Fundamentals of Nursing: Concepts and Competencies for Practice 9th EditionCraven Test Bank Chapter 1 Professional Concepts Multiple Choice Identify the choice that best completes the statement or answers the question. 1. What is the most influential factor that has shaped the nursing profession? 1) Physicians need for handmaidens 2) Societal need for healthcare outside the home 3) Military demand for nurses in the field 4) Germ theory influence on sanitation ANS: 3 Throughout the centuries, stability of the government has been related to the success of the military to protect or extend its domain. As the survival and well-being of soldiers iscritical, nurses provided healthcare to the sick and injured at the battle site. The physicians handmaiden was/is a nursing stereotype rather than an influence on nursing. Although there has been need for healthcare outside the home throughout history, this has more influence on the development of hospitals than on nursing; this need provided one more setting for nursing work. Germ theory and sanitation helped to improve healthcare but did not shape nursing. PTS: 1 DIF: Moderate REF: dm 910 KEY: Nursing process: N/A Client need: N/A | Cognitive level: Recall 2. Which of the following is an example of an illness prevention activity? Selectall that apply. 1) Encouraging the use of a food diary 2) Joining a cancer support group 3) Administering immunization for HPV 4) Teaching a diabetic patient about hisdiet ANS: 3 Administering immunization for HPV is an example of illness prevention. Although cancer is a disease, it is assumed that a person joining a support group would already have the disease; therefore, this is not disease prevention but treatment. Illness- prevention activities focus on avoiding a specific disease. A food diary is a health- promotion activity. Teaching a diabetic patient about diet is a treatment for diabetes; thepatient already has diabetes, so it cannot prevent diabetes. PTS: 1 DIF: Moderate REF: p. 18; high-level question, not directly stated in textKEY: Nursing process: N/A | Client need: HPM | Cognitive level: Application
3. Which of the following contributions of Florence Nightingale had an immediate impact on improving patients health? 1) Providing a clean environment 2) Improving nursing education 3) Changing the delivery of care in hospitals 4) Establishing nursing as a distinct profession ANS: 1 Improved sanitation (a clean environment) greatly and immediately reduced the rateof infection and mortality in hospitals. The other responses are all activities of Florence Nightingale that improved healthcare or nursing, but the impact is long range, not immediate. PTS: 1 DIF: Easy REF: V1, p. 3; student must infer from content | V1, p. 10; studentmust infer from content KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 4. All of the following are aspects of the full-spectrum nursing role. Which one is essential for the nurse to do in order to successfully carry out all the others? 1) Thinking and reasoning about the clients care 2) Providing hands-on client care 3) Carrying out physician orders 4) Delegating to assistive personnel ANS: 1 A substantial portion of the nursing role involves using clinical judgment, critical thinking, and problem solving, which directly affect the care the client will actually receive. Providing hands-on care is important; however, clinical judgment, critical thinking, and problem solving are essential to do it successfully. Carrying out physician orders is a small part of a nurses role; it, too, requires nursing assessment, planning, intervention, and evaluation. Many simple nursing tasks are being delegated to nursing assistive personnel; delegation requires careful analysis of patient status andthe appropriateness of support personnel to deliver care. Another way to analyze this question is that none of the options of providing hands-on care, carrying out physician orders, and delegating to assistive personnel is required for the nurse to think and reason about a clients care; so the answer must be 1. PTS:1DIFifficultREF: p. 11 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis 5. Which statement pertaining to Benners practice model for clinical competence is true? 1) Progression through the stages is constant, with most nurses reaching the proficient stage.
2) Progression through the stages involves continual development of thinking andtechnical skills. 3) The nurse must have experience in many areas before being considered anexpert. 4) The nurses progress through the stages is determined by years of experience and skills. ANS: 2 Movement through the stages is not constant. Benners model is based on integration of knowledge, technical skill, and intuition in the development of clinical wisdom. The model does not mention experience in many areas. The model does not mention years of experience. PTS:1DIF:ModerateREF:p. 15 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 6. Which of the following best explains why it is difficult for the profession to develop a definition of nursing? 1) There are too many different and conflicting images ofnurses. 2) There are constant changes in healthcare and the activities of nurses. 3) There is disagreement among the different nursing organizations. 4) There are different education pathways and levels of practice. ANS: 2 The conflicting images of nursing make it more important to develop a definition; they may also make it more difficult, but not to the extent that constant change does. Healthcare is constantly changing and with it come changes in where, how, and what nursing care is delivered. Constant changes make it difficult to develop a definition. Although different nursing organizations have different definitions, they are similar in most ways. The different education pathways affect entry into practice, not the definition of nursing. PTS: 1 DIF: Moderate REF: p. 11; How Is Nursing Defined? KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis 7. Nurses have the potential to be very influential in shaping healthcare policy. Which of the following factors contributes most to nurses influence? 1) Nurses are the largest health professional group. 2) Nurses have a long history of serving the public. 3) Nurses have achieved some independence from physicians in recent years. 4) Political involvement has helped refute negative images portrayed in the media. ANS: 1
Nurses are trusted professionals and the largest health professional group. As such, they have political power to effect changes. If nursing were a small group, there wouldbe little potential for power in shaping policies, even if all the other answers were true.Serving the public, while positive, does not necessarily help nurses to be influential in establishing health policy. Independence from physicians, although positive, does not necessarily make nurses influential in establishing healthcare policy. Refuting negative media, although positive, does not necessarily make nurses influential in establishing healthcare policy. PTS: 1 DIF: Moderate REF: p. 21 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis 8. Nursing was described as a distinct occupation in the sacred books of which faith? 1) Buddhis m 2) Christianit y 3) Hinduis m 4) Judais m ANS: 3 The Vedas, the sacred books of the Hindu faith, described Indian healthcare practicesand were the earliest writings of a distinct nursing occupation. PTS:1DIF:EasyREF:p. 7 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 9. The American Red Cross was established by 1) Louisa May Alcott 2) Clara Barton 3) Dorothea Dix 4) Harriet Tubman ANS: 2 Clara Barton was an American teacher, nurse, and humanitarian who organized the American Red Cross after the Civil War. Louisa May Alcott was an American novelist who wrote Little Women in 1868. Dorothea Dix was an American activist who acted onbehalf of the indigent population with mental illness. She was credited for establishing the first psychiatric institution. Harriet Tubman was an African American abolitionist and Union spy during the Civil War. After escaping captivity, she set up a network of antislavery activists, known as the Underground Railroad. PTS:1DIF:EasyREF:p. 10
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 10. Which of the following is the most important reason to develop a definition of nursing? 1) Recruit more informed people into the nursing profession 2) Evaluate the degree of role satisfaction3) Dispel the stereotypical images of nurses and nursing 4) Differentiate nursing activities from those of other health professionals ANS: 4 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 health professionals, and help student nurses understand what is expected of them. A definition of nursing would not be likely to increase the number of informed people recruited into nursing. A definition of nursing would do little to improve the nurses role satisfaction. Although a definition of nursing might contributeto fighting stereotypes of nursing, other, more powerful influences (e.g., media portrayals) exist to counteract it. PTS:1DIF:EasyREF:V1, dm 1113; students must infer from content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 11. Which of the following provides evidence-based support for the contribution that advanced practice nurses (APNs) make within healthcare? 1) Reduced usage of diagnostics using advanced technology 2) Decreased number of unnecessary visits to the emergency department3) Improved patient compliance with prescribed treatments 4) Increased usage of complementary alternativetherapies ANS: 3 Studies demonstrate that APNs have improved patient outcomes over those of physicians, including increased patient understanding and cooperation with treatments and decreased need for hospitalizations. No well-known, scientific studies support APNseffect on the use of advanced technology. No well-known, scientific studies support APNs effect on the frequency of emergency department visits. No well-known, scientific studies support APNs effect on the use of alternative therapies. PTS:1DIF:ModerateREF:p. 20 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 12. Which of the following is an example of what traditional medicine and complementary and alternative medicine therapies have in common? 1) Both can produce adverse effects in some
patients. 2) Both use prescriptionmedications. 3) Both are usually reimbursed by insurance programs. 4) Both are regulated by the FDA. ANS: 1 Both traditional and complementary therapies can produce adverse effects in some patients. Many medications are derived from herbs, but the alternative treatments usually use the herbs, not prescription medication. Insurance programs do not necessarily reimburse alternative treatments, because many are not supported by soundscientific research methodology. Alternative medications are not regulated by the FDA. PTS:1DIF:ModerateREF:p. 20 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 13. Of the following, the biggest disadvantage of having nursing assistive personnel (NAP) help nurses is that the nurse 1) Must know what aspects of care can legally and safely be delegated to theNAP 2) May rely too heavily on information gathered by the NAP when making patient care decisions 3) Is removed from many components of direct patient care that have been delegated tothe NAP 4) Still maintains responsibility for the patient care given by the NAP ANS: 2 All of the options may be disadvantages to using NAPs, but making decisions based on anothers information is the greatest drawback because of the potential for negatively affecting patient care. Treatment decisions based on incorrect informationmay cause harm to the patient. PTS:1DIFifficultREF:p. 2021; students must conclude from content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis 14. An older adult has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be mostappropriate for him? 1) Acute care facility 2) Ambulatory care facility 3) Extended care facility 4)
Assisted living facility ANS: 4 Assisted living facilities are intended for those who are able to perform self-care activities but who require assistance with meals, housekeeping, or medications. Acutecare facilities focus on preventing illnesses and treating acute problems. These facilities include physicians offices, clinics, and diagnostic centers. Ambulatory care facilities provide outpatient care. Clients live at home or in nonhospital settings and come to thesite for care. Ambulatory care facilities include private health and medical offices, clinics, surgery centers, and outpatient therapy centers. Extended care facilities typically provide long-term care, rehabilitation, wound care, and ongoing monitoring of patient conditions. SystemsExpanded Discussion, Where is Healthcare Provided? KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 15. The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care deliverymodel can you infer that this nurse is following? 1) Functional 2) Primar y 3) Case method 4) Team ANS: 3 The nurse is following the case method model of nursing care. In this model, one nurse cares for one patient during a single shift. 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. In primary nursing, one nurse plans the care for a group of patients round-the-clock. The primary nurse assesses the patient and develops the plan of care. When he or she is working, he or she provides care for those patients that he or she is responsible for. In his or her absence, 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. If the team nursing approach is utilized, a licensed nurse (RN or LVN) is paired with a nursing assistant. The pair is then assigned to a group of patients. PTS:1DIF:ModerateREF:ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, What Models of Care Are Used to Provide Nursing Care? KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis 16. Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors affecting healthcare? 1) Social
worker 2) Occupational therapist 3) Physicians assistant 4) Technologi st ANS: 1 The social worker coordinates services and counsels patients about financial, housing, marital, and family issues affecting healthcare. The occupational therapist helps patients regain function and independence for activities of daily living. Physicians assistants work under the physicians direction to diagnose certain diseases and injuries. 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:1DIF:ModerateREF:ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, What Healthcare Providers Will You Work With? KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension 17. Which type of managed care allows patients 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 ANS: 3 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. Health maintenance organizations allow the patient to choose a primary care provider within the organization to coordinate his care. This type of program will onlyreimburse medical care when the patient has first obtained a referral from the primary provider. Integrated delivery networks combine providers, healthcare facilities, pharmaceuticals, and services into one system, and the patient must remain withinthe system to receive care. Employment-based private insurance is not a managed care organization. PTS:1DIF:EasyREF:ESG, Chapter 1, Healthcare Delivery Systems, Expanded Discussion, How Do Healthcare Policy and Reform Efforts Affect Care? KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis 18. A patient who underwent a total abdominal hysterectomy is assisted out of bed as soon as her vital signs are stable. This intervention is most likely being directed
by a 1) Critical pathway 2) Nursing care plan 3) Case manager 4) Traditional care model ANS: 1 This patients care is most likely being directed by a critical pathway. A critical pathway is a multidisciplinary approach to care that sequences interventions over a length of stay for a given case type, such as total abdominal hysterectomy. Using this model, the patient can be assisted out of bed as soon as her vital signs are stable. Using the traditional model, the nurse would have to obtain a physicians order to assist the patientout of bed after surgery. The nursing care plan guides nursing care but cannot specify when the patient can get out of bed postoperatively without a physicians order. When case management is used, care is coordinated by the case manager across the healthcaresetting, but the case manager does not direct each care intervention. PTS:1DIF:ModerateREF:ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, Issues Related to Healthcare Reform KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 19. Which member of the healthcare team typically serves as the case manager? 1) Occupational therapist 2) Physicia n 3) Physicians assistant 4) Registered nurse ANS: 4 Typically, registered nurses serve as case managers for patients with specific diagnoses. Their role is coordinator of care across the healthcare system. The occupational therapist, physician, and physicians assistant all serve on the healthcare team and take direction from the case manager. PTS: 1 DIF: Easy REF: ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, What Healthcare Providers Will You WorkWith? KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Recall 20. Which of the following is considered a primary care service? 1) Providing wound care 2) Administering childhood
immunizations 3) Providing drug rehabilitation 4) Outpatient hernia repair ANS: 2 Primary care services focus on health promotion and disease prevention; administering childhood immunizations is one such service. Providing wound care and drug rehabilitation are examples of tertiary care services. Outpatient hernia repair surgery is an example of a secondary care service. PTS:1DIF:ModerateREF:ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, Categories of Healthcare? KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 21. Which of the following nursing activities represent direct care? Choose all that apply. 1) Bathing a patient 2) Administering a medication 3) Documenting an assessment 4) Making work assignments for the shift ANS: 1 B Direct care involves personal interaction between the nurse and clients (e.g., giving medications, dressing a wound, or teaching a client about medicines or care). 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 bluecart [an emergency cart], ordering unit supplies, or arranging unit staffing). PTS:1DIF:EasyREF:p. 17 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension 22. An 80-year-old patient fell and fractured her hip and is in the hospital. Before the fall, she lived at home with her husband and managed their activities of daily living very well. The goal is for the patient to recover from the injury and return to her home. The hospital is ready to discharge her because she has exceeded the recommended length of stay in a hospital. However, she cannot walk or care for herselfyet, and she will require lengthy physical therapy and further monitoring of her medications and her physical and mental status. To which type of facility should she betransferred? 1) Nursing home 2) Rehabilitation center 3)
Outpatient therapy center 4) None of these; she should receive home healthcare ANS: 2 A skilled nursing facility 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 to get skilled care until she is able to return home. A nursing home provides custodial care for people, like this patient,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. This patient cannot ambulate or perform activities of daily living, so outpatient therapy and home care would not be appropriate. Chapter 2 The Nurse's Role in Healthcare Quality and Patient Safety 1. Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking1) Requires reasoned thought2) Asks the questions why? or how? 3) Is a hierarchical process 4) Demands specialized thinking skills ANS: 1 The definitions listed in the text as well as definitions in Box 2-1 state that critical thinking requires reasoning or reasoned thinking. Critical thinking is neither linear norhierarchical. That means that the steps involved in critical thinking are not necessarily sequential, where mastery of one step is necessary to proceed to the next. Critical thinking is a purposeful, dynamic, analytic process that contributes to reasoned decisions and sound contextual judgments. PTS:1DIF:ModerateREF: p. 25; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level:Analysis 2. A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will helpthe manager to 1) Consider all the possible advantages and disadvantages 2) Maintain an open mind about the proposed change 3) Apply the nursing process to the situation 4) Make a decision based on past experience with
documentation ANS: 2 A critical attitude enables the person to think fairly and keep an openmind. PTS:1DIF:ModerateREF:dm 26 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 3. The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first? 1) Assessme nt 2) Diagnos is 3) Plan outcomes 4) Plan interventions ANS: 1 Assessment is the first step of the nursing process. The nursing diagnosis is derivedfrom the data gathered during assessment, outcomes from the diagnosis, and interventions from the outcomes. PTS:1DIF:EasyREF: p. 30-31 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 4. Which of the following is an example of theoretical knowledge? 1) A nurse uses sterile technique to catheterize a patient. 2) Room air has an oxygen concentration of 21%.3) Glucose monitoring machines should be calibrated daily. 4) An irregular apical heart rate should be compared with the radial pulse. ANS: 2 Theoretical knowledge consists of research findings, facts, principles, and theories. The oxygen concentration of room air is a scientific fact. The others are examples of practical knowledgewhat to do and how to do it. PTS:1DIF:ModerateREF:p. 30; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level:Application 5. Which of the following is an example of practical knowledge? (Assume allare true.) 1) The tricuspid valve is between the right atrium and ventricle of the heart. 2) The pancreas does not produce enough insulin in type 1 diabetes. 3)
When assessing the abdomen, you should auscultate before palpating.4) Research shows pain medication given intravenously acts faster than by other routes. ANS: 3 Practical knowledge is knowing what to do and how to do it, such as how to do an assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve), fact (type 1 diabetes), and research (IV pain medication). PTS:1DIF:ModerateREF:p. 30; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level:Application 6. Which of the following is an example of self-knowledge? The nurse thinks, I know that I 1) Should take the clients apical pulse for 1 minute before giving digoxin 2) Should follow the clients wishes even though it is not what I would want 3) Have religious beliefs that may make it difficult to take care of some clients 4) Need to honor the clients request not to discuss his health concern with the family ANS: 3 Self-knowledge is being aware of your religious and cultural beliefs and values. Taking the pulse is an example of practical knowledge. Following client wishes andhonoring client requests are examples of ethical knowledge. PTS:1DIFifficultREF: p. 30; high-level question, answer not stated verbatim | V1, p.32; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 7. Which of the following is the most important reason for nurses to be critical thinkers? 1) Nurses need to follow policies and procedures. 2) Nurses work with other healthcare team members. 3) Nurses care for clients who have multiple health problems. 4) Nurses have to be flexible and work variableschedules. ANS: 3 Critical thinking is essential for client care, particularly when the care is complex,involving numerous health issues. Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible andworking different schedules do not necessarily require critical thinking. PTS:1DIF:ModerateREF: p. 26-27; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level:Application
8. The nurse administering pain medication every 4 hours is an example of which aspect of patient care? 1) Assessment data 2) Nursing diagnosis 3) Patient outcome 4) Nursing intervention ANS: 4 Interventions are activities that will help the patient achieve a goal, such as administering pain-relieving medication. An example of assessment data might be, Patient reports pain is a 5 on a 1 to 10 scale. The nursing diagnosis would be Pain. The nurse might define the patient outcome in this scenario as, The patient will state the level of pain is less than 4. PTS:1DIF:ModerateREF:p. 31; high-level question, answer not stated verbatim KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 9. How does nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is 1) Terminology for the clients disease or injury 2) A part of the clients medical diagnosis 3) The clients presenting signs and symptoms4) A clients response to a health problem ANS: 4 A nursing diagnosis is the clients response to actual or potential health problems. PTS:1DIF:ModerateREF: p. 31 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall 10. Which statement about the nursing process is correct? 1) It was developed from the ANA Standards of Care. 2) It is a problem-solving method to guide nursing activities. 3) It is a linear process with separate, distinct steps. 4) It involves care that only the nurse will give. ANS: 2 The nursing process is a problem-solving process that guides nursing actions. The ANA organizes its Standards of Care around the nursing process, but the process was
not developed from the standards. The nursing process is cyclical and involves carethe nurses give or delegate to other members of the healthcare team. PTS:1DIF:EasyREF: p. 31 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 11. What do critical thinking and the nursing process have in common? 1) They are both linear processes used to guide ones thinking. 2) They are both thinking methods used to solve a problem. 3) They both use specific steps to solve a problem. 4) They both use similar steps to solve a problem. ANS: 2 Critical thinking and the nursing process are ways of thinking that can be used in problem solving (although critical thinking can be used beyond problem-solving applications). Neither method of thinking is linear. The nursing process has specific steps;critical thinking does not. PTS:1DIFifficultREF: p. 31 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis 12. A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now 1) Analyze the assessment data 2) Consult standards of care 3) Decide which interventions are appropriate 4) Ask the clients perceptions of her health problem ANS: 1 The basis of the nursing diagnosis is the assessment data. Standards of care are referredto when establishing nursing interventions. Customizing interventions personalizes nursing care. Asking the patient about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment. PTS: 1 DIF: Moderate REF: p. 31 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application 13. The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patients position every 2 hours. In the evaluation phase of the nursing process, which of the following would the nurse do first? 1)
Determine whether she has gathered enough assessmentdata. 2) Judge whether the interventions achieved the statedoutcomes. 3) Follow up to verify that care for the nursing diagnosis was given. 4) Decide whether the nursing diagnosis was accurate for the patients condition. ANS: 2 The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the nursing process steps and revising the care plan. PTS:1DIF:ModerateREF: p. 31 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis 14. In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. These activities are bestdescribed as 1) Full-spectrum nursing 2) Critical thinking 3) Nursing process 4) Nursing knowledge ANS: 1 Full-spectrum nursing (1) involves the use of critical thinking, nursing knowledge, nursing process, and patient situation. Although the other answers are important for planning and delivering nursing care, they do not reflect all the nurse has demonstrated. PTS:1DIFifficultREF:dm 32-33; high-level question, answer not statedverbatim KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Analysis 15. The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient is obese. The nurse has been overweight atone time and works very hard now to maintain a healthy weight. She immediately thinks, I know I tend to feel negatively about obese people; I figure if I can stop eating, they should be able to. I must remember how very difficult that is and be very careful not to be judgmental of this patient. This best illustrates 1) Theoretical knowledge 2) Self-
knowledge 3) Using reliable resources 4) Use of the nursing process ANS: 2 Self-knowledge is self-understandingawareness of ones beliefs, values, biases, and so on. That best describes the nurses awareness that her bias can affect her patient care. Theoretical knowledge consists of information, facts, principles, and theories in nursing and related disciplines; it consists of research findings and rationally constructed explanations of phenomena. Using reliable resources is a critical thinkingskill. The nursing process is a problem-solving process consisting of the steps of assessing, diagnosing, planning outcomes, planning interventions, implementing, andevaluating. The nurse has not yet met this patient, so she could not have begun the nursing process. PTS:1DIFifficultREF:dm 30; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: ComprehensionMultiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which aspects of healthcare are affected by a clients culture? Select all that apply. 1) How the clients views healthcare 2) How the client views illness 3) How the client will pay for healthcare services 4) The types of treatments the client will accept 5) When the client will seek healthcare services 6) The environment where the healthcare services are provided 7) The ease of accessibility of healthcare services ANS: 1, 2, 4, 5 Culture affects clients view of health and healthcare. It influences how they will define illness, when they will seek healthcare, and what treatments are acceptable intheir culture. How services are paid for is related to economic status. Regardless of culture, anyone can be affected by previous healthcare experiences, the environment in which healthcare is provided, and accessibility of services. Chapter 3 Values, Ethics, and Legal Issues 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 hospitalizedfor 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 nurseshould tell 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 even family. 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 positionas the nurse. Telling her that her mother has pneumonia would be a lie. The nurse, of course, should inform the physician of the patients wishes so that he will be preparedif 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 ariseout of nursing practice? 1) Nursing ethics 2) Bioethi cs 3) Ethical dilemma 4) Moral distress ANS: 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 distress occurs when someone is unable to carry out his or her moral decision. PTS:1DIF:ModerateREF:V1, p. 1526 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 a standardthat influences decision making is called which of the following? 1) Mora ls 2)
Attitud es 3) Belie fs 4) Values ANS: 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 something that 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 neck injury.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 set 2) Value system 3) Value neutrality 4) Value awareness ANS: 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 toleast 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 patient intends 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) Nonmaleficenc e 2) Autonom y 3) Beneficenc
e 4) Fidelit y ANS: 2 Autonomy refers to a persons right to choose and his ability to act on that choice. 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 door 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 that the value of an action is determined by its usefulness? 1) Ethics of care 2) Utilitarianis m 3) Deontolog y 4) Categorical imperative ANS: 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 action to be right or wrong independent of its consequences. A categorical imperative is a principle, established byImmanuel Kant, that states that one should act only if the action is based on a principlethat 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 which of the following? 1) Ethical agency 2) Attitud es 3) Beli ef 4) Value neutrality ANS: 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. A belief 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 nonjudgmental when providing care to clients. 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 dilemma 2) Resolve the dilemma 3) Review theproblem 4) Recall the history of the problem ANS: 2 MORAL is an acronym for the following steps: M, Massage the dilemma; O, Outlinethe options; R, Resolve the dilemma; A, Act by applying the chosen option; L, Look back and evaluate. PTS: 1 DIF: Easy REF: dm 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 nurse informs the patient that he must first assist another patient to the bathroom and then hewill 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) Nonmaleficenc e 2) Autonom y 3) Beneficenc e 4) Fidelit y ANS: 4 Fidelity is the obligation to keep promises. 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 10. The nurse is a member of the ethics committee. An alert, oriented, and
competent 87-year-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 likely use which model in this patients case? 1) Social justice 2) Patient benefit 3) Autonom y 4) DNAR determination ANS: 3 The autonomy model is useful when the patient is competent to decide. This model 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 decided not 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 nursedisplayed? 1) Nonmaleficenc e 2) Autonom y 3) Paternalis m 4) Beneficenc e ANS: 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 abilityto 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: 1)
Legally binding. 2) Not legallybinding. 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 and licensure boards, which may use sanctions to punish code violations. However, nursing codes arenot 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 doesnot agree with his decision and asks the healthcare team to ignore the request. After a great deal of discussion among the physician, nurse, and family, they are no closer to 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 dilemma 2) OOutline the options 3) RResolve the dilemma 4) LLook back and evaluate ANS: 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, including those 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. Resolvingthe 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 evaluateis 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: dm 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 doesnot agree with his decision and asks the healthcare team to ignore 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 2) An ethically sound compromise 3) Settlement of an issue byforce 4) An effort to keep peace on the unit ANS: 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 effortto 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 without the need for court order. PTS:1DIFifficultREF:p. 1542 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 the question. 1. Which of the following is an example of whistle-blowing? Choose all that apply. 1) Reporting fraudulent billing practices 2) Reporting patients health status against the patients wishes 3) Reporting unsafe work practices 4) Reporting a coworker for working under the influence of drugs ANS: 1, 3, 4 Reporting a patients health status against the patients wishes is a breach of patient confidentiality. Whistle-blowing is identifying incompetent, unethical, or illegal situations or actions of others in the workplace and reporting to someone who may be ina position to rectify the situation. Fraudulent billing practices are illegal 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 ones 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 ethical decision making. Confidentiality is a basic patient right. The nurses role is to uphold that right. Chapter 4 Nursing Research and Evidence-Based Care Identify the choice that best completes the statement or answers the question.
