplies, for example, would be ordered and kept in the home. Old dressings should be doublebagged to prevent leakage, and discarded in thehome. There is no evidence that a sharps disposal container is needed.

PTS: 1 DIF: Moderate REF: p. 1520 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

19. Which of the following unique aspects of home care do Medicare reimbursement regulations require that the nurse include in documentation? 1) 1) Patient assessment data and interventions performed2) Patient response to care and assessment of environment3) Evidence of homebound status and continued need for skilled care4) Skilled care delivered and communication with other providersANS: 3 All of the aspects mentioned should be documented. However, the unique requirements of home care include documentation of homebound status and thecontinued need for skilled care.

PTS:1DIF:ModerateREF:p. 1513 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level:Application 20. At a home visit, the nurse asks the patient, Have you taken your blood pressure medicine today?

The patient replies, I dont remember. Maybe. On the table are several bottles of medication, some open, some not. They have all been prescribed for the patient. The patient cannot say how often to take eachone, when asked.

A compartmentalized medication organizer is on the table, with a few capsules in it, and some compartments left open. What should the nurse do?

1) Show the patient how to put the medications in the organizer for the next 2days, and observe while he fills the rest of the organizer.

2) Arrange for a home health aide to come each day to show the patient which pillsto take.

3) Administer todays medications and arrange for the pharmacy to put medicationsin easyto-open containers in the future.

4) Fill the organizer for each day of the week, explain how to use it, and return in aday or two to evaluate ANS: 4 From the cues given, it seems likely the patient would not be able to accurately load the medication organizerand, in fact, may not be able to use it properly to take the correct medications at the correct time. The nurse would need to returnevery day or so until he is certain that the patient can actually administer his own meds after someone else loads the organizer.

Showing the patient how to load the organizer solves part of the problem; however, this would not allow the nurse to evaluate whether the patient would then know to take the medications each day. Home health aides cannot be responsible for patient medications.

There is no indication that the patient is having difficulty opening his medication containers, so there is no need to talk to the pharmacy.

PTS:1DIFifficult REF: p. 1519; critical thinking needed to answer question KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 21. A family caregiver is learning to administer insulin injections to herhomebound sister.

What should the nurse advise her to do with the used needles?

1) Discard the needle and syringe in a thick plastic milk jug with a lid.2) Securely recap them and place them a paper bag in the household trash.3) Remove the needle and put it in a coffee can with a lid; put the syringe in thetrash.

4)Do not recap the needle; break it by bending it on the tabletop.ANS: 1 1) The caregiver should discard the syringe and needle in a thick plastic milk jugwith a lid, a metal coffee can with a lid, or a commercial sharps container.

Patients and caregivers should not recap used needles. They should not removethe needle from the syringe or attempt to break it because this increases the risk of needlestick injury.

PTS:1DIF:ModerateREF:p. 1520 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. A community health nurse prepares for a new assignment. She has been assigned census tracts 131 and 132. This large area crosses the border of twotowns and includes 4,000 people. As a community health nurse, she recognizesthat assignments are based on census tracts because census tracts do which ofthe following? Choose all that apply.

1) Define the geopolitical boundaries of a community.2) Are made up of persons who share a common heritage and customs.3) Divide populations into smaller groups that can be assessed more readily.4) Are natural divisions in communities that are based on voting patterns.ANS: 1, 3 Census tracts are derived from the national census. They typically include 1,500to 8,000 people. The area of the tract varies based on the density. Census tractsshow geopolitical boundaries that are useful to anyone who studies the characteristics and concerns of smaller groups of people.

PTS:1DIF:ModerateREF:p. 1499 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension 2. A community health nurse is assigned to work in a different area of thecity.

Which of the following assessment techniques would she likely use to develop an overview of the community? Choose all that apply.

Windshield survey2) Review of demographic data3) Physical assessment of a sample of the inhabitants4) Review of the records of area providersANS: 1, 2 A windshield survey and review of demographic data provide data about the community. She may interview area residents about their experiences or ideas about this community; however, physical examination of a sample of the inhabitants would not give her community-level data.

Similarly, she may wish tomeet with area providers, but reviewing their records violates HIPAA laws and assumes that the records accurately reflect the health concerns of the population.

PTS:1DIF:ModerateREF:p. 1506 1) KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Application 3. Which of the following groups represents a vulnerable population?Choose all that apply.

1) Homeless persons with no known illnesses2) Women

who have experienced domestic violence Fifth-grade students at the local elementary school4) Persons with type 1 diabetes mellitusANS: 1, 2, 4 Vulnerable populations include those with limited economic or social resources,the very young and the very old, those with chronic disease, and people who have experienced abuse or trauma.

PTS:1DIF:ModerateREF:pp. 1500-1501 KEY: Nursing process: Assessment | Client need: Physiological Integrity |Cognitive level: Application 4. Which of the following is a primary intervention? Choose all that apply.1) Immunization for meningitis of college-bound students2) Safer sex education for high school students3) Lobbying for health education in the schools4) Tuberculosis screening via PPD testingANS: 1, 2, 3 Primary interventions are interventions that occur before disease appears. Thegoal of primary interventions is to promote health and prevent disease.

Secondary interventions aim to reduce the impact of the disease process by early detection and treatment. Tertiary interventions aim to halt diseaseprogression and restore client functioning.

PTS:1DIF:ModerateREF:p. 1503 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 5. Identify the nurse who is acting as a community health nurse. Choose allthat apply.