1. The concept of holism focuses on which of the following? 1) Relationship between nurse and patient 2) Practice of spiritualism 3) Relationships among all living things 4) Totality of the body ANS: 3 The concept of holism focuses on the relationships among all living things. PTS:1DIFifficultREF:p. 2 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 2. A patient is receiving healthcare focused on his illness and counteractinghis symptoms. What type of healthcare is he receiving? 1) Holisti c 2) Integrativ e 3) Complementary 4) Allopathic ANS: 4 Allopathic care is conventional medical care focused on counteracting symptoms. Holistic healthcare uses the concept of holism to focus on the relationships among all living things. Integrative healthcare encompasses all traditional and alternative
health practices used by a patient. Complementary healthcare is alternative careused in conjunction with traditional medical care. PTS: 1 DIF: Moderate REF: p. 3 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 3. A client has a diagnosis of chronic pain. The physician has prescribed tramadol hydrochloride (Ultram) for the pain. The patient also receives therapeutic touch (TT) from a practitioner three times a week. In this situation, TT is consideredto be which of the following? 1) A complementary modality 2) An alternative modality 3) A placebo response 4) Holistic healthcare ANS: 1 A complementary modality is one that is used alongside traditional medical care. The patient receives prescription medication from a physician as well as receivingTT. An alternative modality is one that is used instead of traditional medical care. A placebo response is the clients expectation that a treatment will be effective. Holistic healthcare uses the concept of holism to focus on the relationships among all living things. PTS: 1 DIF: Moderate REF: p. 3 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 4. A client tells the nurse that he is having difficulty sleeping. He says, I dont want to use sleeping pills, but Im thinking about getting some melatonin. Which of thefollowing is most important for the nurse to include in a response to the client? 1) Melatonin is an effective treatment for certain sleep disorders. 2) Melatonin appears to be a relatively safe sleep aid for most people. 3) You may experience some side effects, such as elevated blood pressure.4) Before taking melatonin, you should consult your primary care provider. ANS: 4 All of the statements are true about melatonin; however, side effects are rare. It is most important to consult the primary care provider because melatonin is known tointeract with other medications, including prescription medications. Therefore, the client should talk with the provider about this possibility. PTS:1DIFifficultREF:p. 14 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
5. A woman is receiving physical therapy after surgery to repair a hip fracture. She tells the therapist before therapy begins that she expects therapy to be very painful.She rates her pain as 1 on a scale of 1 to 10 before therapy. Three minutes into the treatment session, the patient complains of excruciating pain rated as 10 and says she cannot tolerate exercise any longer. The therapist is concerned with the amount of pain,because severe pain is not expected during that form of exercise. The therapist considers the patient could be experiencing: 1) Phantom limb pain. 2) Ineffective pain medication.3) A nocebo effect. 4) A complication from the surgery. ANS: 3 The nocebo effect is a demonstration of the power of the mind to create bodily distress. The patient was expecting the treatment to be very painful, and this tends to increase the treatment discomfort. Phantom limb pain is sometimes experienced afteran amputation but has nothing to do with surgery to repair a hip fracture. There is no evidence that the patients pain medication is ineffective or that she is experiencing a complication from surgery. PTS:1DIF:ModerateREF:p. 3 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 6. Identify the holistic nursing theorist who describes disease as disequilibrium, which stimulates the person toward growth and regaining wholeness. 1) Jean Watson 2) Margaret Newman 3) Martha Rogers 4) Charles Darwin ANS: 2 Margaret Newman identifies disease as disequilibrium, which stimulates the person toward growth and regaining wholeness. Jean Watson identifies caring as the primary focus of nursing. Martha Rogers states that the environmental energy field is in constant and meaningful interaction with the human energy field. Charles Darwin created the theory of natural selection. He is not a nursing theorist. PTS:1DIFifficultREF:p. 5 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
7. A client wishes to avoid taking blood pressure medications. He is eating a healthy diet and exercising regularly. In addition, a CAM therapist has recommendedan alternative therapy that will allow him to learn voluntary control over his blood pressure. What type of therapy is the therapist probably recommending? 1) Homeopath y 2) Naturopath y 3) Biofeedbac k 4) Hypnos is ANS: 3 Biofeedback is a technique by which people learn voluntary control over typically involuntary activities. Homeopathy is based on an understanding of how the body heals itself and an acceptance that all symptoms represent the bodys attempt to restore itself to health. Naturopathy is the belief that nature and each living being have the innate ability to establish, maintain, and restore health. Hypnosis is a trancelike state characterized by relaxed brain waves, hypersuggestibility, and heightened imagination. Hypnosis has been used to promote relaxation, weight loss, and smoking cessation and to suppress various symptoms. PTS:1DIF:ModerateREF:dm 9-10 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 8. What is the best rationale to gather data about patients use of herbal products? 1) The nurse practice act requires RNs to monitor all drug dosages. 2) Herbal products need to be evaluated for research purposes. 3) Patients medication records must be kept accurate. 4) Many herbs are known to interact with medications. ANS: 4 Many herbs are known to interact with medications and to affect some disease processes adversely. Nurse practice acts do require RNs to assess patients but do not specifically require monitoring of drug dosages. Herbal products do need to be evaluated in research, and medication records must be accurate, but they do not providethe rationale for patient data collection. PTS:1DIF:ModerateREF:p. 11 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 9. A patient at the Integrative Health Clinic is scheduled for a massage technique that promotes unblocking of a terminal nerve in order to improve functionalong that nerve pathway. What type of therapy is he receiving?
1) Myofascial release 2) Shiatsu massage 3) Swedish massage 4) Reflexology ANS: 4 Reflexology is a massage technique that promotes unblocking of a terminal nerve in order to improve function along that nerve pathway. Myofascial release restores balance, alignment, and mobility to the body by releasing tension in the soft connectivefasciae. Shiatsu massage is a finger pressure method that balances the energy force in thebody. Swedish massage is used to induce relaxation and restore flexibility. PTS:1DIF:ModerateREF:p. 15 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 10. Therapeutic touch, Reiki, and Qigong are examples of: 1) Energy therapies. 2) Manipulative therapies. 3) Biologically based therapies. 4) Mindbody interventions. ANS: 1 Therapeutic touch, Reiki, and Qigong involve manipulation of energy fields and are classified as energy therapies. Manipulative therapies focus on body manipulation and movement to improve health. Biologically based therapies use substances found in nature, such as food, herbs, vitamins, and aromatherapy. Mindbody therapies are based on awareness of the unity of the mind and body and on the ability of social, familial, and economic factors to affect all aspects of health and illness.
Chapter 5 Nursing Process: Foundation for Clinical Judgement 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 that each situation is different and that leaders must consider a number of factors when deciding how to take action. Transformational theories focus on the ability of 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 thevarious job responsibilities on each shift. What type of leadership is the CNO displaying? 1) Manageme nt 2) Laissezfaire 3) Democrati c 4) Authoritaria n ANS: 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 isreally 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 an experienced 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 experiencedRN assuming?
1) Ment or 2) Manag er 3) Precept or 4) Leade r ANS: 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 directing the 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 resistance 2) Unfreezin g 3) Forming a comfort zone 4) Actively resisting ANS: 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 notthe first stage of the process. PTS:1DIF:ModerateREF:p. 13 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 toattend a private training session with the nurse manager. Meanwhile, she continues to use the old documentation process. What do the nurses actions illustrate? 1) Unfreezin g 2)
Active resistance 3) Passive resistance 4) Comfort zone ANS: 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 and how 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 when the person begins moving out of the comfort zone, unfreezing. This nurse is resisting, not unfreezing. PTS:1DIF:ModerateREF:p. 13 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 one nurse 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 thisprocess? 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 whether the problem has been resolved. PTS:1DIFifficultREF:dm 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 day, even when his assignment load is light. The charge nurse describes his problem as running from one duty to the next and having no organization or daily routine. Whichsituation most likely describes this nurse? 1) Has time management
problems 2) Has a heavy patientload 3) Works at a hospital that is understaffed 4) Is in a management position ANS: 1 This nurse most likely has trouble managing his time. Time management entails setting your own goals and organizing your work. Although there will be difficult days, 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 ones workload. PTS:1DIF:EasyREF:dm 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 2) Effective management skills 3) Empowerment in her role 4) Followership skills ANS: 3 Empowerment is a psychological state, a feeling of competence, control, and entitlementthat 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 is an authority figure. Empowerment is not always associated with management. Managers have authority by virtue of their positionbut 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 upthe 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 andthis leaves a shortage of nursing personnel on the floor. Managers from both departments have attempted to resolve the conflict with input from nursing and therapystaff members. All attempts at conflict resolution have failed. What is the next step the
managers should take? 1) Inform the nurses that they must take the patients to and fromtherapy. 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:dm 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 recentlythere was an argument about who would be scheduled for first lunch each day. At this stage of the informal negotiation, the manager is focusing on managing the emotions and setting the ground rules. Which stage does this demonstrate? 1) Setting the stage 2) Conducting the negotiation3) Making offers and counteroffers 4) Agreeing on resolution of the conflict ANS: 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, Whatam I trying to achieve? What problems am I likely to encounter? The next step, settingthe 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 theconflict. 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 feedback to 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 entiregroup. 4) 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 the nurse manager to be present because staff nurses are responsible for delegating to 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 handwashing errors until her annual formal review because this can pose a threat to patient safety and increase the risk of transmitting infectious microbes. Chapter 6 Nursing Assessment 1. What is the role of the Joint Commission in regard to patient assessment? The Joint Commission 1) States what assessments are collected by individuals with different credentials 2) Regulates the time frames for when assessments should be completed 3) Identifies how data are to be collected and documented4) Sets standards for what and when to assess thepatient ANS: 4 The Joint Commission sets detailed standards regarding what and when to assess but does notaddress credentials. Nurse practice acts specify what data are collected and by whom. Agencypolicy may set time frames for when assessments should be done and how they should be documented. Nursing knowledge identifies how data are to be collected. PTS:1DIF:ModerateREF:p. 39 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 2. Which of the following is an example of data that should be validated? 1) The clients weight measures 185 lb at the clinic. 2) The clients liver function test results are elevated.3) The clients blood pressure is 160/94 mm Hg; he states that that is typical for him. 4) The client states she eats a low-sodium diet and reports eating processed food. ANS: 4
Validation should be done when the clients statements are inconsistent (processed foods are generally high in sodium). Validation is not necessary for laboratory data when you suspect an error has been made in the results. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale. PTS:1DIF:ModerateREF: p. 47 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 3. Which of the following examples includes both objective and subjective data? 1) The clients blood pressure is 132/68 and her heart rate is88. 2) The clients cholesterol is elevated, and he states he likes fried food. 3) The client states she has trouble sleeping and that she drinks coffee in theevening. 4) The client states he gets frequent headaches and that he takes aspirin for the pain. ANS: 2 Elevated cholesterol is objective, and states he likes fried food is subjective. Objectivedata can be observed by someone other than the patient (e.g., from physical assessments or lab and diagnostic tests). Subjective data are information given by the client. Blood pressure and heart rate measurements are both objective. States . . . trouble sleeping and . . . drinks coffee . . . are both subjective. States . . . frequent headaches and . . .takes aspirin . . . are both subjective. PTS:1DIF:ModerateREF:dm 40 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 4. The Joint Commission requires which type of assessment to be performed onall patients? 1) Functional ability 2) Pai n 3) Cultur al 4) Wellnes s ANS: 2 The Joint Commission requires that pain and nutrition assessment be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors. PTS:1DIF:ModerateREF:p. 39 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 5. Which of the following is an example of an ongoing assessment? 1)
Taking the patients temperature 1 hour after giving acetaminophen (Tylenol)2) Examining the patients mouth at the time she complains of a sore throat 3) Requesting the patient to rate intensity on a pain scale with the first perception ofpain 4) Asking the patient in detail how he will return to his normal exercise activities ANS: 1 An ongoing assessment occurs when a previously identified problem is being reassessedfor example, taking an hourly temperature when a patient has a fever. Examining the mouth is a focused assessment to explore the patients complaint of sorethroat. Asking for a pain rating is a focused assessment at the first complaint of pain. Adetailed interview about exercise is a special needs assessment; there is no way to know if it is initial or ongoing. PTS:1DIF:ModerateREF: p. 41 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 6. When should the nurse make systematic observations about a patient? 1) When the patient has specific complaints 2) With the first assessment of the shift 3) Each time the nurse gives medications to the patient 4) Each time the nurse interacts with the patient ANS: 4 The nurse should make observations about the patient each time she enters the roomor interacts with the patient to gain ongoing data about the patient. PTS:1DIF:EasyREF:p. 41-42 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 7. Which of the following is an example of 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? ANS: 3 Open-ended questions such as What happens when you have a headache? are broad soas to encourage the patient to elaborate. The questions about surgery, menstrual period, and family history can all be answered with a yes, no, or short, specific answer (a date). PTS:1DIF:ModerateREF:dm 45 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
8. Of the following recommended interviewing techniques, which one isthe most basic? (That is, without that intervention, the others will all be less effective.) 1) Beginning with neutral topics 2) Individualizing your approach 3) Minimizing note taking 4) Using active listening ANS: 4 All are important techniques, but active listening focuses the attention on the patientand lets her know you are trying to understand her needs. The interviewer is more likely to get the patient to open up. Patients will forgive you for most errors in technique, but if they think you are not listening, that can negatively affect your relationship. PTS:1DIFifficultREF:47 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 9. Which of the following is an example of the most basic motivation in Maslows hierarchy of needs? 1) Experiencing loving relationships2) Having adequate housing 3) Receiving education 4) Living in a crime-free neighborhood ANS: 2 The most basic needs are centered on physiological survivalshelter (housing), food, and water. All other options are for higher needs. The order from most basic to highestlevel is physiologic, safety and security, love and belonging, esteem, and self- actualization. Loving relationships fall under the love and belonging category. Education is a form of self-actualization. Living in a crime-free neighborhood meetsthe need for safety and security. PTS:1DIF:ModerateREF:p. 48 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 10. What makes a nursing history different from a medical history? 1) A nursing history focuses on the patients responses to the health problem. 2) The same information is gathered; the difference is in who obtains the information. 3) A nursing history is gathered using a specific format. 4)
A medical history collects more in-depth information. ANS: 1 A medical history focuses on the patients current and past medical/surgical problems. A nursing history focuses on the patients responses to and perception of the illness/injury or health problem, his coping ability, and resources and support. Nursing history formats vary depending on the patient, the agency, and the patients needs. Both nursingand medical histories typically use a specific format. A medical history does not necessarily contain more in-depth information. A nursing history can be in-depth, covering a wide range of topics, including biographical data, reason(s) patient is seeking healthcare, history of present illness, patients 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. Other topics might deal with nutrition, psychosocial needs, pain assessment, or other special needs topics. PTS:1DIF:ModerateREF:dm 44-45 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:Comprehension 11. Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies? 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 you to understand cultural and spiritual beliefs4) To identify potential interaction with prescribed medication and therapies ANS: 4 Herbs and nutritional supplements can interact with prescription medications, and complementary and alternative treatments can interfere with conventional therapies. Physical assessment and laboratory tests are needed to assess a nutritional deficiency. To identify cultural and spiritual beliefs and well as what therapies are acceptable to theclient, you need more than just information about nutritional and herbal supplements. PTS:1DIFifficultREF: p. 45 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 12. What do the nursing assessment models have in common? 1) They assess and cluster data into model categories. 2) They organize assessment data according to body systems. 3) They specify use of the nursing process to collect data. 4) They are based on the ANA Standards of
Care. ANS: 1 All the models categorize or cluster data into functional health patterns, domains, or categories. None of the assessment models clusters data according to body system. Assessment is the first step of the nursing process; the nurse does not use the entire nursing process in data collection. 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:1DIFifficultREF:dm 48 KEY: Nursing process: Assessment | Client need: SACE | Cognitive level: Analysis 13. Nondirective interviewing is a useful technique because it 1) Allows the nurse to have control of the interview 2) Is an efficient way to interview apatient 3) Facilitates open communication 4) Helps focus patients who are anxious ANS: 3 Nondirective interviewing helps build rapport and facilitates open communication. Because it puts the patient in control, it can be very time-consuming (inefficient) and produce information that is not relevant. Directive interviewing should be used to focus anxious patients. PTS:1DIF:EasyREF:p. 45 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall 14. A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicatethe 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 call him Mr. 3) When reading my patients health record, I thought of a few questions toask. 4) When I give my patient his pain medication, I will have time to ask questions. ANS: 4 A patient should be comfortable when interviewing. The pain medication should have time to work before considering interviewing the patient, so asking questions when giving the medication is not a good idea. It is appropriate to interview patients withoutfamily/friends around. In nearly every culture, calling a patient Mr. or Mrs. shows respect and is therefore correct. Reading the patients health record is appropriate preparation for an interview. PTS:1DIF:ModerateREF:p. 46 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application
15. A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform? 1) Comprehensive 2) Ongoin g 3) Initial focused 4) Special needs ANS: 3 An initial focused assessment is performed during a first exam for specific abnormal findings. A comprehensive assessment is holistic and is usually done upon admission toa healthcare facility. An ongoing assessment follows up after an initial database is completed or a problem is identified. A special needs assessment is performed when there are cues that more in-depth assessment is needed. PTS:1DIF:ModerateREF: dm 4243 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 16. A patient has left-sided weakness because of a recent stroke. Which type of special needs assessment would it be most important to perform? 1) Famil y 2) Function al 3) Communit y 4) Psychosoci al ANS: 2 A functional assessment is most important because of discharge needs (e.g., self-care ability at home) and patient safety. A family and community assessment would be helpful to evaluate support systems, and a psychosocial assessment would be helpful to evaluate a patients understanding of and coping with his recent stroke. Remember that special needs assessments are lengthy and time-consuming, so they should be used onlywhen in- depth information is needed about a topic. PTS:1DIF:ModerateREF:dm 43 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Analysis 17. The nurse is interviewing a patient who has a recent onset of migraine headaches. The patient is highly anxious and cannot seem to focus on what the nurseis saying. Which of the following questions would be best for the nurse to use to begin gathering data about the headaches? 1) When did your migraines begin? 2)
Tell me about your family history of migraines. 3) What are the types of things that trigger your headaches? 4) Describe what your headaches feel like. ANS: 1 For someone who is anxious, it is best to use closed questions. (When did your migraines begin?) A closed question can be answered in one or very few words and hasa very specific answer. The other questions are open-ended questions. PTS:1DIF:ModerateREF:p. 45 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 18. Which of the following is an example of an active listening behavior? 1) Taking frequent notes 2) Asking for more details 3) Leaning toward the patient4) Sitting with legs crossed ANS: 3 Active listening behaviors include leaning toward the patient; facing the patient; open, relaxed posture without crossing arms or legs; and maintaining eye contact. Taking frequent notes makes it difficult to keep eye contact. Asking for more details may seem like idle curiosity. Sitting with legs crossed may indicate to the patient that you are not open to her. PTS:1DIF:EasyREF:p. 47 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension 19. 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) Its 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 didnt say much, so I charted that he acted depressed. ANS: 4 When charting data, chart only what was observed, not what it meant. Inferences shouldnot be made about a patients behavior during data collection (he acted depressed); so that response reflects the students lack of knowledge and need for teaching. Chart specific data, not vague phrases; the student is acknowledging the importance of this.
There are no universally accepted phrases, just agency-approved abbreviations; the student is acknowledging the need to use agency-approved abbreviations. The student iscorrect that charting should be completed as soon after data collection as possible. PTS:1DIF:ModerateREF:p. 50 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application 20. For which of the following purposes is a graphic flow sheet superior to other methods of recording data? 1) Easy documentation of routine vitalsigns 2) Seeing the patterns of a patients fever 3) Describing the symptoms accompanying a rising temperature 4) Checking to make sure vital signs were taken ANS: 2 All are benefits of the graphic flow sheet, but to easily and graphically see trends over time, the graphic flow sheet is superior to other methods of documentation. For the other options, other kinds of flow sheets would be equally effective. PTS:1DIF:ModerateREF:p. 50 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis 21. The most obvious reason for using a framework when assessing a patient is to 1) Prioritize assessment data 2) Organize and cluster data 3) Separate subjective and objective data 4) Identify primary from secondary data ANS: 2 A framework is used to organize and cluster data to find patterns. During the assessment phase, the nurse is collecting and recording data, not prioritizing the data. Aframework includes subjective and objective data as well as primary and secondary data; it does not help you to separate them. PTS:1DIF:EasyREF:p. 48 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 22. Which situation is the most conducive to conducting a successful interviewof an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented. 1) Provide enough chairs so the family and you are able to sit facing the client. 2) Introduce yourself and ask, Dear, what name do you prefer to go by? before askingany questions.
3) After the family leaves, ask the client if she is comfortable and willing to answer afew questions. 4) Ask the client if you can talk with her while her family is watching the television. ANS: 3 The interview should be done when the client is comfortable and there are no distractions. Endearing terms are inappropriate unless the client prefers them. Family members may offer information that may or may not be pertinent and may distract from the interview. The presence of family members may also inhibit full disclosure ofinformation by the client. PTS:1DIFifficultREF:p. 46-47 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: ApplicationMultiple Response Identify one or more choices that best complete the statement or answer the question.
23. Which of the following questions would be effective for obtaining information from a patient? Choose all that apply. 1) How did this happen to you? 2) What was your first symptom? 3) Why didnt you seek healthcare earlier?4) When did you start having symptoms? ANS: 1, 2, 4 How, what, and when are acceptable lines of questioning. Asking why can put thepatient on the defensive and may suggest disapproval, limiting the amount of information the patient is willing give. PTS:1DIF:ModerateREF:p. 45-46 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 24. A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health 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) or a registered nurse (RN). To which sources should thenurse turn for the answer to his question? Choose all that are appropriate. 1) The nurse practice act of his state 2) The American Medical Association guidelines 3) The Code of Ethics for Nurses 4) The American Nurses Associations Scope and Standards of Practice ANS: 1, 4
State nurse practice acts specify which portions of the assessment can legally be completed by individuals with different credentials. The ANA Scope and Standards of Practice provide a guide for who is ultimately responsible and qualified to collect assessment data. The American Medical Association provides guidelines and standards for physicians, not nurses. The Code of Ethics for Nurses says merely that the nurse should delegate tasks appropriately; it does not speak to credentials of personnel. Chapter 7 Nursing Diagnosis Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which of the following is an example of a problem that nurses can treat independently? 1) Hemorrhag e 2) Nausea 3) Fractur e 4) Infectio n ANS: 2 A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. Nausea is the only problem that meets that criterion; all others are medical or collaborative problems. PTS:1DIF:ModerateREF: dm 57 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 2. Which of the following is an example of a cluster of related cues? 1) Complains of nausea and stomach pain after eating 2) Has a productive cough and states stools are loose 3) Has a daily bowel movement and eats a high-fiberdiet 4) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 ANS: 1 A cue is an unhealthy response; a cluster of cues consists of cues related to each other. Productive cough and loose stools are abnormal findings but are not obviously or usually related to each other. Daily bowel movement and high-fiber diet are related butnormal responses. The vital signs are also within normal limits. PTS:1DIFifficultREF: dm 62 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 3. Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology
1) Is the cause of the problem2) Cannot always be observed 3) Directs nursing care 4) Is an inference ANS: 3 The etiology directs nursing interventions. If the incorrect etiology is given, the nursing care would not be appropriate for the client. The other statements are true butnot a reason for the importance of the etiology being correct. PTS:1DIFifficultREF:dm 63 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 4. How does a risk nursing diagnosis differ from a possible nursing diagnosis? 1) A risk diagnosis is based on data about the patient. 2) A possible diagnosis is based on partial (or incomplete) data.3) Nurses collect the data to support risk diagnoses. 4) A possible diagnosis becomes an actual diagnosis when symptoms develop. ANS: 2 A possible nursing diagnosis is based on nursing knowledge, intuition, and experience and does not have enough data to support it; it is based on incomplete data. A risk diagnosis describes a problem that may develop in a vulnerable client if nursing care isnot initiated to prevent it; it is made when risk factors are present in the data. Nurses collect data to support both risk and possible diagnoses; therefore, this statement does not differentiate them. A risk diagnosis becomes an actual diagnosis when symptoms develop. PTS:1DIF:ModerateREF:p. 60 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 5. Which of the following describes the difference between a collaborative problem and a medical diagnosis? 1) A collaborative problem is treated by the nurse; a physician is responsible forthe treatment of a medical problem. 2) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. 3) A collaborative problem has the potential to become an actual nursing diagnosis;a medical diagnosis rarely changes.
4) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician. ANS: 4 Collaborative problems are physiological complications a client may be at risk for dueto her medical diagnosis, medical treatment, or diagnostic studies. A collaborative problem requires monitoring by the nurse and intervention by a physician. A medical diagnosis requires interventions (medications, treatments) by the physician. Medical diagnoses do not direct all nursing care. Collaborative problems have the potential to become medical, not nursing, diagnoses. PTS:1DIF:ModerateREF: dm 5859 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 6. Which of the following is the best approach to validate a clinical inference? 1) Have another nurse evaluateit. 2) Have the physician evaluateit. 3) Have sufficient supportivedata. 4) Have the clients family confirmit. ANS: 3 All clinical inferences should be well supported by data. The more reliable data you gather, the more certain you can be that your inference is accurate. Because inferences are nursing diagnoses, it would be inappropriate to have a physician evaluate them. Although another experienced nurse could evaluate the inference, it still needs to be supported by sound and sufficient data. Even clients can validate clinical inferences in some situations, but adequate supporting data are still needed. Keep in mind that the clients data might or might not be sufficient to prove the inference. PTS: 1 DIF: Easy REF: p. 63 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall 7. What is wrong with the following diagnostic statement? Impaired Physical Mobility related to laziness and not having appropriate shoes. The statement is 1) Judgment al 2) Too complex 3) Legally questionable 4) Without supportive data ANS: 1 Lazy implies criticism of the client and therefore is judgmental. There need to be
several (certainly more than two) etiological factors for the statement to be complex. There is no blame implied or harm resulting, so the statement is not legally questionable. There is no minimum amount of supportive data for a diagnosis and thestated etiology related to the nursing diagnosis. No supportive data are given in the stem of the question, so you could not choose lack of data as the best answer becauseall the options lack data as far as you can tell from the information given in the question. In addition, it is not necessary to include supportive data in the diagnostic statement (although some do prefer to use A.M.B. and include defining characteristics). PTS:1DIF:ModerateREF:p. 74 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 8. When making a diagnosis using NANDA-I, which of the following provides support for the diagnostic label you choose? 1) Etiolog y 2) Related factors 3) Diagnostic label 4) Defining characteristics ANS: 4 The defining characteristics are the signs and symptoms that must be present to support any given nursing diagnosis. The etiology and related factors are the causes or contributing factors to the problem. The diagnostic label is the name NANDA-I has given the problem; it is chosen based on the presence of defining characteristics. PTS:1DIF:EasyREF:p. 68 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall 9. Based only on Maslows hierarchy of needs, which nursing diagnosis should have the highest priority? 1) Self-care Deficit 2) Risk for Aspiration 3) Impaired Physical Mobility 4) Disturbed SensoryPerception ANS: 2 Highest priority is given to problems that are life threatening or that could be destructive to the client. Safety is most basic in Maslows hierarchy. Even though Riskfor Aspiration is not an actual problem, it poses the most immediate life-threatening risk to the client, and nursing interventions must be performed to prevent it from becoming an actual problem.
PTS:1DIF:ModerateREF:dm 6465 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 10. Which of the following describes the most important use of nursing diagnosis? (All statements are true.) 1) Differentiates the nurses role from that of thephysician 2) Identifies a body of knowledge unique to nursing 3) Helps nursing develop a more professional image 4) Describes the clients needs for nursing care ANS: 4 Benefits to nurses and nursing are that nursing diagnoses differentiate the nurses role, they identify a unique body of nursing knowledge, and some think they help nursing todevelop a more professional image. However, the primary goal of nursing is to serve the good of the patient. Therefore, the most important use of a diagnosis is to specifically identify the clients needs for quality nursing care. PTS: 1 DIF: Moderate REF: p. 56 KEY: Nursing process: Diagnosis | Client need: Safe-care environment | Cognitivelevel: Analysis 11. Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I? 1) There is little research to support nursing diagnoses labels. 2) A perfect nursing diagnosis must be written for it to be useful. 3) They are not included in all states nurse practice acts. 4) Other professions do not recognize nursingdiagnoses. ANS: 1 Best practice is evidence-based practice; that is, it is developed through sound, scientific research. Research is currently being conducted, but many of the diagnoses are not research based. A perfect nursing diagnosis is impossible to write, so that is notan issue. Having standardized nursing diagnoses recognized in state practice acts or byother professions has nothing to do with the value of the NANDA-I taxonomy. PTS:1DIFifficultREF: p. 57 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall 12. Which of the following most accurately describes nursing diagnoses? A nursing diagnosis 1) Supports the nurses diagnostic reasoning 2) Supports the clients medical
diagnosis 3) Identifies a clients response to a health problem 4) Identifies a clients health problem ANS: 3 Nursing diagnoses are statements that nurses use to describe a clients physical, mental, emotional, spiritual, and social response to disease, injury, or other stressor. Diagnostic reasoning is used to identify the appropriate nursing diagnosis; it is not meant to support the diagnosis. A health problem is a condition that requires intervention to promote wellness or prevent illness; it is sometimes, but not always, a nursing diagnosis. Nursingdiagnoses are not medical diagnoses. PTS:1DIF:ModerateREF: p. 57 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 13. The diagnostic label, or patient problem, is used primarily to suggest 1) Client goals 2) Cue clusters 3) Interventio ns 4) Etiolog y ANS: 1 As a general rule, the problem suggests goals for client outcomes. The etiology suggests interventions. Cue clusters support whether the correct nursing diagnosis hasbeen identified. PTS: 1 DIF: Moderate REF: p. 73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall 14. Which nursing diagnosis is written in the correct format when usingthe NANDA-I taxonomy? 1) Bowel Obstruction related to recent abdominal surgery A.M.B. nausea, vomiting,and abdominal pain 2) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight 3) Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacralarea 4) Caregiver Role Strain related to alienation from family and friends A.M.B 24-hourcare responsibilities ANS: 3 The components of NANDA-I nursing diagnosis might include the following fourparts: diagnostic label, defining characteristics, related factors, and risk factors.
Impaired Skin Integrity . . . has the problem statement, etiology, and symptoms. ForBowel Obstruction . . . the problem is a medical diagnosis. The cause-and-effect order of Inability to Ingest Food . . . is incorrect; it starts with the etiology. The etiology and symptoms(A.M.B.) of Caregiver Role Strain . . . are reversed (alienation from family and friends are the symptoms that support the diagnosis). PTS: 1 DIF: Difficult REF: dm 7071 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application 15. What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. statement that When Im busy, I cant always take the time to go to the bathroom. 1) Possible nursing diagnoses do not have signs and symptoms.2) A nursing diagnosis is either a possible risk or a risk, notboth. 3) Constipation is a medical diagnosis. 4) The etiology is actually a defining characteristic. ANS: 2 If there are risk factors, it is not a possible diagnosis, it is a risk diagnosis. It is possible to have a possible risk for diagnosis. The patient with possible diagnoses may have symptoms, just not enough to support the diagnosis. Constipation is a nursing diagnosis,and the etiology is a defining characteristic for a risk diagnosis because it contributes to the problem. In risk diagnoses, the etiology consists of the risk factors. PTS: 1 DIF: Moderate REF: dm 60 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 16. Which nursing diagnosis is written in the correct format? 1) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight 2) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm 3) Impaired Swallowing related to absent gag reflex 4) Excess Fluid Volume related to 3 lb weight gain in 24 hours ANS: 3 The etiology should describe what is causing or contributing to the problem. The etiologies for Ineffective Airway Clearance, Impaired Airway Swallowing, and Excess Fluid Volume describe signs or symptoms rather than causal factors. PTS: 1 DIF: Difficult REF: V1, p. 64 | dm 70-73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 17. The patient shows the necessary defining characteristics, and the nursehas diagnosed Decisional Conflict related to unclear personal values and beliefs.
What essential action should the nurse take to help ensure the accuracy of this diagnosis? 1) Ask a more experienced nurse to confirmit. 2) Have a social worker interview the patient. 3) Ask the patient to confirm the diagnosis. 4) Read about Decisional Conflict in the NANDA-I handbook. ANS: 3 After identifying problems and etiologies (which this nurse has done), the nurse should verify them with the patient to help ensure that her conclusions are accurate. If the patient does not agree that he has Decisional Conflict, the nurse might interview him more to clarify the meaning of the data. Certainly the nurse could ask another nurses opinion, but that is not essential. It would make no sense to have a social worker interview the patient unless the situation remains unclear even after confirming with theclient. If the nurse did have adequate theoretical knowledge of Decisional Conflict for this patient, she should have been informed by reading the NANDA-I handbook before making the diagnosis. If the patient does not confirm the diagnosis, and the nurse concludes the diagnosis is in error, she might then reread the NANDA-I guide. PTS: 1 DIF: Moderate REF: V1, p. 56 | p. 63 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application 18. The clients weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, I probably eat a little too much red meat. And what is this I hear about needing omega 3oils in my diet? I dont like to take supplements, and I think I could really improve my nutrition. Which of the following nursing diagnoses should the nurse use? 1) Balanced Nutrition 2) Possible Imbalanced Nutrition: Less Than BodyRequirements 3) Risk for Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition ANS: 4 You will use a wellness diagnosis when a persons present level of wellness is effectiveand when the person wants to move to a higher level of wellnessin this case, a higher level of nutrition. The format for a wellness diagnosis is Readiness for Enhanced . . . Use a possible diagnosis when you have enough data to suspect a problem but need more data to support a diagnosis. Use a risk diagnosis when there are risk factors for aproblem. PTS: 1 DIF: Moderate REF: p. 72 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application
19. The patient verbalizes an overwhelming lack of energy. He says, I still feel exhausted even after I sleep. I feel guilty when I cant keep up with my usual daily activities or sleep during the day. Ive been a little depressed lately, too. The patient seems to have difficulty concentrating but has no apparent physical problems. Which ofthe following diagnoses best describes his health status? 1) Fatigue related to depression 2) Fatigue related to difficulty concentrating 3) Guilt related to lack of energy 4) Chronic confusion related to lack of energy ANS: 1 The diagnosis that best describes the overall health status is Fatigue. The only cue that might cause Fatigue is depression. You cannot use depression as the problem because it is a medical diagnosis, and it is not a NANDA-I label. The other cues (difficulty concentrating, inability to perform ADLs, and guilt) are symptoms of Fatigue, not etiologies. These diagnoses would lead the nurse to focus on dealing with guilt and confusion, so the source of the Fatigue would not be addressed. PTS: 1 DIF: Difficult REF: dm 70-73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application 20. Which of the following nursing diagnoses is written in correct format? Assume the facts are correct in all of them. 1) Readiness for Enhanced Nutrition2) Pain related to stating, On a scale of 1 to 5, its a5. 3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever ANS: 1 Wellness diagnoses (e.g., Readiness for Enhanced . . .) are usually one-part statements.A pain ranking of 5 is a symptom of pain, not an etiology, so it should be preceded by A.M.B. or as manifested by. Hip fracture is a medical diagnosis that is causing an etiology of pain; therefore, it should be preceded by secondary to. Risk diagnoses donot have symptoms, so it is not correct to put anything after A.M.B. Chapter 8 Outcome Identification an PlanningMultiple Choice Identify the choice that best completes the statement or answers the question. 1. For which patient would it be most important to perform a comprehensive 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 lives alone 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 whohas complex needs, including self-care deficits. The other patients do not have the complex needs of the older adult patient who has had a stroke that 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 theplan. 4) Involve the multidisciplinaryteam. ANS: 3 The discharge plan may be developed in a timely manner and involve the family anda multidisciplinary team, but if the patient does not agree with the plan, it will not be successful. PTS: 1 DIF: Moderate REF: dm 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. 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 planning? 1) A woman who has just given birth to her second child and lives with her husband and18month-old daughter 2) A man who has been readmitted for exacerbation of his chronic obstructivepulmonary 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 a new 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 particularunit 2) Include both medical and nursingorders 3) Specify patient outcomes for eachday 4) Help ensure that important interventions are not overlooked ANS: 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 with a particular medical diagnosis. Unlike protocols, they do not include medical orders. Unlike critical pathways, they do not specify predicted patient outcomes for each day. 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 of care? Standardized (model) care plans 1) Describe the care needed by patients in defined
situations 2) Include specific goals and nursing orders 3) Become a part of the patients comprehensive careplan 4) Usually describe ideal nursing care ANS: 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. Unit standards are more general and do not have goals for each patient. Unit standards are kept on file in a central place on theunit 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 care planfor Impaired Walking related to left-side weakness. Which of the following activitieswill the nurse perform when individualizing the plan for the patient? 1) Validate conflicting data with thepatient. 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 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? The patient will 1) Use the incentive spirometer whenawake 2) Walk two times during day and evening shifts3)
Maintain oxygen saturation above 92% while performing ADLs each morning 4) Tolerate 10 sets of range-of-motion exercises with physical therapy ANS: 3 Outcome statements should have specific performance criteria and a target time; maintain oxygen saturation is the only one that meets those criteria. The incentive 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 rangeof-motion goal, tolerate is a vague word and is difficult tomeasure, 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 interventions 2) Prescribe minimal care needed to meet recommended lengths of stay 3) Describe care common to all patients with a certain condition or situation 4) Emphasize medical problems and interventions ANS: 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., all patients whohave 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: dm 8687; high-level question, answer not given verbatim KEY: Nursing process: Planning | Client need: SECE | Cognitivelevel: Analysis 10. How is NOC different from the Omaha System? 1) 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) 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 beused 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-term goals 1) Can be met within a few hours or a few days 2) Are developed from the problem side of the nursing diagnosis 3) Must have target times/ dates 4) Specify desired client responses to interventions ANS: 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 long-term 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 plans have in common? They both 1) Reflect critical thinking for a specific patient 2) Are preprinted to apply to needs common to a group ofpatients 3) Address a patients individual needs 4) Provide detailed nursing interventions ANS: 4 They both provide detailed nursing interventions, although the individualized care plan is more specific to the patients needs and reflects critical thinking, whereas standardizedplans do not. It is not true of individual nursing care plans that they are preprinted and apply to a group. PTS: 1 DIF: Moderate REF: dm 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/outcomeson the plan of care? Because outcomes describe 1) Desired changes in the patients health status 2) Specific patient responses to medical interventions 3) Specific nursing behaviors to improve a patients health 4) Criteria to evaluate the appropriateness of a nursing diagnosis ANS: 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 specificnursing 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 example of performance criteria? The patient will 1) Turn herself in bed frequently while awake 2) Understand how to use crutches by day2 3) State that pain is decreased after being medicated 4) Eat 75% of each meal without complaint of nausea ANS: 4 Performance criteria should be specific and measurable. 75% of each meal is specificand 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 affectedby nursing interventions alone. Goals for collaborative problems are specific to the medical condition/treatment. PTS:1DIF:ModerateREF: dm 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 responses 2) Patient response before interventions are done 3)
Patient response in positive terms 4) A pattern of related cues ANS: 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. 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 the following goals/outcomes must be included on the care plan? 1) Checks current medications for mind-altering side effects 2) Demonstrates use of techniques to help with memoryloss 3) Drinks at least 1500 cc of fluid per day 4) Takes electrolyte supplements withmeals ANS: 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 are needed. This scenariodemonstrates 1) Formal planning 2) Informal planning 3) Ongoing planning 4) Initial planning ANS: 2 Informal planning is performed while doing other nursing process steps and is not written; this nurse is forming a plan in her mind. The end product of formal planning isa holistic plan of care that addresses the patients unique problems and 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 nothave enough 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: AnalysisMultiple Response Identify one or more choices that best complete the statement or answer the question. 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 the American Nurses Association standards for outcomes identification? Choose all thatapply. 1) Developing culturally appropriate outcomes 2) Using the outcomes preprinted on the clinicalpathway 3) Choosing the best outcome for the patient, regardless of the costs involved in bringingit about 4) Involving the patient and family in formulating the outcomesANS: 1, 4 ANA standard 3 includes derives culturally appropriate expected outcomes from the 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, and costs. . . . Chapter 9 Implementation and Evaluation Multiple Choice 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 it inthe 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 themost, it is dangerous. Holding the medication and notifying the prescriber prevents the client from receiving timely treatmentmany drugs are less effective if a consistent schedule is 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 adverse reactions 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. Assessing the clients skin condition, changing pressure ulcer dressings, and applying a hydrocolloiddressing to a pressure ulcer are all interventions that require nursing knowledge and judgment. PTS:1DIF:ModerateREF:dm 122124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application 3. The nurse has just finished documenting that he removed a patients nasogastric tube. Which is the next logical step in the nursing process? 1) Assessme nt 2) Plannin g 3) Evaluatio n 4) Diagnos is ANS:
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 steps in order are as follows: assessment diagnosis, planning outcomes, planning interventions, implementation, andevaluation. 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 a specific 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. 4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner. ANS: 4 Positioning the client in the chair for meals considers the clients desire to be out of bedfor 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 | Cognitive level: Application 5. The primary provider prescribes an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? 1) Ask a colleague for help, because the nurse cannot safely perform the procedure alone. 2) Gather the equipment and prepare it before informing the client about the procedure. 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 the clientis confused. ANS: 1 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 beinformed 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 client is confused is inappropriate because the procedure canvery 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. How should the nurse proceed? 1) Postpone the teaching session until the patient is morereceptive. 2) Follow the critical pathway for patient teaching about ostomy care. 3) Administer a prescribed antidepressant and notify the physician. 4) Explain to the patient the importance of skin care around the ostomy site. ANS: 1 A depressed affect and poor eye contact likely indicate that the client is having difficulty 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 does not 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 clients individual 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. Reassuringthe client requires which type of nursing skill? 1) Psychomotor 2) Interpersonal 3) Cognitiv e 4) Critical thinking ANS: 2 Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires
psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastrictube 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 tothe therapy? 1) Inserting an IV catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet ANS: 4 Instituting and adhering to a low-fat, low-calorie diet is an intervention that depends 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 clientto 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 2 diabetes 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 sugar 2) Informing the client he must exercise at least three times per week 3) Explaining to the client that he must come to the diabetic clinicweekly 4) Determining the clients main concerns about his diabetes ANS: 4 Determining the clients main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoringequipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control 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 | Cognitivelevel: Analysis 10. Which statement accurately describes delegation? 1) Transferring authority to another person to perform a task in a selected situation 2) Collaborating with other caregivers to make decisions and plancare 3) Scheduling treatments and activities with other departments 4) Performing a planned intervention from a critical pathway ANS: 1 Delegation is the transfer to another person of the authority to perform a task in a selected situationthe person delegating retains accountability for the outcome of theactivity. 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 plannedinterventions. PTS:1DIF:EasyREF: p. 122 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Knowledge 11. Which statement by the nurse best demonstrates clear communication to 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 than 100.5F (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, and the 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 to the nursing assistive personnel (NAP)? 1)
Nurse who delegated the task 2) Licensed practical nurse working with the NAP 3) Unit nurse manager 4) Charge nurse for the shift ANS: 1 The nurse who delegates the task is responsible for supervising and evaluating the outcomes of tasks performed by the NAP. Another registered nurse, such as a staffnurse, nurse manager, or charge nurse, can answer questions and provide 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 before initiating 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% ofcases). 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 wishes to 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: dm 127-128
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application 15. When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour? 1) At the end of the shift 2) 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 every hour because the goal statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides how often the nurse would reassess the patient. PTS:1DIF:EasyREF: dm 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) Intermitte nt 2) Ongoin g 3) Termin al 4) Proce ss ANS: 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 after an 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 at specific 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 the statusof a patients anxiety at discharge? The patient 1) Has a relaxed facial
expression 2) States that he feels more relaxed today 3) Shows no physiological signs of anxiety (e.g., pallor) 4) Has no further questions about homecare ANS: 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 signsmight 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 he has 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 the patient the options for further treatment. This is an example of 1) Delegatio n 2) Collaboratio n 3) Coordination of care 4) Supervision of care ANS: 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 toobtain the big picture. Supervision is the process of directing, guiding, and influencingthe outcome of an individuals performance of an activity or task. PTS:1DIF:ModerateREF: dm 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 the question. 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
dehydration 2) 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 tract infection 4) • year-old patient with chronic renal failure who has vital signs within his normal 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 the keen 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 forby a registered nurse.
Chapter 10 Healthcare Team Communication: Documenting and ReportingMultiple Choice Identify the choice that best completes the statement or answers the question. 1. Which commonly accepted practice came out of the Framingham study? Use of 1) Mammography in breast cancer screening 2) Colonoscopy in colon cancer screening3) Pap testing in cervical cancer screening 4) Digital rectal examination in prostate cancerscreening ANS: 1 One commonly accepted practice that came out of the Framingham study is the link 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 2. Which theorist developed the nursing theory known as the science of human 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 human caring. 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 ofsoldiers. 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 a mental image of pain based on her own experiences with pain. This mental image is known as a(n) 1) Phenomeno n 2) Conce pt 3) Assumptio n 4) Definitio n ANS: 2 A concept is a mental image of a phenomenon, an aspect of reality that you can observeand experience. In the scenario above, the nurse forms a mental image of 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 trueand 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 to nursing was 1) Transcultural nursing 2) Health promotion 3) Nurse-patient relationship 4) Holistic comfort ANS: 3 Hildegard Peplau was a psychiatric nurse who showed that developing a relationshipwith psychiatric patients made their treatment more effective. From her 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 care area clean. This most directly illustrates the ideas of which nursing theorist? 1) Virginia Henderson 2) Imogene Rigdon 3) Katherine Kolcaba 4) Florence Nightingale ANS: 4 Florence Nightingale was instrumental in identifying the importance of a clean patient care environment. During the Crimean War, Nightingale dramatically reduced the deathrate 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 administer through herNG 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 Neuman 2) Dorothea Orem 3) Callista Roy 4) Madeline Leininger ANS: 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 the nurse address first?
1) Protecting the patient against falls 2) Protecting the patient from an abusive spouse 3) Promoting rest in the critically ill patient 4) Promoting self-esteem after a body image change ANS: 3 According to Maslows hierarchy of needs, basic physiological needs should be metfirst. They include the need for rest, food, air, water, temperature regulation, elimination, sex, and physical activity. Therefore, the nurse should address 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 and stating the problem, the nurse researcher clarifies the purpose of the study. Which stepin 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 the purpose of the study. Next, the researcher should perform a literature search to find outwhat 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 reassurance that 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 harmed 2) To selfdetermination 3) To full disclosure 4)
Of confidentiality ANS: 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 research study 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 theparticipants 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 the right to confidentiality. Typically that right is preserved by giving participants an identification code rather than associating them byname. 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 security 2) Physiological 3) Selfactualization 4) Selfesteem ANS: 2 Cardiac rehabilitation most directly addresses the patients physiological need for physical activity as well as for health and healing. Indirectly, of course, better physicalcondition might enable the patient to perform activities that would lead to higher self- esteem and even self-actualization. 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 met before reaching self-actualization. These needs include 1) Cognitive and aesthetic needs 2) Love and belongingneeds 3) Safety and security needs 4) Physiological and self-esteem needs ANS: 1 In his later work, Maslow identified two growth needs that must be met before
reaching self-actualization. They include cognitive (to know, understand, and explore)and aesthetic (for symmetry, order, and beauty) needs. The needs Maslow identified inhis earlier work were physiological, safety and security, love and belonging, esteem, and selfactualization. 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 low- back pain in adults? Which part of this question comes from the I in PICO? 1) Adul ts 2) Management 3) 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: Whatis 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 analytically 2) Performing a literature review 3) Formulating a searchablequestion 4) Determining the soundness of thearticle ANS: 1 Analytical reading involves questioning the article to be sure you understand it and 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 search of the literature. The nurse would determine whether the article is a research report by looking for the individual parts of the articleto see if they were present in the form of research (e.g., title, problem, hypothesis, purpose, methods, data, data analysis, conclusions).
Chapter 11 Health, Wellness, and Integrative Healthcare 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 teachesthe patient and family about the importance of hygiene and cleanliness. This most closely illustrates the ideas of which of the following people? 1) Jean Watson 2) Jurgen Moltmann 3) Florence Nightingale 4) Robert Louis Stevenson ANS: 3 Florence Nightingale believed that health was prevention of disease through the use of fresh air, pure water, efficient drainage, cleanliness, and light. Jean Watson believes thathealth has three elements: a high level of overall physical, mental, and social functioning; a general adaptive-maintenance level of daily functioning; and the absenceof illness (or the presence of efforts that lead to its absence). 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 nota matter of 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 with stress? 1) Performing meaningful work 2) Consuming simple carbohydrates 3) Drinking three glasses of red wine each day 4) Weight training ANS: 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 hasbeen shown to increase bone density and reduce the 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 who1) Controls feelings to avoidconflict 2) Teaches negotiation skills and independence 3) Encourages risk taking and adventure 4) Views themselves as helpless victims ANS: 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 avoid conflict 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 themselvesas 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. He hasa genetic-linked anemia. He says he does not eat a balanced diet, as he preferssweets to meat and vegetables. Which of the following dimensions of health can the nurse most likely influence by teaching and counseling him? 1) Age-related changes 2) Genetic anemia 3) Eating habits 4) Gender-relatedissues ANS: 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) Privac y 2) Dignit y 3)
Functional 4) Identity ANS: 2 Hospitalized patients commonly experience the loss of dignity. Wearing a hospital gown, having their body exposed, invasive procedures, loss of control over 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 situationsduring 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 athome? 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 his needs are met. Asking about medications, allergies, and an advance directive is also important but does not take priority over asking about the patients greatest concern. 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 patient 2) Developed solely by the healthcareteam 3) Developed without family input, to maintain confidentiality 4) Valued by the multidisciplinary care providers ANS: 1 Goals should be realistic so that progress is recognized by the patient. They shouldbe valued by both the patient and family. The nurse should develop goals with 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 this hospitalization has ended? 1) Administering her medications according to schedule 2) Allowing flexible visitation by her family and friends 3) Explaining treatment options in terms she can understand 4) Providing a healing presence by listening and being attentive ANS: 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, allowing flexible visitation, and explaining treatment options are important contributions that 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, perhaps through the rest of their lives, is thepeople 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. 3) 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 cannotbe 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 diet 2) Physical
activity 3) Restful sleep 4) Comfortable room temperature ANS: 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 reduces the risk of chronic disease and promotes longevity. Keeping the body at a comfortable temperature helpsmaintain health but not release of growth hormone. 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 on helpingthe patient cope with the emotional responses to prolonged hospitalization? 1) Providing skin care every shift to prevent skin breakdown 2) Encouraging the patient to get up in a chair to eatmeals 3) Assisting the patient to ambulate in the hallway for several minutes eachday 4) Designating a corner of the patients room to display personal mementos ANS: 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 specifically dealing with hospitalization as is designatinga portion of the room that is uniquely hers. PTS:1DIF:ModerateREF:p. 226 KEY: 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 relationships 2) Spirituality 3) Nutritio n 4) Sleep and rest ANS: 2 When a patient is faced with a terminal illness, spirituality can help the patient maintainhis sense of self. Family relationships can provide a loving, supportive source 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 illness as 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 infections 4) 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 scenario suggests 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 been described 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. The patient agrees and signs the informed consent. This patient is experiencing which stage of illness behavior? 1) Sick-role behavior 2) Seeking professionalcare 3) Experiencing symptoms 4) 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 pain at home. He entered the sickrole 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 seeking-professional-care stage of illness. PTS:1DIF:ModerateREF:dm 228-229 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis
15. Many health providers define illness as pathology; however, people experience, rather than define, illness. Which of the following is how most people experience illness? 1) Feeling lousy, a true sense of not being all right 2) A change in the way they feel or a disruption in their typical life 3) Something to be dreaded and avoided if at all possible 4) An experience that offers the potential for learning and spiritualgrowth ANS: 2 People typically describe their illness in terms of how it makes them feel or the effect ithas 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 may have 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. Ifa 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, alwayshas a negative effect on an individuals health 2) Adequate income, food, and shelter create a healthful environment and alwaysimprove physical health status 3) Physical environment, family, and social support may help or hinder the health statusof 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 or negative effect on a clients health status. The effect of poor living conditions may be offset by the presenceof loving family and friends. Poverty does not always have a negative effect on health. Similarly, the presence of food, shelter, and 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 when providing community-based care. Chapter 12 Healthcare in the Community and Home Identify the choice that best completes the statement or answers the question. 1. The inhabitants of Yulupa, California, form which of the following? 1) Aggregat e 2) Communit y 3) Populatio n 4) Vulnerable population ANS: 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 a common purpose, andan 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 andincludes 4,000 people. What components of the community must the community healthnurse assess prior to beginning her new assignment? 1) Income levels, health status, and relationships among groups 2) Structure of the tracts, effectiveness of the community, and current status 3) Number of clients with health problems compared to the number of healthcare providers 4) Community organizations and beliefs about their role in the community ANS: 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 part of 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 inthe 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 5years. ANS: 1 Evidence of health in a community can be judged by examining progress in the focus areas delineated in Healthy People 2020. Access to primary care services is 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 provideevidence 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 whole andthe health status of individuals as an aggregate? 1) School nursing 2) Community health nursing3) Community-oriented nursing 4) Public health nursing ANS: 4 Public health nursing focuses on the community at large and the eventual effect of 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 and public 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 their needs. Which of the following nursing roles best describes these actions? 1) Case manager 2) Client advocate 3)
Collaborat or 4) Counsel or 5) Educat or ANS: 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 nursemakes 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 offers practical 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 lowincome neighborhood perceive the community and its state of health. Which of the following assessment strategies would be appropriate? 1) Conducting a windshield survey while driving 2) Reviewing a multitude of community databases 3) Interviewing residents living on every fifth block 4) Analyzing demographic data on the community ANS: 3 To assess community perceptions, the nurse will need to interact with a cross-section ofthe 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:dm 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 contribute to 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 strengths and 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 language 2) Nursing diagnoses expressed in standardizedlanguage 3) Diagnoses, outcomes, and interventions 4) Labels that are intended for use in any healthcare setting ANS: 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 likely perform which of the following functions within a particular community? 1) Tracking the prevalence of gonorrhea between January and June 2) Screening for scoliosis among 12- to 14-year-old girls in middleschool 3) Weighing premature infants receiving phototherapy athome 4) Giving the H1N1 vaccine to fire and police personnel ANS: 1 Public health nursing focuses on the community at large and the eventual effect of 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 promotingand protecting the health of the community as a whole, such as tracking the prevalenceof 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 buildings 2) Demographic data of the residents 3) Morbidity and mortality rates of the population 4) Common strategies for conflict resolution ANS: 2 Structure refers to the general characteristics of a community. These include demographic data, such as gender, age, ethnicity, and educational and income levels, aswell as data about healthcare services, such as the number of primary care 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 care unit 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 activities are directed at fostering independence or teaching the family or other caregivers to assistthe 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 whohas 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 more enjoyablefor nurses to work in home care. 2) Home care is much more organized than hospital care; you have access to the
whole team, and there is less interference from others.3) A home health nurse has more autonomy and skills than a hospital nurse; Ill get todo 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 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. The level 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 bemore autonomous than hospital 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 orientedbut 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 andadminister insulin. He has never given himself insulin, and he does not understand how to interpret his blood sugar readings. The physician has prescribed discharge from the hospital with home health follow-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, and needs tobe monitored. 3) No; the patient should remain hospitalized; he has too many needs for home care services. 4) No; the patient is relatively young and oriented; he should be able to provide his own 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, and to 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 provider 2) Client and family educator 3) Client advocate 4) Care coordinator ANS: 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 families to 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 isunable 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 home visit and has driven to the home. What is the nurses objective in the first few minutes of thevisit? 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 rapport and trust. Once rapport and trust have been developed, the nurse can gather data, assess the client, anddetermine 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 nurses use 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 doesnot. 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 doesnot. 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 home care; 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 usedin any setting, including home healthcare. NIC and NOC 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 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 whenI was a child. The most appropriate nursing diagnosis for this woman is: 1) Caregiver Role Strain 2) Impaired Home Maintenance 3) Interrupted Family Processes 4) Risk for Caregiver Role Strain ANS: 1 This caregiver is experiencing fatigue, isolation, and difficulty adjusting to role changes. These are signs of Caregiver Role Strain. Because symptoms exist, this is anactual 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 and filthy. The patients room is not clean. What supplies would be essential for the nurse to bring withhim when visiting this client? 1) All wound care supplies needed for the duration of the care 2) Reclosable plastic bags for disposal of old dressings 3)
Small, biohazard sharps container to be left in the room 4) Waterless, antibacterial hand sanitizer solution ANS: 4 The nurse should use a waterless antibacterial hand sanitizer in place of soap and 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. Wound care supplies, for example, would be ordered and kept in the home. Old dressings should be double- bagged to prevent leakage, and discarded in the home. 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) Patient assessment data and interventions performed 2) Patient response to care and assessment of environment 3) Evidence of homebound status and continued need for skilledcare 4) Skilled care delivered and communication with other providers ANS: 3 All of the aspects mentioned should be documented. However, the unique requirements of home care include documentation of homebound status and the continued 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 areseveral bottles of medication, some open, some not. They have all been prescribed for the patient. The patient cannot say how often to take each one, 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 2 days,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 pills totake. 3) Administer todays medications and arrange for the pharmacy to put medications in easy- to-open containers in the future. 4) Fill the organizer for each day of the week, explain how to use it, and return in a dayor 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 return every day or so until he is certain that the patient can actually administer his own meds after someone else loadsthe 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 her homebound 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 alid. 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 thetabletop. ANS: 1 The caregiver should discard the syringe and needle in a thick plastic milk jug with 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 remove the needle from thesyringe or attempt to break it because this increases the risk of needlestick injury. Chapter 13 Culture and Diversity Multiple Choice Identify the choice that best completes the statement or answers the question. 1. North American healthcare culture typically reflects which culture? 1) Asia n 2) European American 3) Latin o 4) African American ANS: 2 Although the demographics are changing in this recent decade with increasing Hispanic and Asian inhabitants, North American healthcare culture typically reflects the dominant (European American) culture because most healthcare providers belong
to that culture. PTS: 1 DIF: Easy REF: p. 317 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall 2. A 26-year-old man of Mexican heritage is admitted for observation after sustaining injuries in a motor vehicle accident. When assessing this patient, the nurse must consider that he may possess which view of pain? 1) A belief in taboos against narcotic use to relieve pain 2) Expectation of immediate treatment for relief of pain 3) Endurance of pain longer and report it less frequently than some patientsdo 4) Use of herbal teas, heat application, and prayers to manage his pain ANS: 3 In general, patients of Mexican heritage may endure pain longer and report it less frequently than some. Patients of Japanese heritage may have taboos against narcotic use to relieve pain. Patients of Puerto Rican heritage may use herbal teas, heat application, and prayers to manage pain. Remember that all of these are archetypes andare not necessarily true for all members of a cultural group. PTS:1DIFifficultREF:p. 329 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
3. The nurse is caring for a 42-year-old Chinese American patient who underwent emergency coronary artery bypass graft surgery. He is self-employed and has no health insurance. Each day members of his family spend hours at his bedside. Which is the most important factor for the nurse to focus on when planning the patientsdischarge? 1) Ethnic background 2) Family support 3) Employment status 4) Healthcare coverage ANS: 2 The nurse should focus on the patients strengths and resources for health restoration and self-care. In this case, that is the patients family. His family can be a great supportfor him when he is discharged (e.g., preparing healthy meals, helping him manage exercise and treatment regimens). Although the patients ethnic background is very important to his care, discharge planning should revolve around his available resources. Insurance should not be the focus at this time, although at some point the nurse has probably obtained data about these topics. PTS:1DIF:ModerateREF:dm 320, 326 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 4. A patient who came from Central America is admitted with diabetes
mellitus. The nurse is collecting biographical information. Which informationprovided by the patient represents his ethnicity? 1) Latin o 2) Catholi c 3) Whit e 4) Teach er ANS: 1 Ethnicity refers to groups whose members share a common cultural heritage. This patient came from a Spanish-speaking country in Central America; therefore, his ethnicity is considered Latino. Catholic is his religion, white is his race, and teacher ishis occupation. PTS:1DIF:ModerateREF:p. 318 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 5. A patient who moved to the United States from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet she still retains some customs from her homeland. This patient is experiencing 1) Assimilation 2) Socializatio n 3) Acculturatio n 4) Immigratio n ANS: 3 This patient is experiencing acculturation; she has accepted both her own and the new culture and has incorporated elements of both into her life. Socialization is the processof learning to become a member of a society or group. Cultural assimilation occurs when the new member gradually learns and takes on, to a great extent, the dominant cultures values, beliefs, and behaviors. Immigration is the act of moving to a new country. PTS:1DIF:ModerateREF:p. 319 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Analysis 6. Which of the following is considered a practice (as opposed to a belief or value)? 1) Always drinking water after exercise 2) Thinking often about
cleanliness 3) Emphasis on success 4) Maintaining youth ANS: 1 A practice is a set of behaviors that one follows, such as always drinking water after exercise. Preoccupation with cleanliness, emphasis on success, and maintaining youthare examples of values that are dominant in United States culture. PTS:1DIF:EasyREF:p. 320 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Comprehension 7. The nurse is caring for a patient who emigrated from Puerto Rico. She can best care for this patient by learning about the 1) Practices of the patients ethnic group 2) Patients individual cultural beliefs 3) Values of her own culture 4) Spanish-speaking community ANS: 2 The nurse cares for this patient by becoming familiar with the patients individual cultural and ethnic beliefs and values. It is helpful to become familiar with the patientsethnic group and the Spanish-speaking community; however, the nurse should not assume that the individual holds the same values, beliefs, and practices as his ethnic group or community. The nurse should explore her own culture but not assume that thepatient holds those same beliefs and practices. PTS: 1 DIF: Moderate REF: p. 320 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 8. The nurse is teaching a clinic patient about hypertension. Which statement bythe patient suggests that he is present oriented? 1) I know I need to lose weight; Ill have to begin an exercise program right away. 2) If I change my diet and begin exercising, maybe I can control my blood pressurewithout medications. 3) I know I need to give up foods that contain a lot of salt, but with teenagers in the houseit is very difficult. 4) I will reduce the amount of calories, salt, and fat that I eat; I certainly do not want tohave a stroke. ANS: 3 Knowing an action is needed but giving reasons for not beginning it just now shows a focus on the present. The patient knows that he should reduce his sodium intake, but his
present situation is preventing him from doing so. Therefore, he is disregarding the impact consuming sodium might have on his future. The other responses are future oriented because they indicate that the patient is planning lifestyle changes that will affect his future. PTS:1DIFifficultREF:dm 321, 326 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 9. A patient of Japanese heritage avoids asking for narcotics for pain relief. The nurse writes a nursing diagnosis of Pain related to reluctance to take medication secondary to cultural beliefs. If the cultural archetype is true for this particular patient, this probably means that the patient views pain as 1) A punishment for immoral behavior 2) A part of life 3) Best treated with herbal teas and prayer 4) A virtue and a matter of family honor ANS: 4 Patients of Japanese heritage may view pain as a virtue and a matter of family honor. They may be more accepting of pain medications if the nurse reassures them that pain control enhances healing. Patients of Mexican heritage may view pain as punishment for immoral behavior. Those of Navajo Indian heritage commonly view pain as a part oflife, whereas those of Puerto Rican heritage may feel that pain is best treated with herbal teas and prayer. Keep in mind that these are all archetypes and do not necessarilyapply to all members of a cultural group. PTS:1DIF:ModerateREF:dm 320-321, 326 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Comprehension
10. The nurse is developing a plan of care for a patient of Aleut descent who sustained a hip fracture. Which intervention by the nurse recognizes the patients indigenous healthcare system and should be included in the plan of care? 1) Asking the family to bring in medals and amulets 2) Scheduling a visit from the shaman 3) Providing the patient with her favorite herbal tea 4) Requesting that the physician consult the patientsacupuncturist ANS: 2 For the patient of Aleut descent, contacting the shaman and scheduling a visit with the patient might be helpful in recovery. Patients of Hispanic descent might benefit from herbal tea and medals and amulets brought in by the family. However, it is important to check with the physician before administering any herbal preparations that might
interfere with prescribed medications. Asians and Pacific Islanders might benefit froma visit by the acupuncturist. PTS:1DIFifficultREF:dm 323, 325 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 11. A client incorporates alternative healthcare into her regular health practices.For which alternative therapy should the patient visit a formally trained practitioner? 1) Use of herbs and roots 2) Application of oils and poultices 3) Burning of dried plants 4) Acupuncture ANS: 4 Acupuncture requires a formally trained practitioner. Use of herbs and roots, the application of oils and poultices, and the burning of dried plants do not require formally trained practitioners. Patients should be advised to inform their traditional primary healthcare provider when using various herbal remedies, as they can interferewith other prescribed medication and cause untoward side effects. PTS:1DIF:ModerateREF:dm 325-326 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 12. An elderly patient tells the charge nurse that she wants another nurse to take care of her. When the charge nurse questions the patient, she states I dont wanta man taking care of me. Which cultural barrier is this patient exhibiting? 1) Ethnocentris m 2) Racis m 3) Sexis m 4) Chauvinis m ANS: 3 This patient is exhibiting sexism; she is objecting to the nurse merely because of his sex. Although we tend to think of sexism in a negative light, this woman may merelybe reflecting a cultural attitude. The patient is in no position to actually discriminate against the nurse, in terms of employment, and so on. Therefore, her preferences should be respected. Ethnocentrism occurs when a person is positively biased towardtheir own culture. Racism is a form of prejudice and discrimination based on race. Chauvinism occurs when a person assumes that he is superior. PTS:1DIF:EasyREF:p. 328 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 13. A patient who had surgery 8 hours ago has not voided. The nurse notifies the physician for an order to insert an indwelling urinary catheter. Which of the