1) School nurse who provides screening and direct care in the elementary school2) Parish nurse who offers health education after services each Sunday3) Nurse who works for the Red Cross by providing disaster relief4) A nurse administering vaccines to inmates in a correctional facilityANS: 1, 2, 3, 4 Community health nurses function as client advocates, counselors, case managers, educators, and collaborators for patients and their families in the community setting. All of these nurses are working in community health settingsin roles as school nurse, parish nurse, disaster nurse, and prison nurse.

PTS: 1 DIF: Easy REF: pp. 1501-1503 1) KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 6. Which of the following interventions has a public health focus? Choose allthat apply.

1) Controlling the blood sugar of a diabetic client with cardiovascular disease2) Assisting with the launch of an after-school program in a high-crimeneighborhood 3) Providing an influenza vaccination program for seniors and persons with chronicillness 4) Offering counseling to the family of a child with severe cognitive deficitsANS: 2, 3 Public health nursing focuses on the community at large and the eventual effectof the communitys health status on the health of individuals and families.

Diabetic care is focused on individual health. Family counseling is focused onfamily health.

PTS:1DIF:Moderate REF:p. 1501; question involves critical thinking with synthesis of informationacquired from reading this passage KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:Application 7. Which of the following clients would most likely require home healthservices?

Choose all that apply.

1) 45-year-old man with an injured rotator cuff that requires surgery 32year-old terminally ill woman with a supportive family3) 92-year-old man living independently with multiple medical problems4) 6year-old with a fractured hip requiring a leg and pelvic castANS: 2, 3 Home care is appropriate for a client with health needs that exceed the abilitiesof family and friends.

Older adults who wish to avoid placement in a skilled nursing facility, those who require ongoing skilled care after discharge from the hospital, the terminally ill, and persons with chronic illness that must be monitored to avoid hospitalization are the most likely home health clients.

PTS:1DIF:Moderate REF: p. 1510; critical-thinking item requires synthesis of knowledge acquiredfrom passage KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application 8. Which of the following services are provided by home health agencies?Choose all that apply.

1) 1) Direct care of clients in the home, performing treatments2) Indirect care such as provision of medication and supplies3) Acute care services for clients with complex diseases Respite care of clients to relieve family caregiversANS: 1, 2, 4 Home care agencies provide direct, indirect, and respite care in the home. Acutecare services are provided in the hospital.

PTS:1DIF:ModerateREF:p. 1511 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 9. Home healthcare and home hospice care are two different types of homehealth services. What are the differences between these services? Choose all that apply.

1) Home healthcare promotes independence in clients; home hospice carepromotes comfort and quality of life.

2) Home healthcare promotes comfort and symptom management; hospice care promotes self-care.

3) Home healthcare is focused on teaching self-care; home hospice care is focusedon teaching skilled care to caregivers.

4) Home hospice care is focused on managing symptoms; home healthcare isfocused on fostering independence.

ANS: 1, 4

The purpose of home healthcare is to promote self-care and foster independence. The purpose of home hospice care is to promote comfort andquality of life by managing symptoms.PTS: 1 DIF: Moderate REF: p. 1512 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 10. The nurse has been assigned to a caseload of home health clients. Before making home visits, which two planning activities must she perform first?

1) Order supplies for the home care services.2) Review the cases to determine the reasons for the visits.3) Contact the clients to arrange for the visits.4) Develop a schedule for the day so that all visits can be made.ANS: 2, 3 All of these interventions are appropriate. However, it is essential to determine the nature of the visits and to secure permission for visiting before the nurse canorder supplies and plan her day.

PTS: 1 DIF: Difficult REF: p. 1514 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 11. The nurse is visiting a client who resides in a single-room occupancy hotel.

Groups of people are leaning against the building and smoking on the steps. There is 1) obvious drug abuse occurring in the lobby and halls of the building. There is no running water in the room, and the bathroom down the hallis in disrepair and filthy. A primary concern that the nurse must consider when making this visit is safety. Which of the following actions are appropriate safety measures? Choose all that apply.

1) Notify the police that the nurse plans to visit this site.2) Carry something that can be used as a weapon if necessary.3) Inform the home health agency of the nurses route and time of visit.4) Do not visit if the nurse senses danger when he arrives at the site.ANS: 3, 4 Safety is a primary consideration in home care. The nurse should file a route and planned schedule with the agency. In addition, he should not enter the building if he feels he may be in danger. He should notify the police if he senses danger, but not to tell them of a planned visit. The nurse should always carry a cell phone to alert police when security is threatened. It is not recommended that the nurse carry a weapon.

PTS:1DIF:ModerateREF:pp. 1514-1515 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 12. The nurse is visiting a patient who lives alone in a two-room house. Thepatient requires wound care and medication management, but his health is not expected to improve much, even with care. There is no running water in the house, and the bathroom is in disrepair and filthy. At the first home visit, which of the following should the nurse assess? Choose all that apply.

1) Wound status2) Patient concerns

3)Ability to perform care independently4) Endof-life planningANS: 1, 2, 3 The nurse should assess the patients status, condition of the wound, concerns,and ability to perform care independently. End-of-life care is a topic the nurse may wish to explore after a relationship has developed.

PTS:1DIF:Easy REF:pp. 1516-1517; critical-thinking item requiring synthesis of previouslyacquired knowledge KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Application True/False Indicate whether the statement is true or false.

1. Florence Nightingale is known as the first community health nurse.ANS: F Florence Nightingale was influential in community health because she established the importance of promoting health by manipulating the environment. Lillian Wald is known as the first community health nurse.

PTS:1DIF:ModerateREF:p. 1502 1) KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall

Chapter 38. Nursing Informatics Multiple Choice Identify the choice that best completes the statement or answers the question.

1. In informatics, raw, unprocessed numbers, symbols, or words that have no meaning by themselves are called which of the following?

1) 2) Data 3) Knowledge 4) Wisdom ANS: 2 Data are raw, unprocessed numbers, symbols, or words that have no meaningby themselves.

Information consists of groupings of data processed into a meaningful, structured form.

Knowledge is formed when data are grouped, creating meaningful information and relationships, which are then added to other structured information. Wisdom is the appropriate use of knowledge in managing or solving human problems. PTS:1DIF:EasyREF: p. 1572 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 2. Which informatics concept concerns the appropriate use of knowledge in managing or solving human problems?

1) Wisdom2) Data3) Knowledge4) ANS: 1 Wisdom is the appropriate use of knowledge in managing or solving human problems. Data are raw, unprocessed numbers, symbols, or words that have nomeaning by themselves. Information consists of groupings of data processed into a meaningful, structured form. Knowledge is formed when data are grouped, creating meaningful information and relationships, which are then added to other structured information.

PTS:1DIF:EasyREF:p. 1573 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 3. Computers are important for evidence-based practice because:1) They are available in all healthcare institutions.2) Extra training is not required for information retrieval.3) Information can be accessed and managed more efficiently.4) All of the best evidence is located on a computer.ANS: 3

To incorporate the current, best evidence in your nursing practice, you must beable to locate the evidence, evaluate its quality and relevance to the problem, and apply the solution to clinical care. Computers are useful for data access, management, storage, and retrieval when conducting research or reviewing research findings. Specialized software aids in statistical analysis of research data. Computers are not available to all personnel in all healthcare institutions nor can the entirety of best evidence be found electronically. Training and experience are required to learn how to use a computer as well as how to conduct a literature search.

PTS:1DIF:ModerateREF:p. 1582 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 4. You are a preceptor for a new nursing employee at the local hospital. Sheneeds to access a patients electronic health record (EHR) to retrieve laboratory results; however, the newly hired nurse has not yet received a computer password. What action should you take?

1) Give her your password to use until she obtains her own password.2) Log on and remain with her while she views the record.3) Notify your supervisor that the new employee needs a password.4) Inform her that she will not receive a password until her orientation is complete.ANS: 3 Never share your password with another person or log on to a computer to allowanother access to information. Instead, notify your supervisor that the new employee needs a password. In most hospitals, nurses are given a password during their orientation.

PTS:1DIF:ModerateREF:p. 1581 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 5. Review the following: 38 years old; growth in height to 52; female gender; weight gain of 15 pounds. This list can be referred to as which of thefollowing?

1) Information2) Knowledge3) Data4) Patient recordANS: 1 The segments are grouped into a meaningful, structured form and are considered together as information. However, 38, 52, female, 15 standing alonewould be examples of raw, unprocessed numbers, symbols, or words that have no meaning by themselves and therefore would be data.

PTS:1DIF:ModerateREF:p. 1572 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis 6. CINAHL is a(n):1) Popular periodical.

2) Internet site.3) Scholarly journal.

4) Literature databaseANS: 4 CINAHL, The Cumulative Index of Nursing and Allied Health Literature, is a literature database covering nursing, allied health, biomedical, and consumer health journal articles.

CINAHL may be accessed by the Internet or in hard copyin most libraries.

PTS: 1 DIF: Easy REF: p. 1583 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 7. A nurse is entering a pharmacy request for patient medication in the patients electronic health record (EHR) while seated at a computer in the nursing station. A physician approaches her and asks her to access another patients EHR so that he can look at the patients laboratory report. Which of thefollowing is the best action for the nurse to take?

1) Access the lab report for the physician.2) Log off the computer before proceeding.3) Quickly finish the pharmacy requisition before the physician logs on.4) Allow the physician to access the laboratory report without logging out.ANS: 2 The nurse should log off the computer and then allow the physician to log on under his own password. Accessing information that is not relevant to the care that the nurse is providing is a HIPAA violation. Rushing to complete a pharmacyrequest for patient medication is a situation of risk for medication error. The nurse should never hurriedly order or administer medication because that is when errors are more likely to occur. The nurse should never allow anyone to use her password to access information.

PTS:1DIFifficult REF: p. 1581; critical thinking item requiring synthesis of knowledge acquiredfrom text KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 8. What is (are) the primary benefit(s) of computer physician order entry(CPOE)? 1) Increased privacy2) Improved access to patient data3) Cost savings4) Reduced medication errorsANS: 4 Computer physician order entry (CPOE) is technology that allows healthcare providers to enter orders into a computerized prescribing system instead of handwriting them.

Orders are integrated with patient information, including allergy history and laboratory and other prescription data. The new order is thenautomatically checked for potential errors or problems. This reduces prescription errors resulting from illegible penmanship. It can detect dosing errors by flagging medication dilution or dosages that fall outside normal dosing standards. The system warns about the possibility of a drug interaction, allergy,or incorrect dose. As some drug names sound like other drugs, CPOE can alert prescribers and potentially avoid a drug error that could be serious or fatal.

Although the efficiencies of the CPOE reduce costs, it is not the primary benefit of the system.

Likewise, orders entered into the computer are more convenientlyaccessed by nurses and pharmacists, but the most important benefit of CPOE is to reduce errors.