following statements should the nurse use to describe the procedure to the patient?1) I need to put a Foley in you because you havent voided since your surgical procedure. 2) I need to insert a tube into your bladder to drain the urine because you havent urinated since surgery. 3) I need to catheterize you because you havent urinated since having your surgery. 4) I need to place a catheter in your bladder because you havent voided since surgery. ANS: 2 I need to insert a tube into your bladder . . . best describes the procedure for the patient because the explanation is in terms most patients will understand. The otheroptions contain medical jargon that could confuse the patient. PTS:1DIF:ModerateREF:p. 328 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 14. A Hispanic patient is frustrated because the healthcare team does not understand the importance of hot and cold therapies. Which nursing diagnosis is most appropriate for this patient? 1) Powerlessne ss 2) Impaired Verbal Communication 3) Spiritual Distress 4) Risk for Noncompliance ANS: 1 Powerlessness is the best nursing diagnosis for the patient who is unable to make healthcare personnel understand the importance of his cultural beliefs. Impaired Verbal Communication can be used for patients who do not speak or understand thehealthcare personnels language. Spiritual Distress might occur because a treatment is not in agreement with the patients religious beliefs. Risk for Noncompliance can be identified when a patient fails to follow a health-promoting or therapeutic plan the healthcare provider believes they agreed to. PTS:1DIF:ModerateREF:p. 330 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 15. A patient of Scandinavian heritage is admitted for observation after sustaining injuries in a motor vehicle accident. The nurse expects that he may endure pain stoically, without grimacing or vocalizing. The nurses thinking is an example of a/an 1) Archetyp
e 2) Bi as 3) Prejudic e 4) Stereotyp e ANS: 1 An archetype is an example of a person or thingsomething that is recurrentand it has its basis in facts. Therefore, it becomes a symbol for remembering some of the culture specifics and is usually not negative. A bias is the tendency to see only one side of an issue, a lack of impartiality. Prejudice refers to negative attitudes toward other people that are based on faulty and rigid stereotypes about race, gender, sexual orientation, and so on. A cultural stereotype is the unsubstantiated belief that all people of a certain racialor ethnic group are alike in certain respects. Similar to biases, a stereotype may be positive or negative. PTS:1DIF:ModerateREF:dm 320-321 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 16. A patient reports experiencing gas, abdominal bloating, and diarrhea after consuming milk or cheese. Lactose intolerance might immediately be suspected if the patient is of which heritage? 1) African American 2) Mexican American 3) European American 4) Arab American ANS: 1 Lactose intolerance, caused by a deficiency of the enzyme lactase, is more commonly seen in African Americans than in the other cultural groups listed. Of course, one wouldassume lactose as the cause of the patients symptoms, but it would be important to rule it out. Chapter 14 Communication in the Nurse-Patient RelationshipMultiple 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)
Grou p 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 internal dialogue.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 nurse notes 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 thepatient? Patient will 1) Explain the reason for his incongruent statements2) Engage in diversional activities to cope with stress 3) Express his concerns to his primary care provider 4) Discuss his concerns and fears with the nurse ANS: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 and behavior is identified. PTS: 1 DIF: Moderate REF: p. 476 KEY: Nursing process: Planning | Client need: PSI | Cognitive level:Application3.The nurse is preparing a patient for a computed tomography (CT) scan of the 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 yourtest. 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 CTscan. 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. Theother options use medical jargon that many patients may not understand. PTS:1DIF:ModerateREF:p. 465 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application4.The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows she should use touch cautiously, especially when communicating with which patient? 1) Middle-aged woman just diagnosed with terminal lungcancer 2) Middle-aged man experiencing the acute phase of myocardialinfarction 3) Older adult with a history of dementia admitted for dehydration 4) Young adult in the rehabilitative phase after arthroscopic surgery ANS:3 The nurse should use touch especially cautiously when communicating with a personwho suffers from impaired mental health, such as dementia, because the patient 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 to help 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 someof the people working the other shifts. 2) It really helps me to share feelings about how hard it is to see pain and suffering every day. 3) I now have a group to help me when I need to work through situations in my ownlife 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 feelings about 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 arenot 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 for this patient? 1) Impaired Communication 2) Readiness for Enhanced Communication 3) Impaired Verbal Communication 4) Sensory Alteration ANS: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 patient expresses willingness toenhance communication. Sensory Alteration is appropriate when there is a change in the characteristics of the patients incoming 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 tothe emergency department with signs of respiratory distress. When the nurse performs the admission assessment, she notes that the patient is not able to say where she is or the time. Which nursing diagnosis is probably most suitable for this patient? 1) Chronic Confusion 2) Acute Confusion 3) Impaired Verbal Communication 4) Readiness for Enhanced Communication ANS: 2 This patient is experiencing Acute Confusion caused by lack of oxygen related to his 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. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia, but not with confusion. Readiness for Enhanced Communication is appropriatewhen 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 expected outcome is appropriate for this patient? 1) Uses alternative methods of communication 2) Communicates effectively using a translator3) Interprets messages accurately 4) Follows commands when asked ANS:1 An appropriate outcome for a patient with expressive aphasia is uses alternative methods of communication. Expressive aphasia means the patient cannot verbalize hisintended 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 patientwho 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 nursepatient relationship? 1) Avoiding topics that may provoke emotional responses from the patient 2) Listening to the patient while performing careactivities 3) Performing care interventions quietly and respectfully 4) Greeting the patient by name whenever entering the patients room ANS: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 have
surgery as soon as possible. The patient is not certain she wants to pursue this treatment approach but responds by saying, Ill do whatever you think I should do. Which communication style is this patient using? 1) Assertiv e 2) Aggressiv e 3) Passive aggressive 2 4) Passiv e ANS: 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 be in 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 helpthe 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? 3) 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 assessing and 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 responseand does not use an assertive approach. Asking the nurse to explain why she has not been assessing and documenting pain is also judgmental. PTS:1DIF:ModerateREF:dm 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 nurse
appropriately 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 options offer 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-patient relationship 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 botheringyou? 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 you beforeI 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 anurses 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 preinteraction phase of the nurse-patient relationship. 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 term 2) Ongoin
g 3) Selfhelp 4) Work-related social support ANS:1 The organized group is a short-term group. Short-term groups focus on the task at 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. Work-related 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 your stomach empty. 2) Im going to insert a tube through your nose into your stomach to prevent you from vomiting. 3) Im going to insert an NG tube through your nares to suction your secretions andprevent 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 . . . offers no explanation of why the NG tube is beinginserted, 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 patients nonverbal 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. The nurse 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. Thenurse should not turn and reposition the patient without assessing him. Leaving the patient without addressing his nonverbal cues is neglectful. PTS:1DIF:ModerateREF:dm 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 is the 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-impaired persons. 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, the patient asks the nurse which treatment he should choose. Which response by the nurse is best? 1) IfIwereyou,Idgowith 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 do not 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:dm 478-479 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 19.Which of the following is a nonverbal behavior that enhances communication? 1) Keeping a neutral expression on the face 2) Maintaining a distance of 6 to 12 inches 3) Sitting down to speak with the patient 4) Asking mostly open-ended questions ANS: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 6to 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 nonverbalbehavior. 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 he stopped taking his blood pressure medication 3 weeks ago. Which response by thenurse 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 pressuremedication? 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 a stroke suggests criticism. Asking the patient why he stopped taking his high blood pressure medication may cause the patient to become defensive and halt further communication. Telling the patient thatit is very important to take his blood pressure medication is patronizing and also suggests criticism; at the very least, it fails to elicit more communication from the patient. PTS:1DIF:ModerateREF:dm 477-478
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application21.The wife of an elderly patient begins crying after she is informed that he has 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 uphope. ANS:1 The nurse can intervene best by sitting quietly with the patients wife, allowing her 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. Telling the wife there are always options offersfalse 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. Stating that there have been many advances in breast cancer treatment minimizes the patients concern. Stating that the patient is young and should have no trouble surviving breastcancer 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? 1)
This is a widely used practice. If you read more research, youd probably wonder why we arentalready doing it. 2) There is extensive evidence to support the new method, but I dont want to create an issue. 3) Is the budget more important to the hospital than reducing infections and patient suffering? 4) Id like to help gather information regarding the cost of new materials versus thesavings 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 clearly with 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 asmuch 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:dm 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? 1) Statement of the problem and its probable cause 2) Nurses name, patients name, and reason for thecommunication 3) History of information related to and leading up to the situation 4) A solution to the problem or what is needed from the physician ANS: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 factors leading up to the current situation makeup the Background. What the nurse thinks will correct the problem is categorized under Recommendation. Chapter 15 Patient Education and Health Promotion 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 to perform finger-stick 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 theprocedure. 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 DVD can also be supplied to the patient to reinforce learning. However, they are not the best methodfor teaching a psychomotor skill; enacting the procedure is more effective. PTS: 1 DIF: Moderate REF: dm 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 changes after discharge. When should the nurse schedule the teaching session(s)? 1) Within 10 minutes after his next dose of oral pain medication 2) After the patient wakes up from a restful nap 3) Before the surgeon dbrides the wound 4) Before the patient undergoes flow studies of his affected leg ANS: 2 For learning to be most effective, teaching must occur when the patient is most ready. 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: dm 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 treatmentoptions. 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 becausehe 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 not achieved. Although readiness to learnis 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 blood pressure and treatment options might not be suitable motivation to engage in active learning and to comply with prescribed treatment. Reassuring the patient and promising a good outcome by complying with medical treatment is not appropriate. Adhering to medical therapy reduces the risk for stroke andother complications; however, this cannot be guaranteed. PTS:1DIF:ModerateREF:dm 856-857 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 4. Assume all of the following written instructions about digoxin provide correct 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 digoxin levels. 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 notbe 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 patient teaching because the instruction is short, concrete, and written with easy-to-understand words. Patient instructions must notcontain 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 presenting information to large groups? 1) Distributing printed materials 2) Lecturing using audiovisual format3) Providing online sources of information 4) Role modeling ANS: 2
Lecturing using audiovisual materials appeals to learners who best process informationby 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 ideal for 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 shouldbe avoided for this type of patient? Assume there are data to support all the diagnoses. 1) Deficient Knowledge (disease process) 2) Impaired ability to learn related to fear and anxiety 3) Difficulty learning related to cognitive developmental level 4) Lack of motivation to learn related to feelings ofpowerlessness ANS: 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 Motivationto Learn related to Feelings of Powerlessness. Note that these are not NANDA-I diagnoses. PTS:1DIF:ModerateREF:dm 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 to learn colostomy self-care after surgery. Emptying the colostomy appliance demonstrates a
behavioral learning objective, not a broad teaching goal. Performing skin care is alsoa 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 instruction 2) Computer-assisted instruction 3) Role modeling 4) Simulatio n ANS: 4 ACLS training utilizes this strategy by creating a scenario using resuscitation mannequins and teaching healthcare workers to respond appropriately to life-threateningcardiopulmonary 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 information to 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 teaching strategy? 1) Some people might have difficulty with an interactive approach when there is conflict among participants. 2) Nurses might rehearse responses that are not effective for resolving interpersonal conflict. 3) Nurses do not use the rehearsal technique because it is an inefficient use of timefor participants. 4) This type of interactive teaching strategy is not as effective as dispersing information verbally or in print. ANS: 1 The teaching strategy described is role-playing. Role-playing may cause participants tofeel self-conscious; to be effective, participants must be willing to participate 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 thanreading about the topic or discussing approaches for effective communication. PTS:1DIF:ModerateREF:ESG, General Teaching Strategies: Role Playing 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 requires little analgesia for pain. During the healthcare teams morning rounds, the surgeon informsthe patient that the lesion removed was cancerous. Which factor will likely be the patients most significant obstacle for learning? 1) The patients baseline physical condition 2) A negative environmental influence 3) Anxiety associated with the new diagnosis 4) Reduced ability to understand the diagnosis ANS: 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, and many other fears accompany the anxiety patients often experience when potentiallylife-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. Simply because the patient is an older adult doesnot suggest he has reduced capacity to learn. PTS: 1 DIF: Difficult REF: dm 857-858 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Analysis 11. How can the nurse best provide teaching for a patient whose primary spoken language is not the same as hers? 1) Provide written materials in the patients 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 respond with meaningful information. Written materials in thepatients 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 shouldnot 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 strategy might help lessen the childs anxiety before surgery? 1) Show the child a short, animated video (DVD) about the hospital visit and procedure. 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 the procedure. 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 is in the hospital and afterwardin 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 andolder 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 are about to begin using a new type of patient bed in the ICU. Implementation is planned in6 weeks. When is the best time for the manager to schedule the teaching sessions? 1) Immediatel y 2) One week before implementation 3) Two weeks before implementation 4) Four weeks before
implementation ANS: 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 it is 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 2) Young adult admitted with acute renal failure who requires hemodialysis 3) Middle-aged woman with breast cancer receiving the last round of chemotherapy 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 likely to be knowledgeable about the disease and course of treatment; therefore, the nursing diagnosis Deficient Knowledge is less relevant than it is to a patient who is newly diagnosed. The adolescent patient with Down syndrome would have a nursing diagnosis of Impaired Ability to Learn. PTS:1DIFifficultREF:dm 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 a fingerstick 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 gives insulin 2) Providing feedback after the patient takes his blood sugar for the firsttime 3) Verbally instructing the patient about how to obtain a finger-stick blood sugar 4) Offering a brochure that describes the technique for checking blood sugar ANS: 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 priorto discharge. Repetition increases the likelihood that the patient will 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 brochure is 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 teach a 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 athome. 2) Discuss the information while assisting the patient with hisbath. 3) Educate the patient about his medications as each one isgiven. 4) Follow up with the patient after discharge with a phonecall. 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 informationpresented. A teaching session about wound care would be appropriate during bathing but not medication teaching. Providing the patient written instructions without discussing the information does not allow the patient an opportunity to ask questions orthe nurse to verify the patient understands the instruction. The patient should not be discharged without education about his prescribed medications, including what they arefor, 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. • The physician prescribes a new drug with which the nurse is unfamiliar. She consults the hospital formulary to learn about the drug.Which learning domain is 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. Chapter 16 Caring for the Older Adult 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 older adults? 1) Dealing with the needs of their children 2) Chronic health problems leading to the loss of independence 3) Loss of the ability to reminisce about the past 4) The decline of intellectualabilities ANS: 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 oftenprovide care for their aging parents. Loss of short-term memory is more common thanrecollection of events involving long-term memory. Older adults have vivid memoriesof 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 assessment focusfor older adulthood? 1) Cancer screening with the annual health examinations 2) Seeking information about consistent use of seatbelts 3) Screening for eating disorders 4) A bone scan (DEXA test) for osteoporosis ANS: 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 in adolescence and young adulthood. Although lossof 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: dm 211-212 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension 3. To which age group do most hospitalized patients belong? 1) Infan ts 2) Young
adults 3) Middle adults 4) Older adults ANS: 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 of older 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 women led 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 ratesfor people of different races is less for older adults than younger ones. PTS: 1 DIF: Moderate REF: p. 206 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension5 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 than men.But many things can happen to change that. 2) You need not worry, because both you and your husband are white. That statistic istrue 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 both wellpast 65. 4) That is true only in certain geographical areas, such as those with a high populationof newly retired persons.
ANS: 3 For infants born in 2005, the average total life expectancy for females is 80.4 years. Life expectancy measured at age 65 was nearly the same for men and women in 1900; 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. Inmigration and out-migration have nothing to do with gender differences in lifeexpectancy, 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 nursing action 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 persons abilityto 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 have new 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, sinceshe 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 thepurchase. How would their living situation be described? 1) Naturally occurring retirement community 2) Retirement community3) Continuing care retirement community4) Assisted living facilities ANS: 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 alwaysand 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: ApplicationMultiple Response Identify one or more choices that best complete the statement or answer the question. 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 veryeasily. 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 of aging. 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, whichis 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: dm 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, and becomes 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 for this 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 physical activity programs are designed for adults in better physical health, not for frail elders. The client would be unlikely to benefit from an APA and probably could not even participate in such a group activity. Depression and impaired mental abilities tend to accompany frailty, so itis 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. Chapter 17 Safety Multiple Choice
Identify the choice that best completes the statement or answers the question. 1. Physiological changes associated with aging place the older adult especially 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 infantsand 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. The nurse 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 pastyear. 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 patient for 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 unsteady with 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; stand with 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 orolder. 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 is cracked. 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 should label the malfunctioning equipment and send it for repair or inspection. Continuing to use the IV infusion pump or any other equipment places the patient 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 the equipment. 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 should the 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 beenshown 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 and increases 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 physicians order before applying restraints. 2) Monitor the patients status every 4 hours while restrained. 3) Release the restraints and check circulation everyhour. 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 applyingrestraints. However, in an emergency, the nurse is permitted to apply restraints for behavior management, but a physician or advanced practice nurse must 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: dm 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 patients personal hygiene needs by bathing the patient, if necessary. Thenurse should encourage the patient to express her feelings; 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 liquid cleanser. He is awake and alert and able to swallow. Which action should the nurse takefirst? 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 the water, 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 charcoal or 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 poisoncontrol center may recommend activated charcoal, depending upon the agent ingested. PTS: 1 DIF: Difficult REF: ESG, 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 poison comein 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 quicklyas 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 toremove contact between the skin and poison before doing anything. PTS: 1 DIF: Moderate REF: ESG, 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 to include 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 containers 3) 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 never be stored on
kitchen counters or bathroom surfaces because children love to explore and climb andcan 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 associated with mercury inhalation? 1) Chest pain, pneumonitis, and inflammation of the mouth2) 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 of mouth, pneumonitis, respiratory damage, wakefulness, muscle weakness, anorexia, headache, and ringing in the ears, Chronic effects include numbness or tingling of thehands, lips, and feet, and personality changes. Intestinal obstruction is an acute effect of mercury ingestion. Hypotension, oliguria, hematuria, and diaphoresis are not acuteeffects 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 nursing assistive personnel? 1) Assessing the patients status 2) Determining the need for restraint 3) Evaluating the patients response to restraints4) Applying and removing the restraints ANS: 4 The nurse can delegate applying and removing the restraints, skin care, and checkingfor skin breakdown. The nurse responsible for care of the patient must assess the patients need for restraint and the patients status and must evaluate the 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 nurse should 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. Ablind 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 Age12 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 sometimesoccur, 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, andinformed 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, ask questions, 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, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) bythe nurse is(are) advisable? 1) Reassure the patient by entering the roomalone. 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 shouldnot enter a room alone with an angry patient. The progression to 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 anxiety and 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. Chapter 18 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-baby checkup. 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 his underwear;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-skinned patient? 1) Nailbe ds 2) Any exposed area 3) Oral mucosa 4) Palms of the hands ANS: 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 color changes may notbe apparent in nailbeds, palms of the hands, and other exposed areas. PTS: 1 DIF: Easy REF: dm 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 is best? 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 report the 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 no hair on the clients lower legs. Which condition does this finding suggest? 1) Venous insufficiency 2) Hyperthyroidis m 3) Arterial insufficiency 4) Dehydration ANS: 3 Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with littleor 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 dehydrationin a middle-aged patient admitted to the hospital with travelers diarrhea? 1) Edem a 2) Hyperhidros is 3) Pall or 4) Tentin g ANS: 4 Tenting, skin that takes several seconds to return to normal after lifting up a fold, maybe a sign of dehydration. Edema, an excessive amount of fluid in the tissues, may be asign 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 be a 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 document this finding as: 1) Alopeci a. 2)
Albinis m. 3) Hirsutis m. 4) Lanug o. ANS: 3 The nurse should document this finding as hirsutism, excess facial or trunk hair. Hairloss should be documented as alopecia. Albinism is a condition caused by lack of pigment in which the patient has white hair and very pale skin. Lanugo is the 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 compare the 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 the fingers. 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. Brittlenails 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 growthhormone. 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 maybe a sign of hydrocephalus, which is fluid collection in the cavity within the brain. Irregular jaw movement and cracking of the jaw in adults may indicatetemporomandibular 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 this finding, along with other symptoms, might suggest: 1) Hyperthyroidis m. 2) Stroke. 3) Glaucom a. 4) Macular degeneration. ANS: 2 Ptosis, or drooping of the eyelid, may be seen in a patient who experienced Bells palsyor 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 a history of intravenous drug abuse. This finding is associated with: 1) Low albuminlevels. 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 reddishpink covering 20% to 60% of the nail (half and half nails) is seen in patientswith 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 nails 2) Brittle nails 3) Thickened nails 4) Thick nails with yellowing ANS: 1 Soft, boggy nails are seen with poor oxygenation. Brittle nails are seen with hypothyroidism, malnutrition, calcium, and iron deficiency. Thickened nails may result from poor circulation. A thick nail with yellowing is an indication of fungal infection 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 a bony 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 to15 seconds; +3 displays a 6-mm depression that lasts 1 to 2 minutes; and +4 demonstrates an 8-mm depression that persists for 2 to 3 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 time 2) Bilirubi n 3) Hemoglobin 4) Glucos e ANS: 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? 1) CN III 2) CN V3) CN VIII 4) CN X ANS:
1 CN III, the oculomotor nerve, is responsible for accommodation. Failure of a pupil to 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 how many 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 of diminished near vision, which the nurse confirms with testing. She should documentthis finding as: 1) Myopi a. 2) Diplopi a. 3) Presbyopi a. 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 is known 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? 1) External ear 2)
Inner ear 3) Middle ear 4) Ossicles ANS: 2 The inner ear is responsible for hearing and equilibrium. The middle ear, which contains 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 capillary refill? 1) Briefly press the tip of the nail with firm, steady pressure, then release and observefor 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 should press firmly with her fingertip for 5 seconds over a bony area, then release her finger, and observethe 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 the nurse should report? 1) • second 2) • seconds 3) • seconds 4) • seconds ANS: 4 Normal capillary refill is less than 3 seconds; therefore, the nurse should reporta 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 an infant? The infants anterior fontanel (soft spot) typically fuses: 1) At about 8 weeks. 2) At about 14 months. 3) By 6 months ofage. 4) Before 1 year ofage. 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) Myopi a. 2) Hyperopia. 3) Norma l. 4) Presbyopi a. 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 is normal 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 test 2)
Rinne test 3) Pure tone audiometry 4) Tympanometr y ANS: 2 If the Weber test is positive, the patient should undergo the Rinne test to assess the typeof hearing loss. The Romberg test is performed to test equilibrium. Pure tone audiometry uses a machine to hear sounds at different volumes while the patient wears a headset. Tympanometry assesses pressure in the ear; it does not assesshearing. 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 she perform 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 thatit appears dry and furry. This finding suggests: 1) Fungal infection. 2) Dehydratio n. 3) Allerg y. 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 asmooth, red tongue. Chapter 19 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, andblood 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 temperature to 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 on theleft leg. IV fluids are infusing. It would be most important for the nurse to 1) Compare the left pedal pulse with the right pedalpulse 2) Count the clients respiratory rate for 1 full minute3) Take the blood pressure in the arm without an IV 4) Take an oral temperature with an electronic thermometer ANS: 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 can be 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 apicalpulse. 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 pressure and apical pulse andcounting the respiratory rate are not effective for clearing rhonchi and would not be sufficient for the nurse to identify whether the sounds were, 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 for patients at rest? 1) Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54 2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68 3) Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84 4) Older adult: T 98.6F (oral), HR 110, RR 28, BP170/95 ANS: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 the blood 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, Comparisonof 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. Which client situation should be reported to the primary care provider? 1) Decreased blood pressure (BP) after standingup 2) Decreased temperature after a period of
diaphoresis 3) Increased heart rate after walking down the hall 4) Increased respiratory rate when the heart rateincreases ANS: 1 A drop in the clients blood pressure when standing indicates orthostatic hypotension,and the cause should be investigated. The changes in vital signs indicated 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 to centigrade? 1) 38.0C 2) 38.4C 3) 38.8C 4) 39.2 C ANS: 2 To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiplyby 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, over thelast 24 hours. The clients fever would be classified as 1) Consta nt 2) Intermitte nt 3) Relapsin g 4) Remitte nt ANS: 4 Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay above normal with only slight fluctuations. Intermittent fevers alternate between normal orsubnormal 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 anticipatethe 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 than normal respiratory rate? A client who has 1) Had surgery and is receiving a narcotic analgesic 2) Had surgery and lost a unit of blood intraoperatively 3) Lived at a high altitude and then moved to sea level 4) Been exposed to the cold and is now hypothermic ANS: 2 A reduction in hemoglobin from blood loss would increase the respiratory rate. Narcotics and hypothermia slow the respiratory rate. Going from lower altitudes to higher altitudes inhibits oxygen binding, so going to a lower altitude would decrease therespiratory 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 followup 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 mm Hg2) Oral temperature is 97.9F in the morning and 99.8F in the
evening 3) 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 lyingdown ANS: 1 Both the blood pressures would be classified as prehypertension according to the JNC7 Express guidelines. Body temperature normally increases during the course of a day.Heart rate increases for several hours after eating. Respiratory depth 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 nursing assistant 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 bedischarged. 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 state that thevital signs indicate the infection is resolved; vital signs could stabilize even if the infection remains active. The healthcare providers decision regarding the clients readiness for discharge is not based exclusively on the vital signs but rather 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. Althoughthe 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 signsare 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 fifth vital 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 reflect core 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 most reliable and most accurately reflect the core temperature. Tympanic membrane readings are considered by most to be the least accurate andleast reliable. PTS:1DIF:ModerateREF:dm 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 the nurse to monitor for increased 1) Urine output 2) Sensitivity to pain 3) Blood pressure 4) Respiratory rate ANS: 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 afever 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 for the nurse to 1) Ask the client to demonstrate the use of the blood pressure device 2) Explain the importance of frequent calibration of thedevice 3) Give the client a chart to record his blood pressure readings 4) Provide written instructions of the information taught ANS: 1 All are important things to include in client education, but self-monitoring of blood pressure is of little value unless it is done using proper technique. Requesting that the client demonstrate the procedure would allow the nurse to evaluate 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, andblood 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 interventionat 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 differentroute. 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 occurredbefore retaking or otherwise validating the reading. 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 health problems? 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 day until 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 in cold weather. Which of the following instructions would be most important for the nurse to include? 1) Be sure to put mittens on thebaby. 2) Layer the infants clothing. 3) Place a cap on the infants head. 4) Put warm booties on the baby. ANS: 3 All interventions are correct, but because of the many blood vessels close to the skin 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 would be most important to 1) Use the same type of manometer each time 2) Auscultate all five Korotkoff sounds3) 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 BPreading. 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 history might indicate a risk for primary hypertension? 1) Consumes a high-protein diet 2) Drinks three to four beers every day 3) Has a family history of kidney disease 4) Does not engage in physical exercise ANS: 2 Heavy alcohol consumption, age, race, high-sodium diet, tobacco use, family historyof hypertension, and high cholesterol levels put a client at risk for primary hypertension. Kidney disease is a cause of secondary hypertension. PTS:1DIF:ModerateREF:dm 434-435 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 21. The nurse provides client education regarding hypertension prevention and management. Which of these statements indicates that the client understands the instructions? 1) I dont have to worry if my blood pressure is high once in a while. 2) I guess I will have to make sure I dont 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 theclient 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 sodium intake. A diet high in calciumis 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:dm 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 obtain an apical-radial 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 and blood 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 fullminute 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 spaces ANS: 1 Apical pulse is generally indicated for patients with cardiac conditions or who are taking cardiac medications. Often they have irregular heartbeats or slow rates. A moreaccurate 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 which hand is used. Even if the nurse failedto 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 adult client 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 mmHg 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 indicate pain. Theapical 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 overtime 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 to implement? 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, andstanding. 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 irrelevantto the diagnosis. If the nurse observes the patient become dizzy upon standing, the first action would be to help the client lie down and then obtain orthostatic vital signs; but this is not necessary when the symptom is not present. The nurse needs to measure boththe heart rate and the blood pressure but not only in the standing position. Chapter 20 Asepsis and Infection Control Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which of the following behaviors indicates the highest potential for spreading 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 ofhealthcare 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 dry for 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 among institutionalized patients? 1) Airborne microbes from other patients 2) Contact with contaminated equipment 3) Hands of healthcare workers 4) Exposure from family members ANS: 3 Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other patients, family members, and contaminated healthcare equipment. Some of theseare 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 for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Applying sterile drapes 4) Wearing a gown ANS: 1 Scrupulous hand washing is the most important part of medical asepsis. Donning gloves, applying sterile drapes before procedures, and wearing a protective gown maybe needed to ensure asepsis, but they are not the most important aspect because microbes causing most healthcare-related infections 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) pathoge n. 2) fomit e. 3) vecto r. 4) carrie r. 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. A vector is an organism that carries a pathogen to a susceptiblehost 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 precautions must the nurse institute when caring for this patient? 1) Droplet transmission 2) Airborne transmission 3) Direct contact 4) Indirect contact ANS: 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 thatcause diarrhea, such as Clostridium difficile, are spread by direct contact. 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 nosocomial 2) Exogenous nosocomial 3) Late nt 4) Primar y ANS: 1 Thrush in this patient is an example of an endogenous nosocomial infection. This type 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 inthe 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 receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned tonormal. Which stage of infection is the patient most likely experiencing? 1) Incubation 2) Prodrom al 3) Declin e 4) Convalescence ANS: 3 The stage of decline occurs when the patients immune defenses, along with any medical 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 iscapable 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 the organisms 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. Which action is necessary to help maintain sterile technique? 1) Closing the patients door to limit room traffic while preparing the sterile field 2) Using clean procedure gloves to handle sterile equipment 3) Placing the nonsterile syringes containing flush solution on the sterilefield 4) Remaining 6 inches away from the sterile field during the procedure ANS: 1 To maintain sterile technique, the nurse should close the patients door and limit the number of persons entering and exiting the room because air currents can carry dust and microorganisms. Sterile gloves, not clean gloves, should be used to handle sterile equipment. Placing nonsterile syringes on the sterile field contaminates the field. Onefoot, 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) Phagocytos is 2) Complement cascade 3) Inflammatio n 4) Immunit y ANS: 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 membranesof pathogens) do not produce visible findings. 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) Ig A 2) Ig E 3) Ig G 4) 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 body in 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) Cellmediated 2) Passiv e 3) Humor al 4) Activ e ANS: 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 from macrophages that kill pathogens. PTS:1DIF:ModerateREF:ESG, 12. A patient asks the nurse why there is no vaccine available for the common 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 beenidentified. 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 the common 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: 1) acetaminophen (Tylenol). 2) increased fluids. 3) bedres t. 4) tepid bath. ANS: 2 Fever, a common defense against infection, increases water loss; therefore, additionalfluid is needed to supplement this loss. Acetaminophen and a tepid bath 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-based product as a skin protectant? 1) It prevents microorganisms from adhering to theskin. 2) It facilitates the absorption of latex proteins through theskin. 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 prevents microorganismsfrom adhering to the skin.