PTS:1DIFifficultREF:p. 1578 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which of the following are main functions of a computer? Choose all thatapply. 1) Process2) Storage3) Memory4) Output ANS: 1, 2, 4 Memory refers to the amount of space available for storage of digital information on a computer. The four main functions of a computer are input,process, output, and storage. PTS: 1 DIF: Moderate REF: p. 1573 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 2. Which of the following aspects of a computer determine its power?Choose all that apply.

1) User friendliness2) Speed of operations3) Accessibility for the user4) Data storage capacityANS: 2, 4 The power of a computer is determined by its speed, accuracy, reliability, and data storage and processing capabilities. Although ease of use and accessibilityare important features for users, these factors do not determine the power of a computer.

PTS:1DIFifficultREF:p. 1573 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 3. Which of the following health information is protected in the electronichealth record? Choose all that apply.

Social Security number2) Insurance information3) Physicians name4) Laboratory resultsANS: 1, 2, 4 A patients protected health information includes any individually identifiable health information; current, past, or potential physical or mental conditions; and any payment information, such as Social Security numbers or insurance.

PTS: 1 DIF: Moderate REF: p. 1574 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall

4. The nurse is preparing to pass the 0900 medications prescribed for herpatients. She removes the medications from the automated dispensing unit.

When scanning the medication, an alert notifies the nurse that the patient is allergic to this medication. What action should the nurse take? Choose all thatapply.

1) Override the alert and administer the medication.2) Confirm the patients allergies and type of reaction.3) Notify the prescriber of the patient medication allergy.

Be sure an antidote is available at the patients bedside.ANS: 2, 3 Alerts are configured to notify the nurse of potential adverse effects before the patient receives the medication. Sometimes patients state they are allergic to a medication when, in reality, they may only have experienced a side effect. The physician or pharmacist can be instrumental in discerning if the patients reaction was a true allergy. The physician should always be notified before administering medications when an allergy error has been received.

Although anantidote to a medication could be useful in the event of a harmful effect, the medication in the situation should not be given, and therefore, the antidote would not be necessary.

PTS:1DIFifficult REF: p. 1580; critical thinking is necessary to answer question KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application Completion Complete each statement.

1.

is the managing and processing of information necessaryto make

decisions.

ANS: Informatics PTS: 1 DIF: Moderate REF: p. 1572 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 2.

is the use of telecommunication to send healthcareinformation between patients and professionals at different locations.

ANS: Telehealth PTS:1DIF:ModerateREF:p. 1575 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 3. Facebook, MySpace, and LinkedIn are examples of social networking PTS:1DIF:EasyREF:pp. 1574-1575

tools.ANS:

KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 4.

such as NIC, NOC, NANDA-I, and PNDS can be used to describe the unique nursing contributions to patient care.

ANS: Standardized nursing languages Standardized nursing languages communicate health information, promote evidence- based practice using health records, decrease medical error, and protect patient privacy and confidentiality. However, no single nursing language currently describes all of the aspects of nursings contribution to care. Use of standardized terminology helps to match like terms within the electronic medicalrecord.

PTS:1DIF:EasyREF:pp. 1579-1580 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application

Chapter 39. Legal Accountability Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A pregnant 15-year-old girl presents to the emergency department (ED) of the local private hospital. She has been transported by her mother and appears to be in active labor.

The girl is crying uncontrollably and says she is scared and experiencing painful contractions.

Her mother states, We dont haveany money or insurance, but this hospital is closer than the public hospital, andshe needs help now. What is the first step that the ED staff should take?

1) Arrange for an ambulance to transport her to the nearest public hospital.2) Explain to the girl and her mother that the hospital only accepts patients whocan pay the hospital bill.

3) Examine her to determine if her condition is stable or if she requires immediatemedical attention.

4) Inform her mother that she will need to transport her daughter to the nearestpublic hospital.

ANS: 3 When a client comes to the ED requesting examination or treatment for anemergency medical condition (including labor), the hospital must provide stabilizing treatment; the client cannot be transferred until she is stable.

PTS:1DIF:ModerateREF:p. 1550 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 2. For the patient with no healthcare coverage who is seeking medical care,the emergency department staff members decide whether to provide care or transport to a public facility based on which law, enacted by Congress in 1986 and updated in 2003? 1) 1) Health Care Quality Improvement Act (HCQIA)2) Patient Self-Determination Act (PSDA)3) Newborns and Mothers Health Protection Act (NMHPA)4) Emergency Medical Treatment and Active Labor Act (EMTALA)ANS: 4 The intent of the Emergency Medical Treatment and Active Labor Act (EMTALA) is to ensure public access to emergency services regardless of ability to pay. TheEMTALA prohibits patient dumping, which is transferring indigent or uninsured patients from a private hospital to a public hospital without appropriate screening and stabilization. An exception is made if a hospital does not have the capability to stabilize a patient or if the patient requests a transfer.

PTS:1DIFifficultREF:p. 1550 KEY:Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

3. A patient tells you that chart entries made by the nurse from the previous day indicate he was uncooperative when asked to ambulate. He says this is not true and asks his record be corrected. You understand that, if what hesays is accurate, he has the right to have the documentation error corrected based on which of the following regulations?

Americans with Disabilities Act (ADA)2) Patient Self-Determination Act (PSDA)3) Health Insurance Portability and Accountability Act (HIPAA)4) Health Care Quality Improvement Act (HCQIA)ANS: 3 The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule of2004 provides comprehensive protection for the privacy of protected health information (confidentiality of patient records). In addition, patients have the right to see and copy their medical records and to reconcile incorrect information.

PTS:1DIF:ModerateREF:p. 1550 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 4. Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patients arms, legs, and trunk in various stages of healing. You notify your supervisor when you suspect the patient may be a victim of physical abuse. You are complying with which of the following state laws?

1) Good Samaritan Law2) Mandatory Reporting Law Nurse Practice Act4) Nursing Standards of PracticeANS: 2 Under state mandatory reporting laws, nurses must report to designated authorities (e.g., Adult Protective Services) suspected physical, sexual, emotional, or verbal abuse or neglect by healthcare workers or family members.In general, nurses who fail to report suspected abuse or neglect may be held criminally or civilly liable.

PTS:1DIF:ModerateREF:p. 1552 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Application 5. Nursing codes of ethics support which of the following?1) Patients can receive emergency treatment regardless of their ability to pay.2) Nurses will educate patients about advance directives.3) Nurses with HIV must disclose their condition to their employer.4) Patients have the right to dignity, privacy, and safety.ANS: 4 In the Patient Bill of Rights, patients have the right to dignity, privacy, and safety.

Although they are not laws, nursing codes of ethics specify ethical duties of the nurse to the patient as related to corresponding patient rights. Although patients do have a right to receive emergency medical care regardless of their ability to pay, this is not part of the nursing code of ethics. Likewise, a nurses role is to educate patients about advance directives; this is a goal supported bynursing organizations but is not part of the code of ethics.

PTS:1DIF:ModerateREF:p. 1553 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis

6. The charge nurse in a progressive care unit assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) without checking to see that the nurse has been determined competent to care for hemodialysis patients. The LPN is in orientation and fails to inform the charge nurse that she does not have experience with this type of patient. The actions ofthe charge nurse would be considered to be which of the following?

1) Malpractice2) Incompetence3) Negligence4) AbandonmentANS: 3 Negligence is the failure to use ordinary or reasonable care or the failure to act in a reasonable and prudent (careful) manner. It is negligent to assign a nurse tocare for a patient without verifying the nurse has training, experience, and clinical competence in caring for such patients.

PTS:1DIF:ModerateREF:p. 1557 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 7. In which of the following circumstances might the nurse defer obtaininginformed consent for care and treatment of a patient?

1) The patient is confused and cannot understand or sign the consent form.2) The patient is brought to the emergency department in cardiac arrest; no familyis present.

3) The surgeon requests that the patient be sent to the surgical suite before youget the consent form signed.

4) An unconscious patient is admitted to your unit; he is alone.ANS: 2 Informed consent is the necessary authorization by the patient for any and all types of care and must be written and signed by the patient or the person legally responsible for the patient for hospital admission and for invasive or specialized treatments or diagnostic procedures.

Written consent is not necessary in an emergency if experts agree that there was an immediate threatto life or health. The physician responsible for the care of the patient has the duty to obtain informed consent from the patient.

PTS:1DIF:ModerateREF:p. 1563 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 8. A 4-year-old child is brought to the emergency department by his mother.He has a large bruise in his left chest and multiple contusions on his face. His mother tells you her boyfriend intentionally pushed the child down the stairs in anger. The child appears to be in a great deal of pain. Which of the following four items should the nurse do first? 1) Notify the nursing supervisor of the suspected physical abuse.2) Complete a physical assessment of the child.3) Obtain an order for pain medication.4) Notify Child Protective Services of the suspected abuse.ANS: 2

Although the nurse must report to designated authorities (Child Protective Services) suspected physical abuse, the primary responsibility of the nurse in this situation is to evaluate the patients physical condition and extent of his injuries in order for appropriate medical treatment to be provided. Pain medication should not be administered prior to a thorough physical assessment.The nurse should always notify the nursing supervisor if any outside agencies may need to be contacted.

PTS:1DIF:Moderate REF: p. 1552; critical-thinking item requires synthesis of previously acquiredknowledge KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 9. You are caring for an alert, oriented 47-year-old patient who is recoveringfrom abdominal surgery. The patient becomes angry and upset and says, Im leaving this hospital. Remove my IV and surgical drains or I will do it myself. Inorder to keep him from removing his lines and leaving the hospital, you apply bilateral wrist restraints until you can contact the physician for an order for patient restraint. This is an example of which of the following?

1) Assault and battery2) Felony3) False imprisonment4) Quasi-intentional tortANS: 3 False imprisonment involves an intentional or willful detention of a patient without consent or authority to do so. Restraining a patient without consent is another form of civil false imprisonment. Competent patients have a right to leave an institution, even if it is harmful to their health. Whenever possible, havethe person sign a form stating that he is aware that he is leaving against medical advice.

PTS:1DIF:ModerateREF:p. 1557 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 10. A registered nurse forgot to put the side rails up for a confused patient. The patient fell out of bed and fractured his hip. The patient sues and wins a judgment (award) for $2 million. The nurse has an occurrence policy with doublelimit coverage of $3 million/$10 million that covered the time period when the incident occurred. The statement that best describes the nurses situation is thather insurance policy will: 1) Not cover her.

2) Pay $4 million.

3) Pay $2 million.

4) Pay 75% of the $2 million ANS: 3 An occurrence policy will cover those claims that occurred during the time thepolicy was in effect. However, the policy will pay up to $3 million per claim; because the amount awarded does not exceed this, the nurse is covered.

PTS:1 DIFifficult REF:pp. 1566-1567 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis 11. A registered nurse administers the wrong medication to a patient. She does not notify anyone of the error and documents that the correct medication was administered. The nurse was reported

to the state board of nursing. Which of the following actions can the state board of nursing take against the nurse in this situation?