PTS: 1 DIF: Moderate REF: p. 634[answer not directly given in the text. Answer mustbe 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) • to 2 minutes 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 on the typeof 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 who requires airborne isolation? 1) Place the tray in a specially marked trash can inside the patientsroom. 2) Place the tray in a special isolation bag held by a second healthcare worker at thepatients door. 3) Return the tray with a note to dietary services so it can be cleaned and reused for thenext meal. 4) Carry the tray to an isolation trash receptacle located in the dirty utility room and 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 protective garb 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 for effective hand washing? At least: 1) • mL 2) • mL
3)
•
mL
4)
• mL ANS: 2 APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand 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 antiseptic hand 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 dry ANS: 4 The nurse should rub the antiseptic hand solution over all surfaces of the hands untilthe 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) Conta ct 2) Protective 3) Dropl et 4) Airborn e ANS: 2 Protective isolation is used to protect those patients who are unusually vulnerable to organisms brought in by healthcare workers. Such patients include those 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 gloves and
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 isintact. 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 the client. 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 thrown away because they have not been contaminated. PTS:1DIF:ModerateREF:dm 629, 646 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 21. The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1) Gow n 2) Glov es 3) Face shield 4) Hair covering ANS: 2 The gloves are removed first because they are usually the most contaminated PPE 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 face shield, and finally, the hair covering. Chapter 21 Medication Administration 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) Chemic al 2) Bran d 3) Trad e 4)
Generi c ANS: 4 Furosemide, the generic name, was used by the physician in the drug order. The brandor trade name of the drug is Lasix; the chemical name is 4-chloro-N-furfuryl-5sulfamoylanthranilic acid. PTS:1DIFifficultREF: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 thedrug. 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 as a drug formulary, Physicians DeskReference, or registered pharmacist before administration. The nurse should not rely oninformation 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:dm 746-747 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 3. A surgeon prescribes potassium chloride 20 mEq by mouth for a patient with 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 viathe nasogastric route. If the patient has a nasogastric tube in place to 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: dm 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 a dose 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 drug for administration?1) Cabinet in the patients room 2) Double-locked medicationdrawer 3) Stock supply cabinet 4) Portable medication cart ANS: 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. Other prescribed medications may be stored in a locked cabinet in the patients room or in the medicationcart. PTS:1DIF:ModerateREF:dm 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 of administration to the bloodstream? 1) Absorptio n 2) Distributio n 3) Metabolis m 4) Excretio n ANS: 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 amore water-soluble form or into metabolites that can be excreted from 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 complainingof severe incision pain. Which drug contained in his medication administration record will offer him the fastest relief? 1) Liquid acetaminophen with codeine 2) Intravenous morphine sulfate3) Intramuscular meperidine 4) Oral oxycodone tablets ANS: 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 more quicklythan drugs administered by the oral or intramuscular routes. PTS: 1 DIF: Moderate REF: dm 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 in the 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 ofa medication is highest in the blood. Duration of action is that period when the medication has a pharmacological effect. Half-life is the amount of 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 of this 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 should occur in 1to 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 the half-life of certain drugs? 1) Heart disease 2) Liver disease 3) Rheumatoid arthritis 4) Tobacco use ANS: 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, prolongingthe 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 digoxin level 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 thedose. 2) Withhold the next dose ofdigoxin. 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 cardiaceffects for the patient. PTS:1DIFifficultREF:dm 755-756 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
11. The primary care provider orders peak and trough levels for a patient who 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 nextdose 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 obtained while 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 women 2) Elderl y 3) Childre n 4) Adolescen ts ANS: 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 to reduce pain. For which effect is this medication prescribed? 1)
Supportiv e 2) Restorativ e 3) Substitutiv e 4) Palliativ e 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 body to 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 is very dry. This is not uncommon for patients taking this medication. Which drug effectis this patient experiencing? 1) Side effect 2) Adverse reaction 3) Toxic reaction 4) Supportive effect ANS: 1 Dry mouth is a side effect of diphenhydramine. Side effects are unintended, often predictable, physiological effects that are well tolerated by patients. Adverse reactionsare harmful, unintended, usually unexpected reactions to a drug administered at a normal dosage. They are commonly more severe than side effects. Toxic reactions aredangerous, damaging effects to an organ or tissue. Supportive effects are intended effects that support the integrity of body functions. 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, andadminister 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 phenytoinfor treatment of seizures. Which type of reaction is the patient most likely 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 pharmacological effects of the medication. Toxic reactions are dangerous, damaging effects to an organ or tissue. Anaphylactic reaction is a life-threatening allergic reaction that occurs duringor 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 extended time.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 incompatibilityANS: 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 an unexpected, 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 opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug: 1) Abus e 2) Misuse 3) Toleranc e 4) Dependence ANS: 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 abuse is the inappropriate intake ofa 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 administeringthe 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 righttime. 2) right drug, right dose, right route, right time, right physician, and right documentation. 3) right patient, right drug, right route, right time, right documentation, and rightequipment. 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, right dose, right route, right time, and right documentation. PTS: 1 DIF: Moderate REF: dm 771-773 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
20. Which expected outcome is best for a patient with a nursing diagnosis of Deficient Knowledge related to new drug treatment regimen?1) After an explanation and written materials, describes the expected actions and adverse reactions of his medication 2) In 1 week after instructional session, describes the expected actions and adversereactions of his medications 3) Follows the treatment plan as prescribed 4) 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 goal and are therefore not measurable. Expected outcome statements must be measurable. PTS:1DIF:Moderate REF:p. 770; Also requires knowledge of goals, from KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 21. When the nurse enters a patients room to administer a medication, he callsout 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 thedose. 3) Withhold the dose until the next administration time later in theday. 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 nurse should not document a missed dose in the medication administration record. PTS:1DIF:ModerateREF:dm 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 8 on a110 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 given 4) 1/16/14 furosemide 40 mg PO given, J. Smith RN ANS: 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:dm 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 IVroute. 2) Administer the medication by the IM route. 3) 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 usea 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 nurse should push the plungerto 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 cannotadminister 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:dm 774-775; under Special Situations. Inductive reasoning needed to determinecorrect 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 thetablet. 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 route are placed inthe 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 prescribedmedication. 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 givenin combination with others. The nurse should verify nasogastric tube placement and auscultate the abdomen for bowel sounds before 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 after administering an injection? 1) Place the needle in a specially marked, puncture-proof container. 2) Recap the needle, and carefully place it in the trashcan. 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 by the contaminated needle places other staff members at risk. PTS:1DIF:ModerateREF:dm 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 3-day-old infant born to an HB Ag-positive mother. Which injection site should the nurse choose to administer this injection? 1) Ventroglute al 2) Vastus lateralis 3) Deltoid 4) Dorsogluteal ANS: 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 muscle can 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 muscle before administering an intramuscular injection into the site? 1) 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 warm compress,
massaging the site, and applying soothing lotion are inappropriate interventions before administering an IM injection. After injection, massaging the site can enhancethe 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 mg tablet 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. 2) 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 given inerror. 4) Complete an incident report according to the facilityspolicy. 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 orders the 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 thefacilitys policy; submit the signed report to the nurse manager. Finally, critically reviewthe 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 she proceed? 1) Pull the pinna down and back before instilling the drops. 2) Pull the pinna upward and outward before instilling thedrops. 3) 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 and outward. 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 upbefore instillation. Chapter 22 Intravenous Therapy 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) Chemic al 2) Bran d 3) Trad e 4) Generi c ANS: 4 Furosemide, the generic name, was used by the physician in the drug order. The brandor trade name of the drug is Lasix; the chemical name is 4-chloro-N-furfuryl-5sulfamoylanthranilic acid. PTS:1DIFifficultREF: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 thedrug. 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 as a drug formulary, Physicians DeskReference, or registered pharmacist before administration. The nurse should not rely oninformation 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:dm 746-747
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 3. A surgeon prescribes potassium chloride 20 mEq by mouth for a patient with 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 viathe nasogastric route. If the patient has a nasogastric tube in place to 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: dm 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 a dose 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 drug for administration?1) Cabinet in the patients room 2) Double-locked medicationdrawer 3) Stock supply cabinet 4) Portable medication cart ANS: 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. Other prescribed medications may be stored in a locked cabinet in the patients room or in the medicationcart. PTS:1DIF:ModerateREF:dm 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 of administration to the bloodstream? 1)
Absorptio n 2) Distributio n 3) Metabolis m 4) Excretio n ANS: 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 amore water-soluble form or into metabolites that can be excreted from 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 complainingof severe incision pain. Which drug contained in his medication administration record will offer him the fastest relief? 1) Liquid acetaminophen with codeine 2) Intravenous morphine sulfate3) Intramuscular meperidine 4) Oral oxycodone tablets ANS: 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 more quicklythan drugs administered by the oral or intramuscular routes. PTS: 1 DIF: Moderate REF: dm 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 in the 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 ofa medication is highest in the blood. Duration of action is that period when the medication has a pharmacological effect. Half-life is the amount of 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 of this 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 should occur in 1to 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 the half-life of certain drugs? 1) Heart disease 2) Liver disease 3) Rheumatoid arthritis 4) Tobacco use ANS: 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, prolongingthe 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 digoxin level 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 thedose. 2) Withhold the next dose ofdigoxin. 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 cardiaceffects for the patient. PTS:1DIFifficultREF:dm 755-756 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
11. The primary care provider orders peak and trough levels for a patient who 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 nextdose 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 obtained while 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 women 2) Elderl y 3) Childre n 4) Adolescen ts ANS: 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 to reduce pain. For which effect is this medication prescribed? 1) Supportiv e 2) Restorativ e 3) Substitutiv e 4) Palliativ e 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 body to 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 is very dry. This is not uncommon for patients taking this medication. Which drug effectis this patient experiencing? 1) Side effect 2) Adverse reaction 3) Toxic reaction 4) Supportive effect ANS: 1 Dry mouth is a side effect of diphenhydramine. Side effects are unintended, often
predictable, physiological effects that are well tolerated by patients. Adverse reactionsare harmful, unintended, usually unexpected reactions to a drug administered at a normal dosage. They are commonly more severe than side effects. Toxic reactions aredangerous, damaging effects to an organ or tissue. Supportive effects are intended effects that support the integrity of body functions. 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, andadminister 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 phenytoinfor treatment of seizures. Which type of reaction is the patient most likely 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 pharmacological effects of the medication. Toxic reactions are dangerous, damaging effects to an organ or tissue. Anaphylactic reaction is a life-threatening allergic reaction that occurs duringor 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 extended time.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 incompatibilityANS: 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 an unexpected, 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 opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug: 1) Abus e 2) Misuse 3) Toleranc e 4) Dependence ANS: 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 abuse is the inappropriate intake ofa 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 administeringthe 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 righttime. 2) right drug, right dose, right route, right time, right physician, and right documentation. 3) right patient, right drug, right route, right time, right documentation, and rightequipment. 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, right dose, right route, right time, and right documentation. PTS: 1 DIF: Moderate REF: dm 771-773 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 20. Which expected outcome is best for a patient with a nursing diagnosis of Deficient Knowledge related to new drug treatment regimen?1) After an explanation and written materials, describes the expected actions and adverse reactions of his medication 2) In 1 week after instructional session, describes the expected actions and adversereactions of his medications 3) Follows the treatment plan as prescribed 4) 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 goal and are therefore not measurable. Expected outcome statements must be measurable. PTS:1DIF:Moderate REF:p. 770; KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 21. When the nurse enters a patients room to administer a medication, he callsout 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 theday. 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 nurse should not document a missed dose in the medication administration record. PTS:1DIF:ModerateREF:dm 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 8 on a110 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 given 4) 1/16/14 furosemide 40 mg PO given, J. Smith RN ANS: 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:dm 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 IVroute. 2) Administer the medication by the IM route. 3) 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 usea 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 nurse should push the plungerto 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 cannotadminister 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. Chapter 23 Perioperative Nursing 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 care 2) Entry into the operating suite until discharge from the hospital 3) The decision to have surgery until admission to postanesthesiacare 4) The decision to have surgery until entry to the operatingsuite ANS: 4 The preoperative phase begins with the decision to have surgery and ends when the 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 the plan 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 after surgery. 4) Prepare the child for discharge from the hospital as soon as she isalert. ANS: 1 It is developmentally normal for toddlers to experience anxiety with separationfrom 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 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. 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: dm 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 be developmental in nature. It is developmentally normal for toddlers to experience anxiety 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 andcause 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 surgicalsite. 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 be performed 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. The patient reportsthat he stopped taking the anticoagulant 4 days ago as instructed by the surgeon. Hehas 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) Is concerned about the vitamin Edosage. 4) 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 dosesof vitamin E may increase the risk for bleeding. This patients use of 1,500 IU of vitaminE daily exceeds the recommended dosage, so the nurse should inform the surgeon of the vitamin E intake. Generally, the surgeon or anesthesiologist instructs patients to continue or discontinue taking their 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 important problem for this patientis which of the following? 1) Potential complication: anemia 2) Risk for infection related to inadequate anticoagulant dosage3) Risk for noncompliance related to inability to follow instructions 4) Risk for bleeding ANS: 4 The patient is at an increased risk for bleeding due to his intake of vitamin E. He maybe 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-than-average risk for infection because he is not 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 takinghis 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 outpatient surgery 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 ofthis, 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 consent form. 2) Inform the surgeon that she will have the patient sign after he discusses the surgerywith the patient. 3) Ensure that the signed surgical consent is witnessed by two nurses, because the surgeonis 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 the surgeon has explained the procedure andanswered 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 surgeon and 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 the purpose is removal of tissue to relieve pain. 1) Procureme nt 2) Ablativ e 3) Palliativ e 4) Diagnosti
c ANS: 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 of a 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 should informthe family that: 1) Patients who have had surgical complications are observed in the PACU until theyare 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 is required. 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 procedure for a patient to be transferred directly from surgeryto 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 and ends
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 surgicalenvironment 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 thanthe maintenance of sterility. Obtaining informed consent and preparing the patient for surgery are activities associated with 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 on call 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 notified to do so bythe 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, he is unable to sign an informed consent for surgery. In this situation: 1) 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 fora procedure if a patient is not capable of giving an informed consent or if the patientis 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 communicates with the surgeon and anesthetist, she tells them that the patient desires which type of
anesthesia? 1) Conscious sedation 2) General anesthesia 3) Local anesthesia 4) Regional anesthesia ANS: 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 desiredsite and is typically used for minor procedures. The client 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 onthe 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 antiembolismstockings, 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 the question. 1. Surgeries are commonly classified by which of the following? Choose all that apply. 1) Acuit
y 2) Level of urgency 3) Length of surgery 4) Organ involved ANS: 1, 2 Surgeries can be classified by body systems, purpose, level of urgency, and degreeof seriousness (acuity). The length of surgery and organ involved are not used 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? Chooseall that apply. 1) A standardized tool for assessing high-risk surgical patients 2) A standardized vocabulary encompassing all surgical patient outcomes 3) The first specialized nursing language recognized by theANA 4) A standardized language designed to describe the care of perioperative patients ANS: 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 patient outcomes appropriate for use in any surgical setting. It was the first specialty language recognizedby 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 ago and 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 infection 2) Performs the dressing change as prescribed 3) Demonstrates absence of surgical incisionpain 4) Completes the regimen of prescribed antibiotics ANS: 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 teach a 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.
Chapter 24 Hygiene and Self-Care Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The patient takes anticoagulants. Which instruction is most important forthe nurse to include on the patients care plan? Teach the patient to: • use an electric razor for shaving. • apply skin moisturizer. • use less soap when bathing. • 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 and use 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 bleeding takes priority over a risk for dry skin. Everyone should be encouraged to floss their teeth daily; however, some patientswith 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 to avoid bathingthe patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly whendrying might also overstimulate, leading to an elevation in intracranial pressure. PTS: 1 DIF: Difficult REF: dm 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 in and
out of the bathtub without assistance. Which nursing diagnosis appropriately addressesthis problem? 1) Total Self-care Deficit 2) Bathing/Hygiene Self-care Deficit 3) Dressing/Grooming Self-caredeficit 4) Activity Intolerance ANS: 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 thepatient is unable to dress or groom himself. Activity Intolerance is present when a patient exhibits extreme fatigue, which is not mentioned in this scenario. PTS: 1 DIF: Moderate REF: ESG, KEY: Nursing process: Nursing diagnosis | Client need: PHSI | Cognitive level: Analysis 4. Which scheduled hygiene care is usually thought of as including a back massage to help the patient relax? 1) Afternoon care 2) Early morning care 3) Morning care 4) Hour of sleep care ANS: 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 visitorsor 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 with toileting, face and hand washing,and mouth care. Morning care occurs after breakfast and commonly consists of toileting, bathing, and mouth, skin, and hair care. 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 the
conditions stated. 1) 32-year-old admitted with a closed head injury 2) 76-year-old admitted with septic shock 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago 4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion ANS: 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 toprovide his morning care safely. The patient 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 Infection 2) Risk for Impaired Skin Integrity 3) Risk for Deficient Fluid Volume 4) Impaired Skin Integrity ANS: 2 The epidermis contains melanin, a pigment that protects against the suns ultraviolet 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 is present. 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 assist in wound healing, thereby helping to prevent infection. PTS: 1 DIF: Difficult REF: dm 688 for coverage of aging effects including lossof melanin, 689 for coverage of impaired skin integrity; students mustsynthesize the information to answer the question; answer is not directly statedin text KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis 7. What is the bodys first line of defense against bacteria? 1)
Intact skin 2) White blood cells 3) Lymph glands 4) Inflammatory response ANS: 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 yellow skin tone. The nurse should document this finding as: 1) Pallo r. 2) Erythem a. 3) Jaundic e. 4) Cyanosi s. 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 the light-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 by the nurse led to this documentation? 1) 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 thatare 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 perineal care because of the irritating effect of enzymes in the stools. The uncircumcised patient, 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: dm 692, 714-716 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 11. A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed? 1) Call for assistance to help the patient into thebathtub. 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 thetub bath will most likely increase the patients agitation, as consistency of caregivers is important for patients with dementia.
PTS: 1 DIF: Moderate REF: dm 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 hisperineum. 3) Wash the patients back, buttocks, and perineum first. 4) Bathe the patient from head-to-toe, cleanest areasfirst. ANS: 4 The nurse should instruct the NAP to give a complete bed bath (a bath for patients whomust 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 water and allow him to wash his perineum when giving an assist bath or bed bath (this is a total bed bath). During a partial bath, the NAP should cleanse only the areas that 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: dm 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 bed bath? 1) Place the nurse call device within reach for safety. 2) Cover the patient with the top linens from thebed. 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 in bed 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 thebath 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 of bath
is preferred for this patient?1) Tub bath 2) Complete bed bath 3) Towel bath 4) Bed bath ANS: 3 A towel bath is a modification of the bed bath, in which a large towel and a bath blanket 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 placedin 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) Tinea pedis 2) Plantar wart 3) Excoriatio n 4) Ingrown toenail ANS: 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. 3) Wearing unventilated shoes prevents the fungus from gaining contact with my feet. 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 person from contractingtinea 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 be prevented by wearing special footwear in the shower. Chapter 25 Mobility 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 tackled while playing football. He asks the nurse what tests he needs to have to determine if he hasa 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 an x-rayof 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 of strainor 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 in a bone. An x-ray 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 day 2) Assisting the patient to sit in a chair three times a day 3) Turning the patient at least every 2hours 4) Administering fluid boluses as directed by the healthcare provider ANS: 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 turnedat 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? 1) 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 Nurses Associations (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 to prevent thrombophlebitis. Which type of muscle is the patient using for these exercises? 1) Skelet al 2) Smoot h 3) Cardia c 4) Slow-twitch fibers ANS: 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 the heart. 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 thecell) 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 contractureand promote joint mobility? 1) Active ROM 2)
Turning the patient every 2 hours 3) Passive ROM 4) Administering glucosamine supplements ANS: 3 Passive ROM involves moving the joints through their ROM when the patient is unable 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: dm 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 program to 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) Anxiet y 2) Orthostatic hypotension 3) Limited activity tolerance 4) 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 recently sustained 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 moves the patients body as a unit and maintains the patients spine in straight alignment. Holdingon 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 explainher health problem. Which of the following is the correct description of osteoporosis? 1) Loss of bone density that increases the risk of fracture2) Degenerative joint disease that produces pain and decreased function 3) Chronic inflammatory joint disease that must be treated with steroids 4) Acute infection in the bone that must be treated with antibiotics ANS: 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 rapid decline in bone mass after menopause. Osteoarthritis is a degenerative joint disease. Osteomyelitisis 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 is the most important action to take to minimize progression of thedisease? 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 strength and 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 would allowthe nurse to know that her teaching was effective? 1) Taking a calcium supplement every day and increasing her phosphorous intake 2) Participating in an aerobic barbell strength class at the gym three times a week 3) 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 demonstrates not 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 partof 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) Immovabl e. 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 toallow for growth, they gradually become rigid and immovable with age. There is no pain associated with synarthroses. PTS:1DIF:ModerateREF:p. 1120 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 assist him with his breathing? 1)
Fowlers position 2) Sims position 3) Lateral recumbent position4) Lateral position ANS: 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 leg extended and right leg flexed. This positionis 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? 1) Flexibility training 2) Resistance training 3) Aerobic conditioning 4) Anaerobic conditioning ANS: 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 amount of resistance is increased with each exercise. When exercising for endurance, the number of repetitions is increased with each exercise. Flexibility training will not increase muscular strength. Aerobic and anaerobic conditioning may have some 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 around which point? 1) Center of body alignment 2) Center of balance 3)
Center of gravity 4) Base of support ANS: 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 gravity must be closeto 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 home resulted in a left hip fracture. After surgery, he is to begin ambulating with a walker but must avoid weight-bearing on his left lower leg. What is the best intervention tohelp him use his walker? 1) Aerobic exercise with deep breathing 2) Quadriceps and gluteal repetitions 3) Isometric toning of lower legs 4) Arm resistance training ANS: 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 himin using the walker more easily. Toning the lower body through exercise of the quadriceps and gluteal muscles, although important for regaining strength in general after surgery, does not aid in using a walker. Aerobic exercise with 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: dm 1152-1156; synthesis of information required; not a direct response to the item KEY:Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 16. Identify the most appropriate nursing diagnosis for promoting the safety ofa frail, elderly patient after hip replacement surgery who also has a history of emphysema. 1) Impaired Mobility related to weakness 2) Ineffective Breathing Pattern related to disease process 3) Activity Intolerance related to injury 4) Risk for Injury related to medical condition ANS: 4 The patients medical condition places him at an increased Risk for Injury: He is at riskfor 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 protectinghim from further injury. We have no data other than a diagnosis of 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 with a 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 bythe time of discharge is not specific and measurable. Additionally, these outcomes do not relate to Risk for Injury. A goal of effective breathing for a frail, elderly patient afterhip surgery does not relate to Risk for Injury. 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 the nurse, Ourson 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 the hospital withan injury will only make that worse. 3) Your son had a major injury; and his immobility might be causing him to feel isolated and depressed. 4) He is bored because he has been in the hospital for 3 weeks; Ill try to find somethingnew 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 changes in 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 increase his 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 squeeze position for6 to 8 seconds, and repeat 5 to 10 times. 2) Grasping the right wrist with the left hand, move the right arm up, down, and side toside; 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 the body; holdthis 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, and repeat 5to 10 times. ANS: 4 Isometric exercise involves muscle contraction without motion. Isometric exercises are useful for developing strength. This type of exercise is appropriate for the patientwho has had an extremity confined to a cast because muscle atrophy occurs when themuscle is not used. Performing repetitions light weight increases strength but this
would stress the healing fracture at this point in the rehabilitation. Pulling an armacross 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 ison strict bedrest for 5 days. During this time she has not had a bowel movement, although normally, passes stool daily. She describes feeling bloated and uncomfortable. What information should the nurse give the patient when explaining constipation? 1) Immobility often causes constipation. 2) 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 prevents constipation. A stool softener may be ordered if other measures are unsuccessful. Some people do find use ofa 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 describes feeling bloated and uncomfortable. A nursing diagnosis that would best address a patient who ison bedrest is Constipation related to: 1) Change in previous pattern. 2) Immobilit y. 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 diagnosis would 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 and has developed strong upper-body strength to maximize his independence. Which transferdevice should be used when transferring him from the bed to his wheelchair? 1) Mechanical lift 2) Transfer belt 3) Draw sheet 4) Transfer board ANS: 4 A transfer board is used by patients with longstanding mobility problems; it offers them the greatest amount of independence while ensuring safety. Patients using a transfer board should have sufficient upper-body strength to perform the transfer 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 draw sheet is useful for movinga 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 isthe appropriate piece of equipment to use when helping her ambulate? 1) Crutch es 2) Transfer belt 3) Can e 4) Walke r ANS: 2 Crutches are commonly used when the patient has an injured lower extremity. A cane 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:dm 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 the patientto 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 hold the 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. Protect the 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 Services 2008 Physical Activity Guidelines for Americans, which of the following statements aboutthe 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 safefor almost everyone, and the health benefits of physical activity far outweigh the risks. Additional health benefits are provided by increasing to 300 minutes a week of moderate- intensity 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 the nurse 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 to bones. 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 at risk 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 10minutes, preferably spread throughout the week. If this is not possible because of limiting chronic conditions, older adults should be as physically active as their abilitiesallow. They should avoid inactivity. Structured calisthenics programs are no more beneficial for achieving health 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. Chapter 26 Skin Integrity and Wound Healing 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 regulation 2) Provides strength and elasticity to the skin 3) Protects the body against the entry of pathogens 4) Continually produces new skin cells ANS: 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 againstthe 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 composed of 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 who takes blood pressure medications because antihypertensives: 1) Can cause cellular toxicity. 2)
Increase the risk of ischemia.3) Delay wound healing. 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 can lead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formationwith 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 arecontaminated. 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 chronic wounds. 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 an ischial 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 wound 2) Penetrating wound 3) Superficial wound 4) Full-thickness wound ANS: 1 Partial-thickness wounds extend through the epidermis into the dermis. Superficial wounds involve only the epidermal layer of skin. Full-thickness wounds extend intothe subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to
indicate that the wound includes internal organs. PTS:1DIF:EasyREF:dm 1226-1227 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 5. A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: 1) Primary intention healing. 2) 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 from the 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 by secondary intention is closed by joining the margins of granulation tissue. Approximation is another word forthe 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 wound after 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. 4) The patient should expect to remain hospitalized until complete wound healing occurs. 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 notexpect an extended hospital stay if wound care can be provided 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 patient with 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 healingprocess. 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 isno evidence presented that the patient needs to increase 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) Sanguineo us 2) Serosanguineous 3) Sero us 4) Purosanguineous ANS: 2 Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds. Serous drainage is straw colored, and sanguineous drainage is bloody. Purosanguineous drainage is pus that is red tinged. 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 there is no obvious drainage. Heart rate is 96 beats/min and oral temperature is 100.8F (38.2C). The nursewould suspect that the patient has what kind of complication? 1) Infection at the incisional site 2) Dehiscence of the wound 3) Hematoma under theskin 4) Formation of granulation tissue ANS: 1 Infection is a complication of wound healing that causes warmth, pain, inflammationof the affected area, and changes in vital signs (i.e., elevated pulse and temperature). Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of 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 wouldnot 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? 1) 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 involves damageto 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 incision site. Evisceration is an urgent complication usually requiring immediate surgical intervention. PTS:1DIF:ModerateREF:dm 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 with severe peripheral neuropathy is effective if the client: 1) begins an aggressive exercise program.2) follows a diet plan of 1,200 calories per day. 3) 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 client at increased riskfor 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 thefeet. 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 conditions atthe site? 1) Compromised bloodflow 2) Edem a 3) Shearing forces 4) Inadequate venous return ANS: 1 Pressure ulcers are caused by unrelieved pressure that compromises blood flow to 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 immobile and 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 ulcer 2) Stage III pressure ulcer 3) Stage IV pressure ulcer 4) Unstageable pressure ulcer ANS: 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,
healing 2) Stage II pressure ulcer, healing 3) Stage III pressure ulcer, healing 4) Stage IV pressure ulcer, healing ANS: 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 not replaced. 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 ofhis fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? 1) Draw a circle around the area of drainage on adressing. 2) 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 through the wound. Marking a circle around the wound is useful for determining the extent of drainage seeping out ofa 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 mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patients left heel. What is the initial treatment for this pressure ulcer? 1) Antibiotic therapy for 2 weeks 2) Normal saline irrigation of the ulcer daily 3) Dbridement to the left heel 4) Elevation of the left heel off the bed ANS: 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 bed would 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 wound limited? 1) A positive culture does not necessarily indicate infection, because chronic woundsare 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 information necessaryto 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 thisdoes not require antibiotic treatment. A needle aspiration of the wound would provide more definitive information about whether the wound is 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 applicable patient 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 6weeks. 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 IV pressure 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 pressureulcer. 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 for himat this time? 1) Risk for Infection related to subcutaneous injuries 2) Risk for Impaired Skin Integrity related toimmobility 3) Impaired Tissue Integrity related to ventilator dependency4) Impaired Skin Integrity related to ventilator dependency ANS: 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 no mention of subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries. Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because thereis no supporting evidence for these nursing diagnoses. PTS:1DIF:ModerateREF:dm 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 dbridement 3) Dressing to keep the wound moist and clean 4) Removal of devitalized tissue and a sterile dressing ANS: 3 A red wound indicates active healing, and the best treatment is gentle cleansing and 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 is covered 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 twicedaily 2) Nonadherent dressing with daily wound
care 3) Hydrocolloid dressing changed as needed 4) Wet-to-dry 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 ofthe 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, it could cause damage to healthy tissue as well. PTS:1DIFifficultREF:dm 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 the desired goal when: 1) The ulcer is completely healed with minimalscarring. 2) The patient reports no pain at the site. 3) A minimal amount of drainage isnoted. 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 the wound 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. Of the following, which would be an appropriate dressing choice? 1) Alginate dressing 2) Dry gauze dressing 3) Hydrog el 4) Hydrocolloid dressing ANS: 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 will conform tofill 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 wound irrigation? 1) Water jet irrigation 2) 35-cc syringe with a 19-gauge angiocatheter 3) 5-cc syringe with a 23-gauge needle 4) Bulb syringe ANS: 2 A 35-cc syringe with a 19-gauge angiocatheter is the best choice for irrigation because itwill 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 is not 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. When performing 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 thepatient. 4) Irrigate wounds from least contaminated to mostcontaminated. ANS: 4 To avoid the possibility of cross-contamination, the wound with the least amountof 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 the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? 1) Steri-
Strips 2) Abdominal binder 3) Tbinder 4) Paper tape ANS: 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-Strips and 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. The nursehas determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? 1) Transparent film dressing 2) Sheet hydrogel 3) Frequent turn schedule 4) Enzymatic dbridement ANS: 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, so a dressing is not warranted. Enzymatic dbridement is used to remove slough or eschar 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 nurse do? 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) before applyingit. 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 15 minutes at a time in an area. This helps prevent tissue injury and also makes the therapy
more effective by preventing rebound phenomenon. Temperatures should be kept between 59F and 113F (15C and 45C), depending on the type of therapy chosen andwhat 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 is using which form of wound healing? 1) Primary intention 2) Regenerative healing 3) Secondary intention 4) Tertiary intention ANS: 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 tissueis 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 activity 3) Reduced oxygen-free radicals 4) Overproduction of elastin ANS: 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 loses firmness 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.
Chapter 27 Infection Prevention and Management Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. In which situation would using standard precautions be adequate? Select allthat apply. 1) While interviewing a client with a productive cough 2) While helping a client to perform his own hygienecare 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter ANS: 3, 4 Standard precautions should be instituted with all clients whenever there is a possibility 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). Wheninterviewing a client, if the disease is not spread by air or droplets, there is no likelihoodof the nurses encountering body fluids. If the 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: dm 619-624 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 2. Which of the following protect(s) the body against infection? Select all that apply. 1) Eating a healthy, well-balanced diet 2) Being an older adult or an infant 3) Leisure activities three times a week 4) Exercising for 30 minutes 5 days aweek ANS: 1, 3, 4 Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body 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:dm 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 thefaucet. 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 lathering all surfaces of the hands and fingers to be effective. The fingers should be held lower thanthe wrists. PTS: 1 DIF: Moderate REF: dm 633-634 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall 4. Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. 1) Viru s 2) Bacterial spores 3) Yea st 4) Mold ANS: 1, 3, 4 If there is potential for contact with bacterial spores, hands must be washed with soapand 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 to transport. 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 notrequired) that covers the mouth and nose to prevent the spread of infection. Moreover, the department where the patient is being transported should be notified about the
precautions before transport. PTS: 1 DIF: Difficult REF: dm 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 wellbeing. ANS: T Organisms that normally inhabit the body, called normal floras, are essential for human 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. Chapter 28 Pain Management 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) Acut e 2) Chroni c 3) Intractabl e 4) Neuropathi c ANS: 1 Acute pain typically has a short duration and a rapid onset. Chronic pain lasts longer than 6 months and interferes with daily activities. Intractable pain is chronic and highlyresistant to relief. Neuropathic pain is a type of chronic pain that 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) Radiatin g 2) Deep somatic 3) Viscer al 4) Referre d ANS: 3 Visceral pain is commonly experienced in the abdominal cavity, cranium, or thorax. Lung cancer produces visceral pain. Radiating pain starts at the source and 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 of pain in his left foot. The nurse should document this finding as what type of pain? 1) Psychogeni c 2) Phanto m 3) Referre d 4) Radiatin g ANS: 2 The nurse should document this finding as phantom pain. Phantom pain is pain that is perceived to originate in an area that has been amputated. Psychogenic pain 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 tothe painful stimuli. Referred pain occurs 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) Histamin e 2) Prostaglandi n 3) Bradykini n 4) Serotoni n ANS: 3 Tissue damage causes the release of the substances histamine, bradykinin, and prostaglandin. Bradykinin triggers the release of inflammatory chemicals that cause theinjured 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 the dorsal horn of the spinal cord?
1) Transductio n 2) Transmissio n 3) Perception 4) Modulatio n ANS: 2 Peripheral nerves carry the pain message to the dorsal horn of the spinal cord during 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 experience of pain. Perception involves the recognition of pain by the frontal cortex of the brain. During modulation, pain signalscan 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 chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process? 1) Perception 2) Transductio n 3) Transmissio n 4) Modulatio n ANS: 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 of pain changes. It isnot during the perception (recognizing the pain sensation), transmission (relaying the pain message), or transduction (converting potentially damaging stimuli into electricalactivity leading to pain sensation). PTS:1DIF:ModerateREF:dm 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 coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that thispatient is experiencing pain? 1) Blood pressure 160/82 mmHg 2) Temperature 100.6F 3)
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 a common response to surgery. Heart rate and oxygen saturation are within normallimits. PTS: 1 DIF: Moderate REF: dm 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 control placesthis patient at risk for which complication? 1) Metabolic alkalosis 2) Pneumothor ax 3) Pneumo nia 4) Hemothor ax ANS: 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 the shallow 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 taken 2) During the admission interview 3) Every 4 hours for the first 2 days after surgery 4) Only when the patient complains of pain ANS: 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 isnot 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. Pain should 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 ratingscales help to quantify the intensity of pain for the nurse providing analgesia. PTS: 1 DIF: Moderate REF: dm 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 surgery 2) Acute pain (abdominal) secondary to surgery for coloncancer 3) Chronic pain secondary to cancer diagnosis 4) Chronic pain (abdominal) secondary to abdominal surgery ANS: 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 painthat is related to his surgery for colon cancer; therefore, a nursing diagnosis that specifies the surgery is the most appropriate diagnosis for this 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 facilitate pain management in a client with chronic pain? 1) Selective serotonin reuptake inhibitor 2) Selective norepinephrine reuptake inhibitor 3) Narcotic analgesic 4) Antiemetic ANS: 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, such as 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 (causingmental 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 and vomiting, which can occur with some analgesic medication. However, the prescriber would more likely change the medication to something the patient tolerates better ratherthan 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 toa patient complaining of a severe headache. When should the nurse reassess the patients pain? 1) 15 minutes after administration 2) 60 minutes after administration 3) 90 minutes after administration 4) Immediately before the next dose isdue ANS: 2 The nurse should reassess pain in the patient who received an oral pain medication 30to 60 minutes after administration. The nurse should reassess the patient receiving IV medications 10 to 15 minutes after administration. The nurse should not wait until just before the patient can receive another dose. The patient 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, the patient 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 in pain simply because he appears comfortable; pain is what the patient states it is. PTS:1DIF:ModerateREF:dm 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. A cold pack should be applied intermittently for the first 24 hours, leaving it in place for nolonger than 15 minutes at a time. The patient should check the skin frequently and discontinuethe 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 experiencing pain. Which pain management technique is this nurse using? 1) Distraction 2) Guided imagery 3) Sequential muscle relaxation 4) Hypnos is ANS: 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 sequential musclerelaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscles while breathing out. This relaxation technique has also been effective for relieving pain. Hypnosis involves the induction of a deeply relaxed state. PTS:1DIF:EasyREF:dm 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 shouldthe 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 after treatment. 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 a loved 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 effectivefor 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 prescriberimmediately. 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 has not 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 the medication? 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 drugdependence. 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 check blood 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 necessaryto routinely monitor a patient who is receiving morphine for acute postoperative painfor psychological drug dependence. 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 acetaminophenuse? 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 oraluse. ANS: 1 Even in recommended doses, acetaminophen can cause hepatotoxicity in those who 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 taking a few doses of the drug? 1) Constipatio n 2) Drowsine ss 3) Dry mouth 4) Difficulty with
urination ANS: 2 Drowsiness as well as nausea are side effects of opioid therapy that commonly improve after afew 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 receivingIV 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 sulfate ANS: 3 The nurse should anticipate administering naloxone to reverse the respiratory depression associated with opioid use. Flumazenil reverses the central nervous systemdepressant 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 nursing assistive personnel? 1) Assessing the quality and intensity of the patients pain 2) Evaluating the effectiveness of pain medication3) Providing a therapeutic back massage 4) Administering oral dose of acetaminophen ANS: 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 patientspain, 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 diagnosis of 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 medicationand 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 patient verbalizing 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 beintolerable. Saying the patients pain is relieved because he is resting quietly does not address the pain relief while he is awake. Some patients will sleep in an attempt to copewith 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 hours 2) Patient-controlled analgesic 3) Oral pain medications instead of the IM form 4) Only nonpharmacological pain measures ANS: 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 oralpain medications every 6 to 8 hours is a typical behavior for a patient 5 days after surgery. Requesting an oral form of the drug does not indicate substance abuse. PTS:1DIF:EasyREF:dm 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 option for this
patient to help provide symptomatic relief?1) Cordotom y 2) Rhizotom y 3) Neurectom y 4) Sympathectomy ANS: 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 procedureis commonly performed to relieve trunk and leg pain. Rhizotomy interrupts the anterior or posterior nerve route located between the ganglion and the cord. It is commonly usedto 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 of 4 onthe sedation rating scale? 1) 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 patients respiratory 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 type2 diabetes mellitus undergoes emergency surgery to remove an embolus in her rightleg. Which factor contraindicates the use of epidural analgesia in this patient? 1)
Anticoagulant therapy 2) Diabetes mellitus 3) Hypertensio n 4) Embolectom y ANS: 1 Patients who undergo mitral valve replacement typically require long-term anticoagulant therapy. Anticoagulant therapy is a contraindication for epidural analgesiause 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 alleviate thepatients 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 the patient is sitting upright or ambulating. Fluid volume deficit will also aggravate a spinal 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 clientfail 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 risk for 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 isnot likely a result of hesitation to ask for it out of habit or reliance on 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 selfreport 2) Past medical history 3) Description by caregiver(s) 4) Behavioral cues ANS: 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. The patient 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 mightbe heightened if other medical conditions coexist, although this perception is also influenced by other factors, such as past experience with pain and the success or failure of the treatment to produce relief. Chapter 29 Sensory Perception Identify the choice that best completes the statement or answers the question. 1. The nurse checks a patients pupils using a penlight. Which receptors is the nurse stimulating? 1) Chemorecepto rs 2) Photorecepto rs 3) Propriocepto rs 4) Mechanorecepto rs ANS: 2 Photoreceptors 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 nasal cavity. 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 and alertness? 1) Reticular activating system 2) Cerebellu m 3) Thalam us 4) Hypothalam us ANS: 1 The reticular activating system, located in the brainstem, controls consciousness and 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 child provides evidence that learning occurred? 1) Cuddlin g 2) Speakin g 3) Feedin g 4) Soothin g ANS: 2 Exposure to voices, music, and ambient sound helps develop the infants auditory nervous system. Cuddling, feeding, and soothing provide comfort and pleasure andteach 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 has suffered from excessively dry mouth. What term should the nurse use to document this complaint? 1) Exophthalm os 2)
Anosmi a 3) Insomni a 4) Xerostomi a ANS: 4 The nurse should document excessively dry mouth as xerostomia. Exophthalmos is abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosmiais 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 with impaired tactile perception? 1) Self-Care Deficit: Dressing and Grooming 2) Impaired Adjustment 3) Risk for Injury 4) Activity Intolerance ANS: 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 apriority as Risk for Injury. Risk for Injury is directly 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 kinesthesia 2) Macular degeneration 3) Seizur es 4) Xerostomi a ANS: 1 Patients with Parkinsons disease are at risk for impaired kinesthesia, placing them atrisk for falling. Drooling, not excessive dry mouth (xerostomia), is common with Parkinsons disease. Seizures and macular degeneration are not associated with Parkinsons disease. PTS:1DIF:ModerateREF:dm 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 theday 2) Applying wrist restraints during periods of agitation 3) Playing soft, calming music during the evening 4) 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 doesnot 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 diagnosis of 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 patient should 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 explain his condition. Which statement by the nurse best describes macular degeneration? 1) The portion of your eye called the macula, which is responsible for central vision,is damaged. 2) Your lens became cloudy, causing your blurred vision. This cloudiness will increase over time. 3)
The pressure in the anterior cavity of your eye became elevated, shifting the positionof 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 cavityof 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 has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss? 1) Otoscleros is 2) Conduction deafness 3) Presbycus is 4) Central deafness ANS: 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 thestapes. Conduction deafness results when one of the structures that transmits vibrations is affected. Presbycusis is a progressive sensorineural loss associated with 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 diuretic 2) Phenytoin, an anticonvulsant 3) Glyburide, an antidiabetic 4) Heparin, an anticoagulant ANS: 2 Phenytoin is a medication that has a high incidence of associated taste disturbance. Furosemide, glyburide, and heparin are not implicated in taste
disturbances. 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 phonecall. 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 rugs on 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 patientwith 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 andsocks. 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 the nurse pull the pinna to straighten the childs ear canal? 1) Up and back 2) Straight back 3) Down and back 4) Straight upward ANS: 3 The nurse should straighten the ear canal of a small child by pulling the pinna downand back. To straighten the ear canal of an adult, the nurse should pull the pinna 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. Thencontinue irrigating until the canal is clean. 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 to uplift and stimulate a patient? 1) Lavend er 2) Roman chamomile 3) Rosemar y 4) Ylangylang ANS: 3 Rosemary is very stimulating and uplifting. Lavender, Roman chamomile, and Ylang- 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) Presbycus is 2) Hyperopia 3) Increased sensitivity to touch 4) Increased sensitivity to taste ANS: 1 Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia isthe 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 not increase. 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 of his
body. Which nursing diagnosis best describes the patients problem?1) Disturbed Sensory Perception 2) Unilateral Neglect 3) Risk for Peripheral Vascular Dysfunction 4) Acute Confusion ANS: 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 patientmay also have Disturbed Sensory Perception, Risk for Peripheral Vascular Dysfunction, and Acute Confusion, but they are not the most appropriate for the defined 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 factor placesthe patient at highest risk for sensory overload? 1) Administering albuterol (a central nervous stimulant) asneeded 2) Administering a tranquilizer intravenously every 2 hours as prescribed 3) Delivering oxygen at 6 L/min via nasal cannula 4) Maintaining complete bedrest in a quiet, dimly lit room ANS: 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 sensoryoverload 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 nerve might have been affected? 1) Trigemin al 2) Glossopharynge al 3) Olfactor y 4)
Vagus ANS: 3 The olfactory nerve is responsible for the sense of smell. Damage to this nerve causesan 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 and abdominal 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 impaired vision? 1) Suggest the patient use bright overhead lighting. 2) Advise the patient to avoid wearing sunglasses whenoutdoors. 3) Do not offer large-print books, as this may embarrass the patient. 4) Place the patients eyeglasses within easy reach. ANS: 4 The nurse should place the patients eyeglasses within easy reach and make sure that they are clean and in good repair. The patient should have sufficient light but avoid bright light, which might cause glare. The patient should be encouraged to wear sunglasses, visors, or hats with brims when outdoors. A magnifying lens or large-printbooks 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 suffered from 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 now 2) Checking the patients sense of smell 3) Having the patient stand to check for balance 4) Assessing for a history of seizures ANS: 1 Many medications cause xerostomia (dry mouth), and xerostomia is the most common cause of impaired taste. Impaired sense of smell also affects the sense of taste; however, there is no reason to assume impaired smell in this patient. Balance is relatedthe 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 beunusual. Even if this were the case, the information would allow the nurse to plan carefor seizures, but not for the symptom of dry mouth.
Chapter 30 Respiratory Function 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, Ive 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 thepatient makes which of the following statements? 1) The babys lungs are well developed now, but he will be at increased risk for SIDS ifI deliver early. 2) We should try to stop this labor now because the baby will be born with sleep apnea ifI deliver this early. 3) If I deliver this early my baby is at risk for respiratory distress syndrome, a conditionthat 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 for respiratory distress syndrome (RDS). RDS is characterized by widespread atelectasis (collapseof alveoli), usually related to a deficiency of surfactant that keeps 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 ofthe following positions would be most effective if incorporated into the patients care? 1) Supin e 2) Head of bed elevated80 3) Head of bed elevated30 4) Lying on left side ANS: 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 action shouldthe nurse
take immediately? 1) Clamp the chest tube close to the insertionsite. 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 the tube tothe 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 the risk of infection, but the immediate action is to placethe 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 thatthe medication is effective? 1) The amount of sputum the patient expectorates decreases with each dose administered. 2) Cough is completely suppressed, and she is able to sleep through thenight. 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 unproductiveand frequent, leading to throat irritation or interrupted sleep. 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 woman witha 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. 4) 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 can be 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 providerhas prescribed. PTS:1DIF:ModerateREF:dm 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 breathing 2) Kussmauls respirations 3) Sleep apnea 4) Cheyne-Stokes respirations ANS: 4 This respiratory pattern is known as Cheyne-Stokes respirations. It is often associatedwith damage to the medullary respiratory center or high intracranial pressure 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) Nonrebreathermask 2)
Nasal cannula 3) Partial rebreather mask 4) Venturi mask ANS: 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 concentrationsof 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 the effectiveness of airway suctioning? 1) The amount, color, consistency, and odor ofsecretions 2) The patients tolerance for the procedure 3) Breath sounds, vital signs, and pulse oximetry before and after suctioning 4) The number of suctioning passes required to clear secretions ANS: 3 Breath sounds, vital signs, and oxygen saturation levels before and after suctioning provide data about the effectiveness of suctioning. Information about the 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 number of suctioning passes required to clearthe 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 tube insertion site? 1) Prevents air from leaking around the site 2) Prevents infection at the insertion site 3) Absorbs drainage from the insertion site 4) Protects the tube from becoming dislodged ANS: 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 negative pressure withinthe 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 in both lungs. What isthe most appropriate action to take? 1) Call the respiratory therapist to check the ventilator settings. 2) Provide endotracheal suctioning. 3) Provide tracheostomycare. 4) 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 secretionsand maintain patency. The patients symptoms should 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 appropriate intervention for which of the following conditions? 1) Congestive heart failure 2) Pulmonary edema 3) Pneumoni a 4) Pulmonary embolus ANS: 3 Chest physiotherapy moves secretions to the large, central airways for expectoration or suctioning. This treatment is not effective for conditions that do not 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 primary stimulus
for breathing? 1) p H 2 ) Oxyge n 3) Bicarbonat e 4) Carbon dioxide ANS: 4 Carbon dioxide (CO2) level provides the primary stimulus to breathe. High CO2 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 followingwould be the best response to his statement? 1) You should quit so your family does not get sick from exposure to secondhand smoke. 2) You will need to use oxygen, but remember it is a fire hazard to smoke with oxygenin your home. 3) Once you stop smoking, your body will begin to repair some of the damage to your lungs. 4) You should ask your primary care provider for a prescription for a nicotine patch to help you quit. ANS: 3 The nurses response should focus on correcting the patients misinformation rather thanon 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 longtime 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 late for 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 for pain
control. She will need to monitor her patient for which of the following adverse effects? 1) Decreased heart rate 2) Muscle weakness 3) Decreased urine output 4) Respiratory depression ANS: 4 Opioids are potent respiratory depressants. Patients receiving opioids shouldbe monitored for decreased rate and depth of respirations. PTS:1DIF:ModerateREF:dm 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, ifpossible. 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 the nurse. 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 under the 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 suction drainage. 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 flowing back into
the pleural cavity and compromising the patients respiratory status. Maintain patient in semirecumbent position (head of bed elevated 30 to 45 degrees), not flat. This is extremely important to promote lung expansion, reduce gastric reflux, and prevent ventilatorassociated pneumonia (VAP), if the person 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 theendotracheal tube. The fluid should not be drained into the humidifier because the patients secretions may have contaminated it. Chapter 31 Cardiac Function 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 following outcomes wouldbe 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/hr ANS: 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 dizzinesson 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 ACE inhibitor is to lower the blood pressure; the urine output is minimally relevant in determining that outcome, if at all. PTS: 1 DIF: Difficult REF: dm 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 ofthe following nursing diagnoses is most appropriate? 1) Decreased Cardiac Output 2)
Impaired Tissue Perfusion 3) Impaired Cardiac Contractility 4) Impaired Activity Tolerance ANS: 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 diagnoses cannot 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 following actions 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 isdry. 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 should be 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. A dry electrode will notconduct 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) Histamin e 2) Catecholamines 3) Cortis ol 4)
Proteas e ANS: 2 The stress response stimulates release of catecholamines from the sympathetic nervous 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 development of 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 oxygen demand 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 to produce this blood as well as to meet fetal requirements. Failure to meet these iron demands can result in maternal anemia, reducing tissue oxygenation of the mother. 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 wave 2) QRS complex 3) T wave 4) U wave ANS: 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 onthe 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) PTS: 1 DIF: Moderate REF: dm 1371-1372 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 thrombosis 2) Dehiscence of the wound 3) Internal bleeding 4) Infection at the incisional site ANS: 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 after trauma. 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 is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. Internal bleeding isa 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., elevated pulse and temperature). PTS: 1 DIF: Moderate REF: dm 1367-1368 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Nursing interventions to reduce the risk of clot formation in the legs include 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 patients to 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 inthe treatment of a patient with congestive heart failure? Choose all that apply. 1) Nitra tes 2) Beta-adrenergic agents 3) Diureti cs 4) Anticoagulan ts ANS: 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 blood and prevent accumulation of fluid inthe pulmonary circulation. PTS: 1 DIF: Moderate REF: dm 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 ofthe following potential complications? Choose all that apply. 1) Decreased heart rate 2) Increased heart rate 3) Decreased cardiac output 4) Decreased strength of ventricular contractions ANS: 1, 3 Normally, the SA node is the primary pacemaker for the heart and initiates a rate of 60to 100 beats per minute. If the SA node fails, the atrioventricular node can 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 to the SA node interferes with the electrical activity of the heart but does not directly affect the pumping actionof the heart. PTS: 1 DIF: Difficult REF: dm 1362-1363 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 4. Which outcome statement is related to Decreased Cardiac Output? Chooseall that apply. 1) No dyspnea or shortness of breath with exertion 2) Normal skin color 3) 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.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 becauseshe reports not feeling like herself. When you are gathering data in your clients health history, she tells you that she is feeling more fatigue when walking up 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 vessels become lesselastic, which creates more resistance to ejection of blood from the heart. As a resultof these changes, the heart becomes less able to respond to increased 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 Trueor 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 constricting effectson blood vessel walls. PTS: 1 DIF: Easy REF: p. 1373 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). Levels of 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. Chapter 32 Fluids, Electrolytes, and Acid-Base 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) Interstiti al 2) Intracellul ar 3) Intravascul ar 4) Transcellul ar ANS: 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 theplasma within the blood. Transcellular fluid includes specialized fluids, such as cerebrospinal, pleural, peritoneal, and synovial; and digestive 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 type of charged particles and why? 1) Cations, because they carry a positive charge 2)
Cations, because they carry a negative charge 3) Anions, because they carry a positive charge
4) Anions, because they carry a negative charge ANS: 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 the patient 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) Hypomagnesemia 2) Hypocalcemi a 3) Hyperkalemi a 4) Hypernatremi a ANS: 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 highsodium 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 concentrationis called which of the following? 1) Osmos is 2) Filtratio n 3) Hydrostatic pressure 4) Diffusio n ANS: 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 anarea 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 levels 2) Respiratory alkalosis withhypoxia 3) Metabolic acidosis with normal oxygen levels 4) Metabolic alkalosis with hypoxia ANS: 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 rangewith no signs of compensation. The PO2 level is normal. PTS: 1 DIF: Difficult REF: dm 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 isineffective. 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 PCO2 has returned the pH to the normal range. This change indicates that the treatment plan is effective. Partial compensation would beindicated by changes in the PCO2, but the pH would still be outside the normal range. The ABG is now complete compensation metabolic acidosis.PTS: 1 DIF: Difficult REF: dm 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 blood gases? 1) Respiratory system 2) Renal system 3) Vascular system 4) Neurological system ANS: 1 In a metabolic problem, the respiratory system compensates. In a respiratory problem,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 ofthe following? 1) Impaired Gas Exchange 2) Metabolic Acidosis 3) Risk for Impaired Gas Exchange 4) Risk for Acid-Base Imbalance ANS: 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 hasan 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 electronic health 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) Diffusio n 2) Osmos is 3) Filtratio n 4) Active transport ANS: 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 concentration gradient. In the presenceof 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 indwelling catheter 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 as which ofthe following? 1)
Lo w 2) Within normallimits 3) Hig h 4) Inconclusiv e ANS: 2 Urine accounts for the greatest amount of fluid loss. Normal urine output for an averagesized adult is approximately 1,500 mL in 24 hr. Urine output varies accordingto 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 and electrolyte balance? 1) Cardiac system 2) Vascular system 3) Pulmonary system 4) Renal system ANS: 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 andelectrolyte 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 of acidbase 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) Potassiu m 2) Calcium
3) Sodiu m 4) Magnesiu m ANS: 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 a key 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 mineralused in more than 300 biochemical reactions in the 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 by her granddaughter. She is a widow and lives alone, although her granddaughter checks 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 that she feels very weak. The following are her laboratoryresults: Sodium 138 mEq/ L Potassium 3.7 mEq/ L Calcium 9.2 mg/dL Magnesiu m 1.8 mg/dL Chloride99 mEq/
L BUN 29 mg/dL The nurse recognizes that the patient is displaying symptoms associated with whichof the following? 1) Hypovolemi a 2) Hypervolemi a 3) Hypernatremi a 4) Hyponatremi a ANS: 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 waterin the extracellular fluid, and the vital sign changes are opposite those of a patient with hypovolemia. Hypernatremia and hyponatremia are not applicable because the 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 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 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
Magnesiu m 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 ineffectivebreathing 2) Excess Fluid Volume related to limited fluid output 3) Deficient Fluid Volume related to abnormal fluidloss 4)
Electrolyte Imbalance related to decreased oral intake ANS: 3 Vomiting has made this patient hypovolemic; therefore, she has deficient fluid volume. There is no information to indicate that she has respiratory problems or Impaired 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 range 3) Patient demonstrates effective coughing and deep breathing techniques. 4) Maintains fluid balance, as evidenced by moist mucous membranes and urinating every4 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 nursing diagnosis would be different. There is no evidence that this patient has a respiratory problem, so coughingand 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 the nurseto a potential problem? 1) Na+ = 137 mEq/ L 2) K+ = 5.2 mEq/L 3) Ca2+ = 9.2 mg/dL4) 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 complaining of feeling itchy and hot. The nurse discovered a rash on the patients trunk. Vital signs 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 mustbe sent to the laboratory for analysis. A new IV line of normal saline should 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 indanger 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 infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize thesefindings to be consistent with which of the following? 1) Infiltratio n 2) Extravasatio n 3) Hematom a 4) Phlebit is ANS: 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 areat 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 blood outside 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 infiltrated intothe 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 the patency 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 above the site of infiltration or in the opposite arm. The nurse may need to inform the primary care provider if she is unable to find a new IV siteor 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 mothertells 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 childdown. 3) Inform the child that this wont hurt abit. 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 draw will not hurt is wrong and will make him distrustful of future interventions. The nurse may need thehelp of a coworker, but she should first try a calm approach.
PTS: 1 DIF: Moderate REF: p. 1399; not found in text; critical thinking requiredKEY: 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 per hour (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 and notes tall T waves. What electrolyte imbalance should the nurse suspect? 1) Hypokalemi a 2) Hypophosphatemia 3) Hyperkalemi a 4) Hypercalcemi a ANS: 3 Potassium levels affect the heart. A tall, peaked T wave on an ECG is associated with
hyperkalemia. A flat T wave is associated with hypokalemia. Phosphorous levels donot 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) Hypovolemi a 2) Hypercalcemi a 3) Hyperkalemi a 4) Hypervolemi a ANS: 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. Thereis no reason to elevate the patients left forearm or to place him in Fowlers position. PTS:1DIF:EasyREF:p. 1414 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
26. When performing a central venous catheter dressing change, whichof the following steps is/are correct? 1) Wear sterile gloves while removing and discarding the soileddressing. 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 turnhis 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 pressure to the catheter-hub junction. The transparent dressing should cover the hub of the catheter, but not the catheter-hub junction; this makes ittoo difficult to remove without disturbing the integrity of the IV line or the site. Chapter 33 Nutrition 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) Appl e 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 that fiber provides no glucose. KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 2. Which organ relies almost exclusively on glucose for energy? 1) Liv er 2) Hea rt 3) Pancre as 4) Brain ANS: 4 The brain relies almost exclusively on glucose for energy. The heart and liver do not.The pancreas produces insulin for glucose utilization but does not use glucose. PTS:1DIF:Easy , 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) Glycoge n 2) Insuli n 3) Keton es 4) Protei ns x 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:dm 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) Insuli n 2) Keton es 3) Glycoge n 4) Glucos e 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 directlyinto ketones. Insulin is a pancreatic hormone that promotes the movement of glucoseinto 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) Strok e 4) Lung cancer ANS: 3 Replacing saturated fats in the diet with mono- and polyunsaturated fats reduces therisk 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 amountsof vitamin D, breastfed infants who are not exposed to enough sunlight are at risk of the deficiency and rickets. There is no 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) Carbohydrate 2) Protei n 3) F at 4) Vitamin K ANS: 2 Protein is necessary for growth and maintenance of body tissues. Protein deficiencyplaces the patient at risk for skin breakdown and pressure ulcer formation. Carbohydrates are the primary fuel of the body. Fat is a source of energy 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 be for him to increase his intake of which nutrient? 1) Calciu m 2) Magnesiu m 3) Potassiu m 4) 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 risk of hypertension andcoronary 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 membranes are dry. Based on these findings, the patient most likely has excess levels of which mineral? 1) Sodiu m 2) Potassiu m 3) Phosphor us 4) Magnesiu m ANS: 1 Signs and symptoms associated with sodium excess include thirst, fever, dry and sticky tongue and mucous membranes, restlessness, irritability, and seizures. Findingsassociated 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? The patient 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 powder have 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 effect does this rise in temperature have on the patients basal metabolic rate? 1) Increases the rate by7% 2) Decreases the rate by 14% 3) Increases the rate by35% 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 returning to 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 whole milk. 4) Your baby weighs 14 pounds, so he will require about 36 ounces of formula a day. 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 of age. 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 ouncesof formula a day (not 36 ounces), based on the nutritional recommendations that infantsrequire 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.2) 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 formeals. 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 can shape an attitude aboutfood 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-meal snacks. 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 which nutrientto prevent neural tube defects? 1) Folic acid 2) Calciu m 3) Protei n 4) Vitamin D ANS: 1 The nurse should emphasize the importance of consuming folic acid even before conception to prevent neural tube defects from developing. Calcium and protein needsalso 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 with acute pancreatitis. This patient will most likely be deficient in which nutrients? 1) Iro n 2) B vitamins 3) Calciu m 4) Phosphor us 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 A deficiency can be associated with night blindness in heavy drinkers; vitamin D deficiency 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, those patients can have delayed clotting, resulting inexcess bleeding. Deficiencies of other vitamins involved in brain function can cause severeneurological 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 nurse provide for the patient? 1) Tea with cream 2) Orange juice 3) Gelati n 4) Skim milk ANS: 3 A clear liquid diet consists of water; tea (without cream); coffee; broth; clear juices, such as apple, grape, or cranberry; popsicles; carbonated beverages; and gelatin. Skimmilk, 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) Dehydration 2) Constipatio n 3) Hyperglycemi a 4) Diarrhe a ANS: 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-richfoods. 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 limit their 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 Body Requirements related to deficiency of which of the following nutrients? 1) Iro n 2) Vitamin A3) Protei n 4) Vitamin
C ANS: 1 Patients with iron deficiency may have spoon-shaped, brittle nails. Other abnormal nail findings include dull nails with transverse ridge (protein deficiency); pale, poor blanching, or mottled nails (vitamin A or C deficiency); splinter hemorrhages (vitamin C deficiency); and bruising or bleeding beneath nails (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 nurse complete? 1) Analyzing the data 2) Obtaining intake and output 3) Weighing the patient 4) Obtaining the history ANS: 1 The registered nurse should review and interpret (analyze) the data collected as part ofa nutritional assessment. The registered nurse can delegate height, weight, and intake and output to nursing assistive personnel. History taking can be safely delegated to thelicensed 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 patients nutritional status? 1) Albumi n 2) Prealbumi n 3) Transferri n 4) Hemoglobi n ANS: 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 ofprotein deficiency than does albumin. However, transferrin is not as fast as prealbumin. Hemoglobin level reflects iron intake 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 his weight
exceeds the ideal body weight for his height by 23%. Which nursing diagnosis shouldthe nurse identify for this patient? 1) Imbalanced Nutrition: More Than Body Requirements 2) Risk for Imbalanced Nutrition: More Than Body Requirements 3) Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition ANS: 1 This patient has defining characteristics for the nursing diagnosis Imbalanced Nutrition: More Than Body Requirements: triceps skinfold thickness more than 15 mmin men and weight that is 20% over ideal for height and frame. The patient does not have defining characteristics for the other nursing diagnoses. Chapter 34 Urinary Elimination Identify the choice that best completes the statement or answers the question. 1. What is the most significant change in kidney function that occurs with aging? 1) Decreased glomerular filtration rate 2) Proliferation of micro blood vessels to renal cortex 3) Formation of urate crystals 4) Increased renalmass ANS: 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, althoughthis 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 the instructor is best? You should: 1) Try to palpate it again; it takes practice but you will locateit. 2) Palpate the patients bladder only when it is distended by
urine. 3) Document this abnormal finding on the patientschart. 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 palpatethe bladder when distended. The nurse should document her finding, but it is not an abnormal finding. It is not necessary to notify the nurse assigned to 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 3) 1.025 4) 1.030 ANS: 4 Normal urine specific gravity ranges from 1.010 to 1.025. Specific gravity less than 1.010 indicates fluid volume excess, such as when the patient has fluid overload (toomuch IV fluid) or when the kidneys fail to concentrate urine. Specific gravity greaterthan 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 heart failure? 1) Thiazide diuretic 2) Loop diuretic 3) MAO inhibitor 4) Anticholinergi c ANS: 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 congestionin the cardiopulmonary circulation. A thiazide diuretic is used to treat high 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 thosewith asthma, for example. is a cholesterol-lowering drug. Although high cholesterol is a leading factor for heart 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) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication? 1) Skin breakdown 2) Urinary tract infection 3) Bowel incontinence 4) Renal calculi ANS: 1 Urine contains ammonia, which may cause excoriation with prolonged contact with 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 thenurse 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 patient shows 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 experiencing deficient 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 bedpan to 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 the bedpan. 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 inthe 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 correctly understands 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 the ambulatory 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-catchspecimen is a one-time collection. PTS: 1 DIF: Moderate REF: dm 1043-1044
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis 9. What position should the patient assume before the nurse inserts an indwelling urinary catheter? 1) Modified Trendelenburg 2) Pron e 3) Dorsal recumbent 4) SemiFowlers ANS: 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 usedfor central venous catheter insertion. Prone position is sometimes used to improve oxygenation in patients with adult respiratory distress syndrome. Semi-Fowlers positionis used to prevent aspiration in those receiving enteral feedings. PTS: 1 DIF: Easy REF: p. 1031 KEY: Nursing process: Interventions | Client need: Physiological Integrity | Cognitivelevel: Application 10. A patient complains that she passes urine whenever she sneezes or coughs. How should the nurse document this complaint in the patients healthcare record? 1) Transient incontinence 2) Overflow incontinence 3) Urge incontinence 4) Stress incontinence ANS: 4 Stress incontinence is an involuntary loss of urine that occurs with increased intraabdominal 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 typically caused by urinary tract infection or medications, such as diuretics. Overflow incontinence is theloss of urine when the bladder becomes distended; it is commonly associated with fecal impaction, enlarged prostate, and neurological conditions. Urge incontinence isthe 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 (targetdate). 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 unable to resume a normal urination pattern; urine, along with mucus, drains continuously from the stoma site, so the urine will not be clear. Also, the phrase sufficient 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 micturitionin a 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 warm water 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 13. The student nurse asks the provider if she will prescribe an indwelling urinary catheter for a hospitalized patient who is incontinent. The provider explains thatcatheters 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 statement by the patient would indicate correct understanding of the procedure? 1) I will need to replace the catheterweekly. 2) 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 catheterin 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 balloon is not inflated after insertion. Straight catheters are removed immediately after use. 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 nurse take? 1) Notify the provider immediately. 2) Flush the catheter tubing with saline solution. 3) Replace the indwelling urinary catheter. 4) 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 tubing of 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 thepast 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 havea 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) Cystit is 2) Renal calculi 3) Enures is 4) Renal failure ANS: 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 but do 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 isoften emotional, developmental, or trauma related. 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-oldson 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 avoidwetting. 3) Suggest time out to reinforce the importance of stayingdry. 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 the early school years. The mother should handle the situation calmly and avoid punishing the child. Medications are occasionally prescribed for nocturnal enuresiswhen the child is older and not sleeping at home, but not for occasional daytime wetting. PTS:1DIF:ModerateREF:dm 1038-1039 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application 19. Which task can the nurse safely delegate to the nursing assistive personnel? 1) Palpating the bladder of a patient who is unable to void 2) Administering a continuous bladder irrigation 3) Providing indwelling urinary catheter care 4) Obtaining the patients history and physical assessment ANS: 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 bladderirrigation, 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 training using 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 eachweek. 3) Frequently ask the patient if she has the urge to void. 4)
Increase the frequency between voiding even if urine leakageoccurs. 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 interval should 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) Hypocalcemi a 2) Hypokalemi a 3) Hypomagnesemi a 4) Hypophosphatemia ANS: 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 cause hypocalcemia (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 weighing 8 pounds? 1) 288 mL 2) 180 mL 3) 36 mL 4) 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 limitsand 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 involuntary leakageof urine? 1) Insertion of a pessary 2) Intermittent selfcatheterization 3) Bladder training 4) Anticholinergic medication ANS: 3 The goal of bladder training is to enable the patient to hold increasingly greater volumes of urine in the bladder and to increase the interval between voiding. Thisinvolves patient teaching, scheduled voiding, and self-monitoring using a voiding 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 reduceorgan prolapse or pressure on the bladder. Clean, intermittent self-catheterization is a good option for managing incontinence that is resistant to conservative measure, suchas bladder training, Kegel exercises, lifestyle modification, and medication. Anticholinergic medication can be highly effective for improving urinary incontinence.However, more conservative measures, such as 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 from an 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, thereby increasing the risk of contamination. Do not takethe 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 the question. 1. Which of the following is/are an appropriate goal(s) for a patient with urinary incontinence? Choose all that apply. 1) Increase the intake of citrusfruits. 2) Maintain daily oral fluids to 8 to 10 servings per day. 3) Limit daily caffeine intake to less than 100mg. 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, spicy foods, and citrus fruit; and maintaining daily oral fluid intake to 8 to 10 servings perday. Highimpact exercise can be associated with stress incontinence for those withweakened pelvic muscles that support the bladder and urethra. Chapter 35 Bowel Elimination 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 green-black, 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 mothers milk comesin. 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 irritating to the buttocks than other stools because they are so sticky and the skin usually must 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) • years 3) • years 4) • 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, maynot achieve consistent bowel control until somewhat later. PTS:1DIF:ModerateREF:dm 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. Otherrisk factors include caffeine consumption and lactose intolerance; however, theyare 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 nursing diagnosis 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 in fiber 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) Yogu rt 2) Past a 3) Oatme al 4) Brocco li ANS: 1 Although the patient may have diarrhea, the goal is not to stop the diarrhea, but to 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 stimulatesperistalsis, 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 explainthe importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce servings)? 1) 3 to 4 servings a day 2) 5 to 6 servings a day 3) 7 to 8 servings a day 4) 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 tothe patient? 1) Stop taking the drug immediately if diarrheadevelops. 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 inthe colon that cause diarrhea. Bacterial populations can be maintained by encouragingthe 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 notbe encouraged to take an antidiarrheal agent at 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 a patient 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 increasethe risk of ileus. Administering IV fluids prevents dehydration but does not directly prevent ileus. Inserting an indwelling urinary catheter prevents urine retention 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 rice
2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice, and bananas ANS: 2 Oranges, raisins, and strawberries are high in fiber. White bread, pasta, and white rice are carbohydrates. Whole milk, eggs, and bacon are high in cholesterol. Peaches, orangejuice, 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, infrequent bowel sounds. How should she document this finding? 1) Hyperactive bowel sounds 2) Abdominal bruit sounds 3) Normal bowel sounds 4) Hypoactive bowel sounds ANS: 4 Hypoactive bowel sounds are low-pitched, infrequent, and quiet. An abdominal bruit isa 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 and more frequent than normalbowel 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 a fecal occultblood test cannot confirm the diagnosis. Colonoscopy is not necessary to obtain a specimento confirm the diagnosis. PTS:1DIF:ModerateREF:dm 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 3days prior to testing, I should avoid eating: 1) Be ef. 2) Mi lk. 3) Eg gs. 4) Oatme al. 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 occult blood testing. PTS: 1 DIF: Moderate REF: dm 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 substance may cause a false- negative fecal occult blood test? 1) Vitamin D 2) Ir o n 3 ) Vitamin C 4) Thiami ne ANS: 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: dm 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 for pinworms? 1) Press clear cellophane tape against the anal opening at night to obtain a specimen. 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 ofreagent. 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 tape immediately, 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 to move independently. How should the nurse position the patient for this procedure? 1) Semi-Fowlers position 2) Left side-lying position 3) Supine with the head of the bed lowered flat 4) Supine with the head of bed raised to 30 degrees ANS: 2 The nurse should position an immobile patient in a left side-lying position to irrigatehis colostomy. Semi-Fowlers, supine with the bed lowered flat, and the supine 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 should the 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 controldiarrhea. 4) Increase the consumption of raw fruits andvegetables. ANS: 1 The nurse should encourage the patient with diarrhea who has an appetite to consumea diet that consists of bananas, white rice, applesauce, and toast. These foods are easyto digest, provide calories for energy, and help provide a source 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 with diverticulitis? 1) Antaci d 2) Antidiarrheal agent 3) Antibiotic therapy 4) NSAI Ds ANS: 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 surgery and notes that bowel sounds are absent. This finding most likely suggest which postoperative complication? 1) Paralytic ileus 2) Small bowel obstruction 3) Diarrhe a 4)
Constipatio n ANS: 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 withhypoactive 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 andtoast 2) Tomatoes and driedfruit 3) Asparagus and melons 4) Yogurt and parsley ANS: 4 Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and 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 foodsthat 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 collectiondevice. 3) 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 stricture or 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 bedlinens. 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 help achieve 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. 4) Avoid returning to the use of an ostomy appliance if he becomesill. 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 achieve the goal of having regular bowel movements and thus, eliminating the need to wear a pouch. When illnessoccurs, it may be difficult to control the output, so the patient can use an ostomy appliance. This willnot make it more difficult to schedule the bowel movements after the illness passes. Chapter 36 Sleep 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) Insomni a. ANS: 3 A person who is deprived of REM sleep for several nights will usually experienceREM 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 overtime.
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 Ativanto 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 throughoutthe day. 3) Benzodiazepines produce daytime sleepiness and alter the sleepcycle. 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 alongacting 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 rhythm2) Sleeping in a quiet environment 3) Spending additional time in stage IV of the sleepcycle 4) Napping frequently during the day hours ANS: 1 A circadian rhythm is a biorhythm based on the daynight pattern in a 24-hour cycle. Sleep quality is best when the time at which the person goes to sleep and awakens is insynchrony 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 cerebellum 2)
Level of sympathetic nervous system stimulation 3) Amount of sleep a person has become accustomedto 4) Amount of light received through the eyes ANS: 4 The circadian rhythm is a biorhythm based on the daynight pattern in a 24-hour cycle. 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 major factor in regulating sleep is the amount of light received through the eyesnot the typical amount of sleep the personhas 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 by all 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 sheis 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 diagnosis would 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 experiencetemporary 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 with sleep 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 awake longer 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 caninterfere with the bodys readiness for sleep at night. PTS:1DIF:EasyREF:dm 1207-1208 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 8. The expected outcome (goal) for a patient with Disturbed Sleep Pattern is that 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 Pattern had 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 to bein 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 most likely experiencing? 1) Stage V 2) Stage IV 3) Stage III 4) 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 repairand 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 sleepwakefulness patterns over a certain period of time. It allows identification of trends in sleepwakefulness patterns and associates specific behaviors interfering with sleep. Thediary 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) Parasomnia
s. 2) Dyssomnia s. 3) Insomni a. 4) Hypersomni a. 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 boys sleep patterns, she says, Sometimes he will get out of bed, walk into the kitchen, and get thecereal 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 leaves the bed and walks about with little awareness of surroundings. He may perform what appearto 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 a medical 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 isnot 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 who sleepwalks 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 isonly 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 certainly not 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 waves 2) NREM, sleep spindles 3) NREM, delta waves 4) 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 IV slow 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 sleeper in this stage is easily roused. REM sleep is the stage at which most dream activity occurs, as well as morespontaneous 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 tend to need the most hours of sleep? 1) Todd ler 2) Adolesce nce 3) Middle adulthood 4) Older adulthood ANS: 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 in a 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 the question. 1. Select the factors known to affect sleep. Choose all that apply. 1) A g e 2 ) Environm ent 3) Lifest yle 4) State of health 5) Ethnicity ANS: 1, 2, 3, 4 Age, environment, lifestyle, and state of health are factors affecting sleep. Many older adults sleep less but require more rest. Alcohol, caffeine, nicotine use, and diet are examples of lifestyle factors that affect sleep. When a person is ill, she may sleep moreor find that she cannot sleep because of pain or other factors associated with illness. Changes in environment also affect sleep. PTS:1DIF:EasyREF:dm 12071208 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 best response 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 atnight. 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 is difficult 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 the symptomsyou would expect the client to exhibit. Choose all that apply. 1) Bruxis m 2) Enures is 3) Daytime fatigue 4) Snorin g 5) Drooling ANS: 3, 4 Obstructive sleep apnea is caused by partial airway occlusion (usually by the tongue or palate) during sleep. The patient experiences interrupted sleep as he arouses frequentlyto clear the airway. As a result, the patient has episodes of snoring and daytime fatigue. Chapter 37- Self-Concept —Chapter 38 Families and Their RelationshipsMultiple 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) Extende d 2) Tradition al 3) Blende d 4) Nucle ar 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 ahusband, 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 liveout 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 homecare. 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 inthe patients care. 4) Encourage liberal visiting hours by the friend and the patientschildren. ANS: 1 The nurse can best intervene by involving the friend and the patients 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 can involve 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 liberalizingvisiting hours and therefore is the best answer. PTS:1DIF:ModerateREF:dm 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 can vary among families, which typical stage of family development is this couple likely experiencing? 1) Family launching young adults 2) Postparental family 3) Family with frailelderly 4) Family with teenagers and young adults ANS: 2 This couple is most likely experiencing the postparental stage of family development. During this stage, the parents prepare for retirement and adjust to their 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 moralvalues 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 community 2) The parents 3) Her mother 4) Her sister ANS: 1 Her surrounding community is considered a suprasystem because it is larger than the family system. Subsystems within the family include the parents, mother, siblings, sister, brother, father, and grandmother; they are smaller components that fit within thefamily 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 resources 3) Adherence to a low-fat diet 4) Importance of physical exercise ANS: 2 When teaching the family of an older adult, the nurse should include information about 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 arelikely 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 the United States after the disease was thought to be eradicated? 1) Lack of health insurance 2) Bioterroris m 3) Reduced compliance with vaccinations 4) Drug resistance ANS: 3 Reduced compliance with community immunization in the United States increases therisk 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 introductionof 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 hasled 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 and relationships amongfamily members. PTS:1DIF:ModerateREF:p. 308 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 8. Which family member is most likely to be
disabled? 1) 60-year-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 prevalenceof 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: ApplicationMultiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which family function(s) is/are outlined in the structural-functional family theory? Select all that apply. 1) Meeting the emotional needs of family members 2) Reinforcing ethical and moral values3) 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 in family development theories. PTS:1DIF:ModerateREF: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? Selectall that apply. Family members 1) Respect each others need for privacy2) Enact decisions made by the most powerful
member 3) Do not consider a conflict resolved until everyone agrees 4) Set boundaries between family members ANS: 2, 3 Respect for privacy and clear boundaries between family members are characteristics ofa healthy family. Boundaries define the responsibilities of adults that are clear and separate from responsibilities of growing children. In healthy families, there is typicallyegalitarian distribution of power. In healthy families, it is not always necessary for all members to agree; instead, they have the 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 that apply. 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 familymembers. Chapter 39 Cognitive Processes 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 focus 2) Psychosocial focus 3) Biopsychosocial focus 4) Physical focus ANS: 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 meetsone of his basic physiological needs? 1) Providing the patient with a dinner tray 2) Administering antibiotics as prescribed 3) Irrigating a wound with normal saline solution 4) Encouraging the patient to express his feelings ANS: 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), andencourage 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 development 2) Developmental tasks 3) Social identity 4) Selfesteem ANS: 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 tasks that 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 individuals 1) Understanding of how others perceive him 2) Evaluation of himself 3)
Overall view of himself 4) Perspective of his role in society ANS: 3 Self-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 medical restriction on visitation. To help maintain the patients social identity while hospitalized, it is most important for the nurse to encourage visits by 1) Pee rs 2) Grandparen ts 3) Siblin gs 4) Parent s ANS: 1 Peers are more important than family in maintaining social identity in this age group. 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 lotworse. ANS: 4 People who demonstrate an internal locus of control take responsibility for their life 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 of control; control of thesituation 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 accident 2) With hypothyroidism who has coarse, dry, thinning hair and weight gain 3) Who is obese and who underwent gastric bypass surgery 4) With peripheral vascular disease who required a wound graft ANS: 1 Theoretically, the patient who suffered a traumatic amputation in an industrial accident will most likely have more difficulty adjusting to his change in body image because thechange 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:dm 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 birth 2) Child who was born with cystic fibrosis 3) Adolescent of average appearance who had an appendectomy 4) Adult born with a spinal defect and associated paralysis of the lowerbody ANS: 3 The adolescent with average appearance who had an appendectomy is likely to have 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 becausemany times the handicap leaves them socially isolated. This is, of course, not to imply that noone 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:dm 275-276 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 a result, his wife misses work whenever the children are ill. She has become increasingly distressed over her situation. Her experience best demonstrates which ofthe following? 1) Role strain 2) Interpersonal role
conflict 3) Role performance 4) Inter-role conflict ANS: 4 The patients wife is most likely experiencing inter-role conflict, in which her role as a mother and worker are making competing demands on her. Role strain is a mismatch 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 selfesteem? 1) View of oneself as a unique humanbeing 2) Ones mental image of ones physicalself 3) Ones overall view of oneself 4) How well one likes oneself ANS: 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:dm 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 risk for experiencing a crisis in which component of self-concept? 1) Body image 2) Selfesteem 3) Personal identity 4) Role performance ANS: 2 Setbacks such as not becoming pregnant after months of fertility treatment can cause the patient to question her self-worth. This might provoke a crisis in self-esteem. The patient is not at risk for experiencing a crisis in body image, personal identity, or role performance.
PTS:1DIFifficultREF:dm 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 laceration on the left side of her face in a motor vehicle accident. The patient tells the nurse that shedoes 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 healquickly. 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 assume that the patient istalking 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 address the patients concerns. PTS: 1 DIF: Moderate REF: dm 288-289; ESG, Supplemental Materials, Psychosocial Nursing Interventions, V2, p. 116; ESG, Supplemental Materials, 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 make for this patient? 1) Parental Role Conflict 2) Interrupted Family Processes 3) Compromised Family Coping 4) Ineffective Individual Coping ANS: 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. Compromised Family Coping occurs when support from a usual family member is compromised or disabled, causinga significant health challenge. Ineffective Individual Coping occurs when the patient isunable 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 is
resolving? 1) Pacing in the hallway at intervals 2) Using relaxation techniques 3) Speaking rapidly when spokento 4) Avoiding eye contact ANS: 2 Using relaxation techniques might suggest that the patients anxiety is resolving. Pacing, speaking rapidly, and avoiding eye contact suggest that anxiety is still a problem for the patient. The patients use of relaxation techniques indicates problemsolving by the patient. PTS: 1 DIF: Easy REF: dm 288-289 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Comprehension 15. Which nursing diagnosis is categorized as a psychosocial, rather than a self- concept, diagnosis? 1) Ineffective Individual Coping 2) Situational Low SelfEsteem 3) Disturbed Personal Identity 4) Disturbed Body Image ANS: 1 Ineffective Individual Coping is considered a psychosocial nursing diagnosis. It implies poor life choices, inability to use available resources, and other interactionaland relationship symptoms. The term psychosocial encompasses both psychological and social factors. The other diagnoses represent primarily individual, psychological factors. They are examples of self-concept nursingdiagnoses. 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 a patient 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 bettersoon. 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 very lucky . . .; that is offeringa judgment. PTS:1DIF:ModerateREF:p. 293 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 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 wants more than whatI am, and now Im not even bringing home any money. Which nursing diagnosis is most appropriate? 1) Chronic Low SelfEsteem 2) Situational Low SelfEsteem 3) Disturbed Personal Identity 4) Disturbed Body Image ANS: 2 Situational Low Self-Esteem occurs when a person exhibits self-disapproval and negative self-evaluations as a specific reaction to loss or change (in this case, of a job and a marriage). There are no data to indicate long-standing (Chronic) Low Self- 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 isonly 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 nurse anticipate in expectation of the body changes associated with the upcoming surgery? 1) Deficient Knowledge 2) Impaired Adjustment3) Hopelessness 4) Grievin g ANS: 4 Grieving may occur as a result of body changes associated with mastectomy. Deficient Knowledge, Impaired Adjustment, and Hopelessness are not associated with 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 Chronic Low Self-Esteem. Which NOC outcome is essential for this nursing diagnosis? 1) Decision Making 2) Distorted Thought Content 3) Role Performance 4) Depression Level ANS: 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 patientslow 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, 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 a newly admitted patient. Which of the following is an example of an individualized goal for that patient? 1) Distorted Thought Control 2) Anxiety Level 3) Self-Mutilation Restraint 4) No Self-Injury, Consistently Demonstrated ANS: 4 No Self-Injury, Consistently Demonstrated is an example of using NOC indicatorsand 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. Following surgical repair, he developed complications and required an extensive stay in the hospital. How can the medical-surgical 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 knowher. 4) Listen attentively when the patient speaks. ANS: 2 Encouraging the patient to his accomplish own self-care, such as bathing and brushing his teeth, encourages independence and promotes self-esteem. Assisting the patient to ambulate in the hallway prevents complications of immobility. Introducing yourself andlistening attentively to the patient prevents depersonalization. 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 accommodatechanges brought on by illness. The purpose of this intervention is to help 1) Promote selfesteem 2) Promote positive body image 3) Facilitate role enhancement 4) Prevent depersonalization ANS: 3 Facilitating communication between the patient and significant other regarding sharing 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-esteemor 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 patient is anxious, the nurse notes tachycardia and trembling. Which level of anxiety is this patient exhibiting? 1) Mild anxiety 2) Moderate anxiety 3) Severe anxiety 4)
Panic anxiety ANS: 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-threateningillness. Physical symptoms include 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 the nurse that he is often short of breath and says, I lie awake nights worrying about everything. 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 cannotwork. 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 health professional. ANS: 4 The nurse should involve a mental health professional immediately, because the patientis exhibiting signs of a disabling anxiety disorder. Although it is important for the nurseto 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 right to 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 remove the right lung is recommended. The patient is uncertain about whether he should consentto the surgery because of the risks involved. Which nursing diagnosis is most appropriate for this patient? 1) Decisional Conflict 2) Death Anxiety
3) Powerlessne ss 4) Ineffective Denial ANS: 1 Decisional Conflict is the most appropriate nursing diagnosis for this patient because heis 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 patient is 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 hydration 2) Giving clear fact pertaining to the patients circumstances 3) Promoting small-group activities to improve selfesteem 4) Monitoring the patient for the risk of suicide ANS: 2 Using clear and factual knowledge that is tailored to the patients circumstances helps reduce anxiety. Teaching the importance of adequate hydration, promoting small- 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 outcome is appropriatefor this diagnosis? 1) Displays stabilization and control of mood 2) Sleeps 6 to 8 hours per night with report of feeling rested 3) Does not engage in risky, self-injurious behavior 4) Eats a well-balanced diet to prevent weight change ANS: 1 An outcome for the nursing diagnosis Hopelessness is displays stabilization and controlof 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 for the 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 following sets of behavioral symptoms may indicate depression? 1) Preoccupation with loss, self-blame, and ambivalence 2) Anger, helplessness, guilt, and sadness 3) Anorexia, insomnia, headache, and constipation 4) Tearfulness, withdrawal, and present substance abuse ANS: 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 unitis 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 of depression in older adults. Any one of the symptoms might occur as a result of physical illness, butthe combination should prompt the nurse to suspect depression and interview and screen for it before exploring physiological causes for 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:dm 291, 295 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application
30. An elderly patient admitted from a skilled nursing residence to a medicalsurgical unit is exhibiting confusion, distractibility, memory loss, and irritability. She has a medical diagnosis of dehydration. Which of the following should lead the nurse tosuspect 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 inappropriately 2) Speaks slowly with delayed response to questions but responds appropriately3) Awakens early in the day yet sleeps almost constantly during theday 4) Sometimes has difficulty concentrating on details of the present situation ANS: 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: ApplicationMultiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which assessment finding(s) might suggest that the patient has low selfesteem and requires more in-depth assessment? Choose all that apply. 1) Infrequent eye contact 2) Straight posture 3) Overly critical of others 4) Careful grooming ANS: 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 person displayed straight posture and careful grooming.
PTS: 1 DIF: Easy REF: dm 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 a sense of personhood during hospitalization? Assume that all are culturally appropriate. Choose all that apply. 1) Addressing the patient by his firstname 2) Making eye contact if it is comfortable for the patient 3) Always offering an explanation before beginning a procedure 4) Speaking to others about the patient so that the patient can hear you ANS: 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. Usingeye contact, always offering an explanation before beginning a procedure, and not talking about the patient to others in the room are additional ways for the nurse to offer care that respects patient rights. Chapter 40 Sexuality 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 a womens 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 menstrualstatus, 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 control requirements in a heterosexual or bisexual woman. PTS: 1 DIF: Moderate REF: dm 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 assessthe clients knowledge and understanding of reproduction and sexuality. 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) Desir e 2) Exciteme nt 3) Stimulation 4) Orgas m ANS: 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 sexually aroused: desire, excitement, plateau, orgasm, and resolution. Desire precedes all other stages of the cycle, but sexual response does not necessarily proceed beyond desire. PTS:1DIF:ModerateREF:dm 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 shehas been dating a widowed man for 9 months and that the relationship is fulfilling in most areas. However, she is unable to have sexual relations because she 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 this woman? 1) Sexual Dysfunction related to conflicted sexual orientation 2)
Ineffective Sexuality Patterns related to values conflicts 3) Ineffective Sexuality Patterns related to impaired relationship with partner 4) Sexual Dysfunction related to fear of the unknown ANS: 2 The nursing diagnosis Ineffective Sexuality Patterns is used when the patient expresses concerns about her own sexuality, whereas Sexual Dysfunction is usedwhen there is an actual change in sexual function that the patient views as unsatisfying, unrewarding, or inadequate. In this situation, the patient still views herself 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 himself as a female. He describes the isolation he feels and concern about fitting in socially and atwork because of these recurrent thoughts. How would you respond to your patient? 1) Provide information about support groups and other community resources fortranssexual people. 2) Reassure him that he is normal, saying there are more people than we know who feelthis way. 3) Share with him that you personally have had thoughts like this but have coped withthese thoughts. 4) Suggest your patient seek mental healthcare for medication to help him deal with his anxiety. ANS: 1 Those experiencing a sexual identity disorder, such as transsexualism, typically feel 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 and support during a time of isolation and emotional inner conflict. Reassuring the patient he is normal discounts his feelings and conveys insensitivity on the part of 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 experiencestrivializes the patients experience. The nurses first action is to offer information rather than imply that the patient has a mental health issue requiring anti-anxiety 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 to
values 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 herpartner. 3) Advise the patient to discuss her value conflict with a counselor. 4) Instruct the patient on effective methods to identify fears. ANS: 3 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 the patient 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 developing intimate 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. Developing intimate 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:dm 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 and competent 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 that are 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 thoseaside 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 that your teaching about detection of STIs has been effective? 1) 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 an STI. 3) A healthcare provider can tell if you have an STI by getting a detailed sexual history. 4) A genital swab culture can be done at the office or clinic to determine if a person hasan 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 from the 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 made the 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 through orgasm. 3) 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 weresuccessful. ED is not related to sexual orientation or exposure to STIs. Comfort with
communicating about sexual needs is helpful for sexual satisfaction but is not the causeof 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 you must 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 the future. 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 PLISSITsteps 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 free to 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 doctoradvised him that his partner should be treated because this problem may affect her future fertility. What disorder should be assessed for? 1) Chlamydi a 2) Trichomoniasis 3) Genital herpes 4) Human papillomavirus ANS: 1 The male partner exhibits symptoms of chlamydia. Women are frequently asymptomatic for chlamydia. As a result, the infection may go untreated and affect 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 materialand regrowth of the endometrium, ending with the release of the ovum? 1) Menstrual phase 2) Follicular phase 3) Luteal phase 4) Fertilizatio n ANS: 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 begins again. Fertilization occurs at thetime 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 the question. 1. Normal physiological changes in womens sexual responses that occur with aging include which of the following? Choose all that apply. 1) Delayed nipple erection 2) Increased vaginal expansion 3) Reduced vaginal lubrication4) Reduced labial separation and swelling ANS: 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 increased because 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 knowwhy 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 to do this. I just dont know howto make him stop. How would you best respond to her concerns? Choose all that apply. 1)
Give him a little time, and hell grow out of it. Hes just too young to understand right now. 2) How often do you punish him by giving him a time-out or by using physicaldiscipline? 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 of his 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 are a 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 incident of sexual assault? Choose all that apply. 1) 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 theabuser 3) Idea that the legal system couldnt prosecute the abuser for the crime 4) Desire to have the incident behind her, as if it never happened in the firstplace ANS: 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 onand 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 disorder 2) Date
rape 3) Orgasmic disorder 4) Low libido ANS: 1, 3, 4 Low libido, arousal disorder, and orgasmic disorder all affect the sexual response cycle. 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 threatof 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 agreedupon social encounter. PTS:1DIF:EasyREF:dm 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 also yield morehonest 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 privacy and 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 as well 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.
Chapter 41 Stress, Coping, and 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 substances promotes a sense of well-being? 1) Aldosteron e 2) Thyroid-stimulating hormone 3) Endorphi ns 4) Adrenocorticotropic hormone ANS:3 Endorphins act like opiates to produce a sense of well-being; they are released by the hypothalamus and posterior pituitary gland in response to alarm. Aldosterone promotes fluid retention by increasing the reabsorption of water by renal tubules. Thyroidstimulating hormone increases the efficiency of cellular metabolism and fat conversionto energy for cell and muscle needs. Adrenocorticotropic hormone stimulates the adrenal cortex to produce and secrete 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) Alar m 2) Resistanc e 3) Exhaustio
n 4) Recover y ANS:3 Physiological responses in the exhaustion stage include low blood pressure and high 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) Epinephrin e 2) Corticotrophin-releasing hormone 3) Aldosteron e 4) 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 to the 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 alarm stage 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 use bythe brain 4) Promotes fluid excretion by causing the kidneys to reabsorb more sodium ANS:1 Antidiuretic hormone promotes fluid retention by increasing the reabsorption of water by kidney tubules. Thyroid-stimulating hormone increases efficiency of cellular metabolism and fat conversion to energy for cells and muscle. Cortisol increases the useof fats and proteins for energy and conserves glucose for use by 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 inflammation 2) Exudate formation 3) Tissue regeneration 4) Vascular response ANS: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 from circulation 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? 1) Ang er 2) Fe ar 3) Anxiet y 4) Hopelessness ANS:3 NANDA-International defines Anxiety as a vague, uneasy feeling of discomfort ordread 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 emotionor 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 tells the 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. 3) You were very sick; dont be angry; youre lucky to be alive. 4) You shouldnt be angry with us; were trying to helpyou. 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 take responsibility for the patients anger by apologizing (Im sorry . . .). Advising the patient dont be angry oryou shouldnt be angry diminishes the patients right to be angry. PTS:1DIF:ModerateREF:p. 266 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis8.You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. Which somatoform disorder is this patient mostlikely experiencing? 1) Hypochondriasis 2) Somatization 3) Somatoform pain disorder 4) Malingerin g ANS: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 turmoilare 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: Application9.After a patient has an argument with her husband, she becomes verbally abusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting? 1) Reaction formation 2) Displaceme nt 3)
Deni al 4) Conversio n ANS: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 of reaction formation, the patient is aware of her feelings but acts in an opposite manner to whatshe 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 a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis? 1) Precris is 2) Impa ct 3) Cris is 4) Adaptiv e ANS: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 patient finds 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: dm 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 plan to helpthe 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 anxiety to help relieve stress, which is the cause of the patients diarrhea. Monitoring stool frequency is an assessment, not a nursing intervention. The other interventions maybe 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: Analysis12.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 each day. 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 the intakeof fat to no more than 30% (not 15%) of daily calories; eat smaller, more frequent meals (not three meals a day); and consume no more than two alcoholic beverages perday 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 assessment finding would suggest that the relaxation technique was successful? 1) Decreased blood pressure 2) Decreased peripheral skin temperature 3) Increased heart rate 4) Increased respiratory rate ANS:1 Reassessment findings that suggest relaxation has been effective include decreasedblood pressures, increased peripheral skin temperature, decreased heart rate, and decreased respiratory rate. PTS:1DIF:ModerateREF:dm 266-267 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension14.The nurse is caring for a patient with unresolved anger. For which associated complication should the nurse assess? 1) Depressio n 2)
Hypochondriasis 3) Somatizatio n 4) Malingerin g ANS:1 Depression is sometimes associated with unresolved anger and may result from stress. 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 nurse removes her stethoscope from around her neck. The best rationale for doing so is that the stethoscope 1) Could be used by the patient to hurther 2) Might cause the patient not to trusther 3) Would distract her from focusing on the patient 4) Will function as another stressor for the patient ANS: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 is unlikely 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. Nursescarry 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 nurse dofirst? 1) 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 safety ofself 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 the question. 1. During the alarm stage of the general adaptation syndrome, which metabolic change(s) occur(s)? Choose all that apply. 1) Rate of metabolism decreases. 2) Liver converts more glycogen to glucose. 3) 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 amino acids and mobilizationof fats for energy. PTS:1DIF:ModerateREF:dm 252-253 KEY: Nursing process: N/A | Client need: Physiological integrity | Cognitivelevel: Comprehension 2. Two days after a patient undergoes abdominal surgery, his surgical incision isred and slightly edematous; it is oozing a small amount of serosanguineous (pink- tinged serous) fluid. On the basis of these data, what can you conclude? Choose all thatapply. 1) The wound is most likelyinfected. 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 commonly appears 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. Chapter 42 Loss and Grieving 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 to care forherself at home. Which type of loss is this patient most likely experiencing? 1) Environmental loss 2) Internal loss 3) Perceived loss 4) Psychological loss ANS: 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 to the 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 takes longest to achieve? 1) Accepting that the loved one is gone 2) Experiencing the pain from the loss 3) Adjusting to the environment without the deceased 4) Investing emotional energy ANS: 1 Worden described the tasks a grieving person must achieve. They progress from an initial numbness or denial through experiencing and working through pain and grief andeventually 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 confrontation phase ofthe grieving process? 1) Anger and bargaining 2)Shock with
disbelief 3) Deni al 4) Emotional upset ANS: 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, the person 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. During a healthcare visit, he tells the nurse he has begun adjusting to life withouthis wife. According to John Bowlby, which stage of grief does this comment most likelyindicate? 1) Shock and numbness2) Yearning and searching 3) Disorganization and despair4) Reorganization ANS: 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 be reconnected withthe 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 Parkinsons disease2) The young adult with three small children whose wife died suddenly in anaccident 3) The middle-aged person whose spouse suffered a slow, painfuldeath 4) The older adult whose spouse died of complications of chronic renaldisease ANS: 2 Although it is impossible to predict with certainty and the grieving process is highly 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 the funeral and burial arrangements, andbegin 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 agoin a motor vehicle accident admits that he drinks at least six bourbon and waters every night before going to bed. Which type of grief does this best illustrate? 1) Delaye d 2) Chroni c 3) Disenfranchise d 4) Maske d ANS: 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. Delayed grief occurs when grief is put off until a later time. Chronic grief begins as normal grief but continues longterm with little resolution of feelings or ability to rejoin 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 bodily function must be lost to declare death? 1) Consciousne ss 2) Brain stem function 3) Cephalic reflexes 4) Spontaneous respirations ANS: 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 is best?
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 youare comfortable with. 3) You need to take care of yourself; go home and shower, and Ill stay at his bedside 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 healthcare provider but rather wanting to be present with her spouse at the time of death. PTS:1DIF:ModerateREF:dm 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 of activity may occur 1) Moments before death 2) Days to hours before death 3) 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 to maintain itself, and body systems begin to deteriorate. Near the time of death, the dying person does not respondto 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 day 3) Administering pain medication to keep the patientcomfortable 4) 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 and promote comfort is also important, but it does not take priority over administering pain medications. The patient may not be able to eat meals or get out of bed into the chair and may tolerate only small amounts at a meal. During the dying process, bowel activityreduces 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 beginsthe 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. Which response 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 self-directed decisions 2) Identifying the activities considered to be evidence of qualitycare 3) Verifying your understanding of the risks and benefits associated with a procedure 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 consentform verifies the patients understanding of risks and benefits associated with a procedure. An against medical advice form allows the patient to leave the hospital against medical advice and releases the hospital of responsibility for the patient. PTS:1DIF:ModerateREF:p. 364 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Comprehension 12. A patient with a history of chronic obstructive pulmonary disease has a living will that states he does not want endotracheal intubation and mechanical ventilation as a means of respiratory resuscitation. As the patients condition
deteriorates, the patient asks whether he can change his decision. Which response bythe 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 anytime. 3) Are you sure you want to change your decision? 4) We must follow whatever is written in your livingwill. ANS: 2 The nurse should inform the patient that he has the right to change his decision about 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 asneeded. Questioning the patients decision is judgmental. The patient has the right to changehis living will at any time. The medical team should not follow the living will if the patient changes his decision about what is in 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 activity 3) Ventricular fibrillation 4) Ventricular tachycardia ANS: 1 Asystole is a dysrhythmia that commonly serves as a confirmation of death. Pulseless electrical activity, ventricular fibrillation, and ventricular tachycardia arepotentially 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? 1) Deficient Knowledge 2) Spiritual Distress 3) Decisional Conflict 4)
Death Anxiety ANS: 3 This patient is experiencing Decisional Conflict related to his end-of-life treatment measures. Deficient Knowledge, Spiritual Distress, or Death Anxiety may be the etiology of his changing decisions, but his indecision about his treatment option clearlyidentifies his Decisional Conflict. PTS:1DIF:ModerateREF:dm 367-368; high-level question, not stated verbatim in text | V2, dm 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 a patient dying of cancer? 1) Encourage at least one family member to remain at the bedside at alltimes. 2) Follow-up with other healthcare team members during weekly meetings. 3) Avoid discussing the dying process with family (to reduce sadness). 4) 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 to take 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: dm 369-371 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 16. Which intervention by the nurse is most appropriate when she notices thather 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 the bed. 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 the respiratory 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 needed 2) Report or demonstrate satisfactory pain control 3) Use only nonpharmacological measures to controlpain 4) Verbalize understanding that it may not be possible to control hispain ANS: 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 anas 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 to control 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 after death. Why is the timing of the action so important? 1) To prevent blood from settling in the head, neck, and shoulders 2) To perform these actions more easily before rigor mortis develops3) To set the mouth in a natural position for viewing by thefamily 4) To prevent discoloration caused by blood settling in the facial area ANS: 2 Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should place dentures in the mouth and close the patients eyes and mouth before that time. The nurseshould 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 underthe chin and around the head keeps the mouth set in a natural position for a viewinglater. 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 patient dies? 1) Ask the family to leave the patients room so postmortem care can be performed. 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 patients death. She should give the family as much time as they need with their loved one and take care to present the body in a restful pose. If family members are not present at the timeof 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 cerebral aneurysm. What recommendation should the nurse make to the family regarding howto 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 toattend. Signs of regression are a normal reaction to the loss of a loved one, especially a parent. The child should be encouraged to express his feelings and 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 mouthfrequently. 4) Administer pain medication on an as-needed basis. ANS: 3 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 for the 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 within a short period of time,but he is still firmly in a state of emotional denial. The patient says to the nurse, Tell mywife 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 more days. 2) You seem very sure that you are not going to die. Please tell me more about what youare feeling. 3) It seems to me you would be feeling some anger and wondering why all this ishappening to you. 4) It would be best for your family if you were able to work through this and come toaccept the reality of your situation. ANS: 2 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 theirfeelings. Nurses need to understand patients, not change them. In this situation, denial may bevery important to this patient, as an emotional defense and coping strategy. You seem sure . . . tell me . . . what you are feeling restates what the patient has said (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. Forecastingthe 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, but not 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 has not yet expressed. This is not therapeutic. Saying It would be best for your family . . . presumesthat 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: dm 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 20 years. 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 cantsleep 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 plain as 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 her sister 2) Experiencing a depressive disorder rather than simply grieving the loss of her sister 3) Feeling guilt and worthlessness because her sister died and she is stillalive 4) Interpreting the holiday as a trigger event, which is causing her to hallucinate ANS: 2 The patient is likely experiencing a depressive disorder. Her symptoms include unrelieved, overwhelming sadness; insomnia; difficulty carrying out ADLs; fatigue; andvisual hallucinations. Note that her sadness is pervasive, not created by a trigger event (holiday). Of those symptoms, insomnia is common to both grief and depression, but the other symptoms are signs of depressive disorder. There is, of course, no correct timeline for what constitutes longer than usual 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. Chapter 43 Spiritual Health True/False Indicate whether the statement is true or false. 1. Religion provides people with instruction and guidance about what to believeand 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 accumulationof experiences and understanding, whereas religion provides general instruction and guidance on beliefs, values, and codes of conduct. PTS:1DIF:EasyREF:dm 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 theworld 2) Doctrines about the human soul and its relation to eternallife 3) A life-long journey involving accumulation of experience and understanding 4) Codes of conduct that integrate beliefs and values ANS: 1 Theology is best described as discussions and theories related to God and His relationto the world. Eschatology includes doctrines about the human soul and its 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 withinthe tradition of Christianity? 1) Buddhis m 2) Jehovahs Witnesses 3) Sikhis m 4) Islam ANS: 2 Jehovahs Witnesses is a religious denomination within Christianity. Buddhism, Sikhism, andIslam are all religious traditions outside of Christianity. PTS:1DIF:EasyREF:dm 342-343; ESG, 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 consumption4) Sacred writings that reveal the nature of the SupremeBeing 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 male nurse caring for her. Which intervention by the charge nurse is best? 1) Explain that hospital policy does not allow nursing assignments based on the genderof the nurse. 2) Explore with the patient her beliefs and determine which might have caused her to make this statement. 3) Assure the patient that each nurse is capable of providing professional nursing care, regardless of their gender. 4) Comply with the patients request and assign a female nurse to care for the patient. 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 preventdiscrimination issues, nursing assignments should not be made based on the gender of the patient or nurse. However, even if this is so, before explaining this to the patient, thecharge nurse should explore the patients beliefs and make special arrangements with hospital administration to uphold the patients beliefs, if possible. Telling the patient thateach 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 alienatethe nursing staff. PTS: 1 DIF: Moderate REF: dm 341-343, dm 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 heart failure on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orallyfor 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 delays treatment 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 theimportance 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 notify the hospital chaplain? 1) Anointing of the Sick 2) Baptis m 3) Euchari st 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, isused to gain forgiveness for past sins. The Eucharist, or communion, can be prepared and administered to a hospitalized patient, but it is not typically administered 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 most likely refuse a blood transfusion? One who is affiliated with 1) Isla
m 2) Bah ai 3) Hinduis m 4) 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 or its 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 caringfor a female Rastafarian patient? 1) Allow the patient to wear her own clothing. 2) Provide a diet that is caffeinefree. 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 in a small leather bag. These are worn for protection and strength and should not be removed. Hindus prefer washing with freeflowing water for bathing, which should be provided when possible. PTS: 1 DIF: Moderate REF: ESG, Religions: 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 spiritual careto a patient of the same religion as the nurse? 1) Understanding that the patient shares the same beliefs 2) Striving to meet the patients spiritual needs independently 3) Explaining her own religious beliefs to the patient 4) Developing a greater awareness of her own spirituality ANS: 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 who shares the same religious affiliation has the same beliefs. Moreover, the nurse should avoid trying tomeet 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? 1) Bathing water 2) Rosary beads 3) Mala beads 4) Prayer cloth ANS: 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:dm 342-343, 350-351; ESG,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 attorney 2) Next of kin 3) Patie nt 4) Patients clergyman ANS: 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:dm 346-347; high-level question, not answered verbatim
in 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 medicine 2) Western medicine 3) Chiropractic medicine 4) Qigon g ANS: 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 Westernmedicine, chiropractic medicine, or Qigong. Qigong, a form of Chinese martial arts, is used to achieve healing through focus on the bodys 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 thatI cant even pray. The patient refuses to see his clergyman when he calls. Which is the most appropriate nursing diagnosis for this patient? 1) Spiritual Distress 2) Risk for Spiritual Distress 3) Impaired Religiosity 4) Moral Distress ANS: 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 toexercise reliance on beliefs or to participate in rituals of a faith tradition (e.g., going tochurch). This patient is not unable to see the clergyman but chooses not to. Moral Distress occurs when a person makes a moral decision but is prevented from carrying out thechosen 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 does this actionimplement? 1) Spiritual Support 2) Self-Esteem Enhancement 3) Values Clarification 4) Hope Inspiration ANS: 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 nursefacilitates this by asking reflective, clarifying questions of the patient. Values clarification does not necessarily directly enhance self-esteem, inspire hope, or providespiritual support, although it can indirectly contribute to development of spiritual identity. 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 name ofJesus. 3) Avoid saying any name for the Supreme Being while praying and quote anOld Testament Bible scripture as the prayer. 4) Say, What name would you like for me to use to address the Supreme Being when 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 multiplegods, each of whom has several names. So seek direction from the patient in these matters: Most people are honored to be able to explain their beliefs 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, butthe most supportive way to 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 TestamentBible verse to be helpful spiritually.