1) Disciplinary action against the nurses’ license to practice 2) Criminal misdemeanor charges against the nurse 41

3.) Medical malpractice lawsuit against the nurse 4)Employment release from the institution ANS: 1 The state board of nursing is empowered to initiate disciplinary action against the nurses license for professional misconduct. The board does not bring criminal charges or sentence the nurse to jail; that is the parameter of the stateprosecutor and judge. A patient or the person harmed can bring medical malpractice lawsuits against the nurse.

PTS: 1 DIF: ModerateREF:pp. 1553, 1555 KEY: Nursing process: Intervention | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which of the following are examples of invasion of privacy by nurses?Choose all that apply.

1)Searching a patient’s belongings without permission 2)Reviewing the plan for patient care in the lunchroom 3) Discussing healthcare issues for an unconscious patient with his power ofattorney Releasing patient health information to local newspaper reportersANS: 1, 2, 4 Invasion of privacy violates a persons right to be free from unwanted interference in her private affairs, such as occurs in discussing patient matters in a public setting; searching patients private items without their permission; and releasing private information to the public. A durable power of attorney is adocument empowering a person selected by the patient to make healthcare decisions in the event that the patient is unable to do so. It is permissible to discuss pertinent issues related to the welfare of the patient with the person holding a power of attorney.

PTS:1DIF:EasyREF:p. 1557 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 2. While you are admitting an adult patient, he asks you whether he shouldcreate an advance directive. To provide him adequate information to make an informed decision, you should tell the patient which of the following? Choose allthat apply.

1) If he is unable to communicate, his family may make changes to his advancedirective. 2) Once he signs an advance directive, no further care will be provided to him.3) He may change his advance directive by telling his physician or by makingchanges in writing.

An advance directive will ensure he gets as much or as little care as he wishes.ANS: 3, 4 Advance directives include living wills and durable powers of attorney. A living will establishes the patients wishes regarding future healthcare should he become unable to give instructions. A patient may specify actions in a living willthat are not supported by family

members, such as a desire for a do not resuscitate order, or for as much or as little care as he wishes. A person may change or revoke an advance directive at any time. Changes and written revocation should be signed and dated and shared with the patients physician. Even without an official written change, orally expressed direction to the physician generally has priority over any statement made in an advance directive as long as the patient is able to decide for himself and can communicate his wishes.

PTS:1DIF:ModerateREF:pp. 1550-1551 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 3. What do negligence and malpractice have in common? Choose all thatapply. 1) Negligence and malpractice are non-intentional torts.2) Negligence and malpractice are felonies.3) Malpractice is the professional form of negligence.4) Negligence and malpractice involve the intent to do harm to a patient.ANS: 1, 3 Negligence and malpractice are non-intentional tortsnurses can be negligent without intending to do harm.

Negligence is simply the failure to use ordinary orreasonable care as dictated by the standards of practice and/or by what a reasonable and prudent nurse would do in the same or similar circumstances.

Intent is not an element of negligence. When a nurse or other licensed professional healthcare provider is negligent and fails to exercise ordinary care,it is called malpractice. Malpractice is the professional form of negligence.

PTS: 1 DIF: Moderate REF: p. 1557 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 4. You are caring for a patient with renal failure. His morning laboratory results reveal an abnormal potassium level of 6.8. This value is more elevated than on the previous day, when the level was within normal limits. You page the patients physician, but he does not return your call right away. You become busywith another patient and forget to notify the physician again and fail to mention the critical laboratory value to the oncoming nurse during shift report.

Which of the following does this scenario illustrate? Choose all that apply.

1) Failure to implement a plan of care2) Failure to evaluate3) Malpractice4) Failure to assess and diagnose Failure to implement a plan of care and failure to evaluate are two of the mostcommon causes of nursing malpractice claims. The above scenario represents a failure to follow standards of care, failure to communicate, and failure to document, which are in the category of failure to implement a plan of care. It also represents a failure to assess and report a significant change in the patients condition, which is part of the category of failure to evaluate. The nurse did assess the potassium level and recognize that it was too high.

PTS: 1 DIF: Difficult REF: pp. 1559-1560 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:Application Completion

Complete each statement.

1. The American Nurses Association (ANA) believes nurses should not participatein active

euthanasia (and assisted suicide) because such acts violate .

1) the Patient Self-Determination Act 2) civil laws 3) the Good Samaritan laws 4) the Code of Ethics for NursesANS: 4 The ANA defines assisted suicide, a form of active euthanasia, as providing a patient the means to end his life, with full knowledge of the patients intentionsto do so. The ANA believes that participation in active euthanasia violates the Code of Ethics for Nurses and the ethical traditions of the profession.

PTS: 1 DIF: Moderate REF: p. 1553; not stated outright in the chapter 2. Prioritize the following guidelines for nursing practice in order of specificity(14, with 4 being the most specific).

1) State laws 2)

Institutional policies and procedures

3)

Federal laws

4) State nurse practice actsANS: 3, 1, 4, 2 Institutional policies and procedures are usually more specific and detailed than standards set by professional organizations. State nurse practice acts identify the minimum level of nursing care for a specific patient in specific situations.

Standards in nurse practice acts are set forth in statutes and enforced by authority granted by the state. Federal laws, both constitutional and statutory,affect nursing practice in the most general terms.

PTS:1DIF:ModerateREF:pp. 1550-1555

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis

Chapter 40. Leading & Managing

Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Theories that focus on what the leader does are called:1) Trait theories.2) Behavioral theories.3) Situational theories.4) Transformational theories.ANS: 2 Behavioral theories are concerned with what a leader does, whereas trait theories are concerned with what a leader is. Situational theories recognize thateach situation is different and that leaders must consider a number of factors when deciding how to take action. Transformational theories focus on the abilityof the leader to communicate her vision in such a way that it inspires commitment among workers.

PTS:1DIF:ModerateREF:p. 3 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 2. At a recent nurse staff meeting, the chief nursing officer (CNO) announced that all nursing staff would work 12-hour shifts on a daynight rotation schedule that would alternate every 6 weeks. The CNO announced that she made this decision as a means to solve discord between the day- and night-shift nurses. She explained that this plan will allow the staff to experience the work on each shift and to appreciate the various job responsibilities on each shift. What type of leadership is the CNO displaying?

1) Management2) Laissez-faire3) Democratic4) AuthoritarianANS: 4 The authoritarian leader makes decisions for the group as a whole, gives orders,and bears most of the responsibility for the outcomes. A laissez-faire leader postpones making decisions or may never make a decision at all. Thus, laissez- faire leadership is really a lack of leadership. A democratic leader shares the planning, decision making, and responsibility for outcomes with other members of the group. This type of leader tends to provide guidance rather than control. There is no leadership style called management.

PTS:1DIF:ModerateREF:p. 3 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Application 3. A graduate nurse completed her nursing education 3 weeks ago and has just begun work at the local hospital. She is orienting to her new position with anexperienced nurse, one who has been an RN for 15 years and an employee at the hospital for 7 years. She will provide guidance and practical teaching to the new graduate as she assumes a new position in the nursing unit. What role is the experienced RN assuming? 1) Mentor2)

Manager3) Preceptor4) LeaderANS: 3 A preceptor is someone with more experience who provides practical teaching and guidance for a student or new employee. In contrast, a mentor is someone more experienced who provides career development information and serves as a role model. A manager is an employee of an organization who has the power, authority, and responsibility for planning, organizing, coordinating, and directingthe work of others. A leader is someone who has the ability to influence others and commit them to action.

PTS:1DIF:ModerateREF:p. 7 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Application 4. What is the first stage of the complex process of change?1) Recognizing resistance2) Unfreezing3) Forming a comfort zone4) Actively resistingANS: 2 The first stage in the change process is unfreezing. In this stage, the person leaves the stable comfort zone that has existed and begins to make changes.Recognizing resistance and actively resisting are activities associated with change, but they are not the first stage of the process.

KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 5. Within the past month, there has been a change in the nursing documentation requirements at the hospital. The nurses have been trained in the new requirements and are documenting as requested, with the exception of one nurse. This nurse has been unable to attend any of the documentation in- service meetings and has been too busy to attend a private training session withthe nurse manager. Meanwhile, she continues to use the old documentation process. What do the nurses actions illustrate?

1) Unfreezing2) Active resistance3) Passive resistance4) Comfort zoneANS: 3 Passive resistance behaviors include avoidance; canceling appointments to discuss implementing change; being too busy to make the change; agreeing to the change but doing nothing to change; and simply ignoring the entire process as much as possible. In the above situation, the nurse is not actively refusing to comply with the new documentation requirements; however, her actions are a passive approach to resisting change. When a person knows what to expect andhow to deal with whatever problems arise in the course of a day, that person is operating within her comfort zone. The first stage in the change process is whenthe person begins moving out of the comfort zone, unfreezing. This nurse is resisting, not unfreezing.

KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 6. The surgical unit is experiencing difficulty recruiting new RNs, although the hospital has an excellent reputation in the community and has no difficulty recruiting nurses for other

units. A task force has been formed, consisting of onenurse from each shift on the unit, the unit manager, and the hospital nurse recruiter. The group has gathered data and identified the problem. What is the next step in this process?

1) Generate possible solutions.2) Evaluate whether the problem has been resolved.3) Implement the solution changes.4) Evaluate suggested solutions.ANS: 1 The next step in the process is to generate possible solutions. Once several possibilities have been identified, each of the suggested solutions should be evaluated. From among that list, the best solution is chosen and then implemented. Finally, the task force critiques the process by evaluating whetherthe problem has been resolved.

PTS:1DIFifficultREF:pp. 15-16 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 7. A nurse with 2 years experience frequently appears stressed and has difficulty completing his work. He is clocking out 30 to 45 minutes late every problem as running from one duty to the next and having no organization ordaily routine.

Which situation most likely describes this nurse?

1) Has time management problems2) Has a heavy patient load3) Works at a hospital that is understaffed4) Is in a management positionANS: 1 This nurse most likely has trouble managing his time. Time management entailssetting your own goals and organizing your work. Although there will be difficultdays, the nurse who consistently finishes late and has no organization to his daily schedule has a problem managing time. Time management includes efficiently meeting clients care needs during a nursing shift and organizing onesworkload.

PTS:1DIF:EasyREF:pp. 16-17 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Analysis 8. An expert nurse feels confident in her role as a clinician on the unit. The nurse enjoys her work and feels in charge of her career. Which leadership state is she experiencing?

1) Power-based authority Effective management skills3) Empowerment in her role4) Followership skillsANS: 3 Empowerment is a psychological state, a feeling of competence, control, and entitlement that a person experiences. Empowerment refers to feelings, whereas power refers to action. The person who feels empowered has feelings of self-determination, meaning, competence, and impact. This nurse may have power on the unit because of her expertise, but there is no evidence that she isan authority figure. Empowerment is not always associated with management. Managers have authority by virtue of their position but do not always thrive in

that role. There is not enough information in the scenario to judge the nurses followership skills.

PTS:1DIFifficultREF:p. 10 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 9. The physical therapy department and the nursing department at a local rehabilitation hospital are in conflict over which department is responsible for transporting patients to and from therapy appointments. The members of the therapy department state they do not have sufficient time to come to the nursing unit to pick up the patients and that patients often are not ready to be transported. Nursing staff members state that they do not have the time to transport the patients from the unit and this leaves a shortage of nursing personnel on the floor. Managers from both departments have attempted to resolve the conflict with input from nursing and therapy staff members. All attempts at conflict resolution have failed. What is the next step the managersshould take?

Inform the nurses that they must take the patients to and from therapy.2) Inform the therapists that they must take the patients to and from therapy.3) Ask the hospital administrator to make an unbiased decision.4) Begin informal negotiation between the two departments.ANS: 4 One of a managers responsibilities is to function as an informal negotiator whena resolution to conflict cannot be reached.

PTS:1DIF:ModerateREF:pp. 15-16 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:Application 10. The manager is conducting an informal negotiation between two staff members who have had ongoing difficulty working together peacefully. Most recently there was an argument about who would be scheduled for first lunch each day. At this stage of the informal negotiation, the manager is focusing onmanaging the emotions and setting the ground rules.

Which stage does this demonstrate?

1) Setting the stage2) Conducting the negotiation Making offers and counteroffers4) Agreeing on resolution of the conflictANS: 2 The manager has begun conducting informal negotiation. This includes managing the emotions, setting ground rules, and clarifying the problem. The first step of conflict resolution is introspective and is similar to data gathering. The negotiator thinks, What am I trying to achieve? What problems am I likely toencounter? The next step, setting the stage, may involve confronting the two parties with their behavior toward one another and making direct statements designed to open communication and challenge them to seek resolution of the situation. After conducting the negotiation, the parties move to making offers and counteroffers, and then to agreeing on the resolution of the conflict.

PTS:1DIF:ModerateREF:p. 16 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Application 11. A nurse observes a nursing assistant (NAP) fail to wash her hands before and after

placing a patient on a bedpan. When giving negative feedbackto the NAP, the nurse should: 1) Be certain to offer constructive criticism about the task and do so in private.2) Ask the unit manager to be present to document responses of both parties.3) Call a meeting of all NAPs and stress hand washing to the entire group.

Keep a record of the NAPs actions and save them for her annual formal review.ANS: 1 It is important to provide negative feedback in private. It is not necessary for thenurse manager to be present because staff nurses are responsible for delegatingto and supervision of NAPs. The nurse should not call a meeting. It would be a waste of time for those who are already washing their hands properly, and it dilutes the effect of the feedback to the NAP who is not washing her hands. She might think, Oh, everybody does it; no big deal. It is important to allow some time every day for timely feedback. This allows the worker to know what she is doing right and wrong, and allows her to make corrective actions. The nurse should not allow this NAP to continue with her hand washing errors until her annual formal review because this can pose a threat to patient safety and increase the risk of transmitting infectious microbes.

PTS: 1 DIF: Moderate REF: pp. 7-8 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:Application Multiple Response Identify one or more choices that best complete the statement or answer thequestion.

1. Which of the following are characteristics of an effective nurse manager? Choose all that apply.

1) Clinical expertise2) Business sense3) Masters degree 4) Leadership skillsANS: 1, 2, 4 An effective nurse manager possesses a combination of qualities: leadership skills, clinical expertise, and business sense. It is the combination of all thesethat prepares a person for the complex task of managing a group or team of healthcare providers. The extent of education that a person has does not determine her effectiveness as a manager. PTS:1DIF:ModerateREF:p. 5 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 2. Which of the following activities is/are involved when delegating tasks toother members of the nursing team? Choose all that apply.

1) Supervising patient care that is given2) Determining the skill mix of unit personnel3) Assessing the needs of the clients involved4) Deciding which tasks to assign to a team memberANS: 1, 2, 3, 4

Delegation of patient care tasks to other healthcare workers is one of the most important responsibilities of the registered nurse. When delegating tasks, the nurse must take into consideration the skills and competency of the team members as well as the condition and needs of the clients receiving care. The nurse is also responsible for supervising patient care to ensure that it is competently delivered.

PTS:1DIFifficultREF:pp. 12-13 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 3. An experienced nurse serves as a mentor to a new graduate. Which of the following are responsibilities of the person being mentored? Choose all that apply. 1) Demonstrates an ability to move toward independence2) Has the ability to encourage excellence in others3) Seeks feedback and uses it to modify behaviors4) Demonstrates flexibility and an ability to change ANS: 1, 3, 4 The ability to encourage excellence in others is a responsibility of the mentor. Responsibilities of the person being mentored are the following: demonstrates an ability to move toward independence; seeks feedback and uses it to modify behaviors; and demonstrates flexibility and an ability to change.

PTS:1DIF:ModerateREF:p. 8; Box 45-2 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension Completion Complete each statement.

1. Compared with management, is the ability to influence other people with or without an official appointment to a position in the organization.

ANS: leadership PTS: 1 DIF: Easy REF: p. 2 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 2. is the ability to influence other people despite resistance from them.

Said another way, it is the ability of one person or group to impose his, or their, will on another person or group.

ANS: Power PTS:1DIF:ModerateREF:p. 10 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 3. A(n) development behaviors.

is someone with more experience who providescareer

ANS: mentor PTS:1DIF:EasyREF:pp. 6-7 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 4. A(n)

is an employee of an organization who has the power,

authority, and responsibility for planning, organizing, coordinating, and directing the work of others.

ANS: manager PTS:1DIF:EasyREF:p. 4 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall