Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Chapter 1: Using Evidence in Nursing Practice MULTIPLE CHOICE 1. Evidence-based practice is a problem-solving approach to making decisions about patient care
that is grounded in: A) the latest information found in textbooks. B) systematically conducted research studies. C) tradition in clinical practice. D) quality improvement and risk management data. ANS: B
The best evidence comes from well-designed, systematically conducted research studies described in scientific journals. Portions of a textbook often become outdated by the time it is published. Many health care settings do not have a process to help staff adopt new evidence in practice, and nurses in practice settings lack easy access to risk management data, relying instead on tradition or convenience. Some sources of evidence do not originate from research. These include quality improvement and risk management data; infection control data; retrospective or concurrent chart reviews; and clinicians’ expertise. Although non–research-based evidence is often very valuable, it is important that you learn to rely more on research-based evidence. DIF: Cognitive Level: Comprehension REF: Text reference: p. 2 OBJ: Discuss the benefits of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care)
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2. When evidence-based practice is used, patient care will be: A) standardized for all. B) unhampered by patient culture. C) variable according to the situation. D) safe from the hazards of critical thinking. ANS: C
Using your clinical expertise and considering patients’ cultures, values, and preferences ensures that you will apply available evidence in practice ethically and appropriately. Even when you use the best evidence available, application and outcomes will differ; as a nurse, you will develop critical thinking skills to determine whether evidence is relevant and appropriate. DIF: Cognitive Level: Application REF: Text reference: p. 2 OBJ: Discuss the benefits of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care) 3. When a PICOT question is developed, the letter that corresponds with the usual standard of
care is: A) P. B) I. PRIMEXAM.COM
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank C) C. D) O. ANS: C
C = Comparison of interest. What standard of care or current intervention do you usually use now in practice? P = Patient population of interest. Identify your patient by age, gender, ethnicity, disease, or health problem. I = Intervention of interest. What intervention (e.g., treatment, diagnostic test, prognostic factor) do you think is worthwhile to use in practice? O = Outcome. What result (e.g., change in patient’s behavior, physical finding, change in patient’s perception) do you wish to achieve or observe as the result of an intervention? DIF: Cognitive Level: Knowledge REF: Text reference: p. 3 OBJ: Develop a PICO question. TOP: PICO KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 4. A well-developed PICOT question helps the nurse: A) search for evidence. B) include all five elements of the sequence. C) find as many articles as possible in a literature search. D) accept standard clinical routines. ANS: A
The more focused a question that you ask is, the easier it is to search for evidence in the scientific literature. A well-designed PICOT question does not have to include all five elements, nor does it have to follow the PICOT sequence. Do not be satisfied with clinical routines. Always question anN dU usR eS crI itic al T thB in.kC ing to consider better ways to provide patient NG OM care. DIF: Cognitive Level: Analysis REF: Text reference: p. 4 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 5. The nurse is not sure that the procedure the patient requires is the best possible for the
situation. Utilizing which of the following resources would be the quickest way to review research on the topic? A) CINAHL B) PubMed C) MEDLINE D) The Cochrane Library ANS: D
The Cochrane Library Database of Systematic Reviews is a valuable source of synthesized evidence (i.e., preappraised evidence). The Cochrane Database includes the full text of regularly updated systematic reviews and protocols for reviews currently happening. MEDLINE, CINAHL, and PubMed are among the most comprehensive databases and represent the scientific knowledge base of health care. DIF: Cognitive Level: Synthesis REF: Text reference: p. 4 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 6. The nurse is getting ready to develop a plan of care for a patient who has a specific need. The
best source for developing this plan of care would probably be: A) The Cochrane Library. B) MEDLINE. C) NGC. D) CINAHL. ANS: C
The National Guidelines Clearinghouse (NGC) is a database supported by the Agency for Healthcare Research and Quality (AHRQ). It contains clinical guidelines—systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific patient population. The NGC is a valuable source when you want to develop a plan of care for a patient. The Cochrane Library Database of Systematic Reviews, MEDLINE, and CINAHL are all valuable sources of synthesized evidence (i.e., preappraised evidence). DIF: Cognitive Level: Synthesis REF: Text reference: p. 4 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 7. The nurse has done a literature search and found 25 possible articles on the topic that she is
studying. To determine which of those 25 best fit her inquiry, the nurse first should look at: A) the abstracts. B) literature reviews. C) the “Methods” sections. NURSINGTB.COM D) the narrative sections. ANS: A
An abstract is a brief summary of an article that quickly tells you whether the article is research based or clinically based. An abstract summarizes the purpose of the study or clinical query, the major themes or findings, and the implications for nursing practice. The literature review usually gives you a good idea of how past research led to the researcher’s question. The “Methods” or “Design” section explains how a research study is organized and conducted to answer the research question or to test the hypothesis. The narrative of a manuscript differs according to the type of evidence-based article—clinical or research. DIF: Cognitive Level: Application REF: Text reference: p. 7 OBJ: Discuss elements to review when critiquing the scientific literature. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 8. The nurse wants to determine the effects of cardiac rehabilitation program attendance on the
level of postmyocardial depression for individuals who have had a myocardial infarction. The type of study that would best capture this information would be a: A) randomized controlled trial. B) qualitative study. C) case control study. D) descriptive study.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: B
Qualitative studies examine individuals’ experiences with health problems and the contexts in which these experiences occur. A qualitative study is best in this case of an individual nurse who wants to examine the effectiveness of a local program. Randomized controlled trials involve close monitoring of control groups and treatment groups to test an intervention against the usual standard of care. Case control studies typically compare one group of subjects with a certain condition against another group without the condition, to look for associations between the condition and predictor variables. Descriptive studies focus mainly on describing the concepts under study. DIF: Cognitive Level: Synthesis REF: Text reference: p. 5 OBJ: Discuss ways to apply evidence in nursing practice. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 9. Six months after an early mobility protocol was implemented, the incidence of deep vein
thrombosis in patients was decreased. This is an example of what stage in the EBP process? A) Asking a clinical question B) Applying the evidence C) Evaluating the practice decision D) Communicating your results ANS: C
After implementing a practice change, your next step is to evaluate the effect. You do this by analyzing the outcomes data that you collected during the pilot project. Outcomes evaluation tells you whether your practice change improved conditions, created no change, or worsened conditions.
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DIF: Cognitive Level: Application REF: Text reference: p. 8 OBJ: Discuss ways to apply evidence in nursing practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment (safety and infection control) MULTIPLE RESPONSE 1. To use evidence-based practice appropriately, you need to collect the most relevant and best
evidence and to critically appraise the evidence you gather. This process also includes: (Select all that apply.) A) asking a clinical question. B) applying the evidence. C) evaluating the practice decision. D) communicating your results. ANS: A, B, C, D
EBP comprises six steps (Melnyk and Fineout-Overholt, 2010): 1. Ask a clinical question. 2. Search for the most relevant and best evidence that applies to the question. 3. Critically appraise the evidence you gather. 4. Apply or integrate evidence along with one’s clinical expertise and patient preferences and values in making a practice decision or change. 5. Evaluate the practice decision or change.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. Communicate your results. DIF: Cognitive Level: Analysis REF: Text reference: p. 2 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 2. In a clinical environment, evidence-based practice has the ability to improve: (Select all that
apply.) A) the quality of care provided. B) patient outcomes. C) clinician satisfaction. D) patients’ perceptions. ANS: A, B, C, D
EBP has the potential to improve the quality of care that nurses provide, patient outcomes, and clinicians’ satisfaction with their practice. Your patients expect nursing professionals to be informed and to use the safest and most appropriate interventions. Use of evidence enhances nursing, thereby improving patients’ perceptions of excellent nursing care. DIF: Cognitive Level: Application REF: Text reference: p. 9 OBJ: Discuss the benefits of evidence-based practice. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 3. During the application stage of evidence-based practice change, it is important to consider:
(Select all that apply.) A) cost. NURSINGTB.COM B) the need for new equipment. C) management support. D) adequate staff. ANS: A, B, C, D
One important step for an individual or an interdisciplinary EBP committee is to consider the resources needed for a practice change project. Are added costs or new equipment involved with a practice change? Do you have adequate staff to make the practice change work as planned? Do management and medical staff support you in the change? If the barriers to practice change are excessive, adopting a practice change can be difficult, if not impossible. DIF: Cognitive Level: Application REF: Text reference: p. 8 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) COMPLETION
is a guide for making accurate, timely, and appropriate clinical
1.
decisions. ANS:
Evidence-based practice
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Evidence-based practice is a guide for making accurate, timely, and appropriate clinical decisions. DIF: Cognitive Level: Knowledge REF: Text reference: p. 2 OBJ: Define the key terms listed. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care) 2. Evidence-based practice requires good
.
ANS:
nursing judgment Evidence-based practice requires good nursing judgment; it does not consist of finding research evidence and blindly applying it. DIF: Cognitive Level: Comprehension REF: Text reference: p. 2 OBJ: Discuss the benefits of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care) 3. While caring for patients, the professional nurse must question
.
ANS:
what does not make sense Always think about your practice when caring for patients. Question what does not make sense to you, and question what you think needs clarification. DIF: Cognitive Level: AnalysN isURSINGRE F:.C Text p. 2 TB OMreference: TOP: OBJ: Describe the six steps of evidence-based practice. Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 4. A systematic review explains whether the evidence that you are searching for exists and
whether there is good cause to change practice. In , all entries include information on systematic reviews. Individual randomized controlled trials (RCTs) are the gold standard for research. ANS:
The Cochrane Library A systematic review explains whether the evidence that you are searching for exists and whether there is good cause to change practice. In The Cochrane Library, all entries include information on systematic reviews. Individual randomized controlled trials (RCTs) are the gold standard for research. DIF: Cognitive Level: Analysis REF: Text reference: pp. 4-6 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
are the gold standard for research.
5. ANS:
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Randomized controlled trials Individual randomized controlled trials (RCTs) are the gold standard for research (Titler and others, 2001). An RCT establishes cause and effect and is excellent for testing therapies. DIF: Cognitive Level: Knowledge REF: Text reference: p. 6 OBJ: Explain the levels of evidence in the literature. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 6. The researcher explains how to apply findings in a practice setting for the types of subjects
studied in the
section of a research article.
ANS:
“Clinical Implications” Clinical Implications A research article includes a section that explains whether the findings from the study have “clinical implications.” The researcher explains how to apply findings in a practice setting for the types of subjects studied. DIF: Cognitive Level: Application REF: Text reference: p. 7 OBJ: Discuss elements to review when critiquing the scientific literature. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 7.
is the extent to which a study’s findings are valid, reliable, and relevant to your patient population of interest. ANS:
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Scientific rigor Scientific rigor is the extent to which a study’s findings are valid, reliable, and relevant to your patient population of interest. DIF: Cognitive Level: Application REF: Text reference: p. 7 OBJ: Define the key terms listed. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 8. Patient fall rates are an example of a
type of study in the evidence
hierarchy. ANS:
quality improvement data Data collected within a health care agency offer important trending information about clinical conditions and problems. Staff in the agency review the data periodically to identify problem areas and to seek solutions. DIF: Cognitive Level: Application REF: Text reference: p. 5 OBJ: Define the key terms listed. TOP: Quality Improvement KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 2: Admitting, Transfer, and Discharge MULTIPLE CHOICE 1. The patient is scheduled to go home after having coronary angioplasty. What would be the
most effective way to provide discharge teaching to this patient? A) Provide him with information on health care websites. B) Provide him with written information on what he has to do. C) Sit and carefully explain what is required before his follow-up. D) Use a combination of verbal and written information. ANS: D
For discharge teaching, use a combination of verbal and written information. This most effectively provides patients with standardized care information, which has been shown to improve patient knowledge and satisfaction. DIF: Cognitive Level: Application REF: Text reference: p. 12 OBJ: Identify the ongoing needs of patients in the process of discharge planning. TOP: Admission to Discharge Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. While preparing for the patient’s discharge, the nurse uses a discharge planning checklist and
notes that the patient is concerned about going home because she has to depend on her family for care. The nurse realizes that successful recovery at home is often based on: A) the patient’s willingness to go home. B) the family’s perceived ability to care for the patient. C) the patient’s ability to livN eU alR onSeI . NGTB.COM D) allowing the patient to make her own arrangements. ANS: B
Discharge from an agency is stressful for a patient and family. Before a patient is discharged, the patient and family need to know how to manage care in the home and what to expect with regard to any continuing physical problems. Family caregiving is a highly stressful experience. Family members who are not properly prepared for caregiving are frequently overwhelmed by patient needs, which can lead to unnecessary hospital readmissions. DIF: Cognitive Level: Analysis REF: Text reference: p. 22 OBJ: Identify the ongoing needs of patients in the process of discharge planning. TOP: Medication Reconciliation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 3. The patient arrives in the emergency department complaining of severe abdominal pain and
vomiting, and is severely dehydrated. The physician orders IV fluids for the dehydration and an IV antiemetic for the patient. However, the patient states that she is fearful of needles and adamantly refuses to have an IV started. The nurse explains the importance of and rationale for the ordered treatment, but the patient continues to refuse. What should the nurse do? A) Summon the nurse technician to hold the arm down while the IV is inserted. B) Use a numbing medication before inserting the IV. C) Document the patient’s refusal and notify the physician. D) Tell the patient that she will be discharged without care unless she complies.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: C
The Patient Self-Determination Act, effective December 1, 1991, requires all Medicare- and Medicaid-recipient hospitals to provide patients with information about their right to accept or reject medical treatment. The patient has the right to refuse treatment. Refusal should be documented and the health care provider consulted about alternate treatment. DIF: Cognitive Level: Application REF: Text reference: p. 13 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Patient Self-Determination Act KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 4. An unconscious patient is admitted through the emergency department. How and when is
identification of the patient made? A) Determined only when the patient is able B) Postponed until family members arrive C) Given an anonymous name under the “blackout” procedure D) Determined before treatment is started ANS: B
If a patient is unconscious, identification often is not made until family members arrive. Delaying treatment can cause deterioration of the patient’s condition. Blackout procedures are intended mainly to protect crime victims. DIF: Cognitive Level: Application REF: Text reference: p. 12 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: The Unconscious Patient KEY: Nursing Process Step: Im ple men tatio n NURSI NG TB.C OM MSC: NCLEX: Physiological Integrity 5. During admission of a patient, the nurse notes that the patient speaks another language and
may have difficulty understanding English. What should the nurse do to facilitate communication? A) Use hand gestures to explain. B) Request and wait for an interpreter. C) Work with the family to gather information. D) Complete as much of the admission assessment as possible using simple phrases. ANS: B
If the patient does not speak English or has a severe hearing impairment, the clerk must have access to an interpreter to assist during the admission procedure. Translation services are preferable to using family members to ensure correct translation of medical terminology. Hand gestures and simple phrases may not be adequate for everything that will be discussed at the time of admission. DIF: Cognitive Level: Application REF: Text reference: p. 15 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: The Patient Who Does Not Speak English KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. The patient has been admitted to the emergency department after being beaten and raped. She
is agitated and is frightened that her attacker may find her in the hospital and try to kill her. What should the nurse tell her? A) She is safe in the hospital, and she needs to provide her name. B) She can be admitted to the hospital without anyone knowing it. C) Her records will be used as evidence in the trial. D) Since she has come to the hospital, she has to be examined by the doctor. ANS: B
A patient who has been a victim of crime can be admitted anonymously under an agency’s “blackout” or “do not publish” procedure. HIPAA places limits on the institution’s ability to use or disclose the patient’s PHI. The Patient Self-Determination Act prohibits the hospital from requiring her to submit to an examination. DIF: Cognitive Level: Analysis REF: Text reference: pp. 13-14 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Victim of Crime KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. The patient is admitted to the ICU after having been in a motor vehicle accident. He was
intubated in the emergency department and needs to receive two units of packed red blood cells. He is conscious but is indicating that he is in pain by guarding his abdomen. To admit this patient, the nurse first will focus on: A) examining the patient and treating the pain. B) orienting the family to the ICU visitation policy. C) making sure that the consent forms are signed.
RIS IANG D) informing the patient of hNisUH PA riT ghB ts. . COM ANS: A
When a critically ill patient reaches a hospital’s nursing division, the patient immediately undergoes extensive examination and treatment procedures. Little time is available for the nurse to orient the patient and family to the division, or to learn of their fears or concerns. DIF: Cognitive Level: Analysis REF: Text reference: p. 15 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Role of the Nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is admitting the patient to the medical unit. The patient indicates that he has had
several surgeries in the past and has been a diabetic for the past 15 years. He also earlier that morning, but the pain has finally gone since he received a “pain shot” in the emergency department. What does this information prompt the nurse to do next? A) Provide the patient with an allergy arm band and document his allergies. B) Postpone routine admission procedures immediately. C) Ask the patient if he wants a smoking room. D) Have all family or friends leave the room. ANS: A
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Provide the patient with an allergy armband listing allergies to foods, drugs, latex, or other substances; document allergies according to hospital policy. Postpone routine admission procedures only if the patient is having acute physical problems. Smoking is prohibited throughout the hospital, and family or friends can remain if the patient wishes to have them assist with changing into a hospital gown or pajamas. DIF: Cognitive Level: Analysis REF: Text reference: p. 16 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Allergies KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. At what age is separation anxiety a common problem? A) School-aged children B) Preschoolers C) Middle infancy D) Newborns ANS: C
Separation anxiety is most common from middle infancy throughout the toddler years, especially from ages 16 to 30 months. Preschoolers are better able to tolerate brief periods of separation, but their protest behaviors are more subtle than those of younger children (e.g., refusal to eat, difficulty sleeping, withdrawing from others). School-aged children are able to cope with separation but have an increased need for parental security and guidance. DIF: Cognitive Level: Synthesis REF: Text reference: p. 18 OBJ: Explain the role of the patient’s family in the admission, transfer, or discharge process. TOP: Pediatric ConsiderationsNURSINGKE Y. : C NuOrsM ing Process Step: Assessment TB MSC: NCLEX: Psychosocial Integrity 10. The patient is being transferred from the emergency department to another institution for
treatment. Which of the following cannot be delegated to nursing assistive personnel (NAP)? A) Helping the patient get dressed B) Gathering IV equipment to go with the patient C) Escorting the patient to the transport area D) Assessing the patient’s respiratory status before transport ANS: D
The assessment and decision making conducted during transfers cannot be delegated to nursing assistive personnel. NAP can assist the patient with dressing, can gather and secure the patient’s personal belongings and any necessary equipment, and can escort the patient to the nursing unit or transport area. DIF: Cognitive Level: Application REF: Text reference: p. 19 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 11. When does the plan for patient discharge from a health care facility begin? A) At admission B) After a medical diagnosis has been determined
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank C) When the patient’s physical needs are identified D) After a home environment assessment is completed ANS: A
Planning for discharge begins at admission and continues throughout the patient’s stay in the agency. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous. DIF: Cognitive Level: Comprehension REF: Text reference: p. 22 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. The phase of the discharge process where medical attention dominates discharge planning
efforts is known as the A) transitional B) continuing C) acute D) multidisciplinary
phase.
ANS: C
The discharge process occurs in three phases: acute, transitional, and continuing care. In the acute phase, medical attention dominates discharge planning efforts. During the transitional phase, the need for acute care is still present, but its urgency declines and patients begin to address and plan for their future health care needs. In the continuing care phase, patients participate in planning and implementing continuing care activities needed after discharge. There is no multidisciplinaryNstagRe; tI ha. rgCe plM U S heNdGisc TB O anning process is comprehensive and multidisciplinary. DIF: Cognitive Level: Comprehension REF: Text reference: p. 22 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. Once a patient’s discharge has been completed, which activity may be delegated to assistive
personnel? A) Provision of prescriptions to the patient B) Completion of the discharge summary C) Gathering of the patient’s personal care items D) Provision of instructions on community health resources ANS: C
The assessment, care planning, and instruction included in discharging patients cannot be delegated to nursing assistive personnel. The nurse may direct the NAP to gather and secure the patient’s personal items and any supplies that accompany the patient. DIF: Cognitive Level: Application REF: Text reference: p. 22 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Safe and Effective Care Environment 14. The nurse is providing discharge instruction to an 80-year-old patient and her daughter. The
patient lives in a two-story home. When asked if the patient has difficulty climbing stairs, the patient says “No,” but the nurse notices a look of surprise on the daughter’s face. What should the nurse do in this circumstance? A) Speak with the daughter separately. B) Cancel the discharge immediately. C) Order a visiting nurse consult. D) Notify the physician. ANS: A
Patients and family members often disagree on the health care needs of a patient after discharge. Identifying these discrepancies early leads to more accurate development of the discharge plan. It often is necessary to talk with the patient and family separately to learn about their true concerns or doubts. DIF: Cognitive Level: Application REF: Text reference: p. 23 OBJ: Explain the role of the patient’s family in the admission, transfer, or discharge process. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 15. The patient has decided that he would like to create an advance directive. The nurse is asked if
she would be a witness. What is the best response for the nurse to make to this request? A) Agree to be a witness. B) Refuse to be a witness. C) Contact social work. D) Contact the physician. NURSINGTB.COM ANS: C
A social worker often fulfills this requirement. Witnesses for an advance directive document should not be medical personnel, and direct refusal does not meet the nurse’s obligation to meet the patient’s needs. Referral to a department that can ensure this service is required. DIF: Cognitive Level: Application REF: Text reference: p. 14 OBJ: Explain the purpose and importance of advance directives. TOP: Advance Directives KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The patient is being admitted to the intensive care department with multiple fractures and
internal bleeding. Which of the following are considered roles of the nurse in this situation? (Select all that apply.) A) Anticipate physical and social deficits to resuming normal activities. B) Involve the family and significant others in the plan of care. C) Assist in making health care resources available to the patient. D) Identify the psychological needs of the patient. ANS: A, B, C, D
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The nurse identifies patients’ ongoing health care needs; anticipates physical, psychological, and social deficits that have implications for resuming normal activities; involves family and significant others in a plan of care; provides health education; and assists in making health care resources available to the patient. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous. DIF: Cognitive Level: Application REF: Text reference: p. 11 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Admission to Discharge Process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 2. Under the Health Insurance Portability and Accountability Act (HIPAA), a patient must:
(Select all that apply.) A) provide his true name before he can be treated. B) be informed of his privacy rights. C) have his personal health information used for treatment or payment only. D) have his personal health information used on a need-to-know basis only. ANS: B, C, D
HIPAA is a federal law designed to protect the privacy of patient health information, referred to as PHI, or protected health information. Three key concepts of HIPAA are (1) institutions are required to inform patients of the privacy rights they have and how the institution will handle their PHI; (2) the institution and health care providers are to use or disclose the patient’s PHI only for the purpose of treatment or payment or for health care operations; and (3) health care providers disclose only the minimum amount of PHI necessary on a need-to-know basis to accomplish the purpose of the use.
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DIF: Cognitive Level: Knowledge REF: Text reference: pp. 13-14 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: HIPAA KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 3. The patient is admitted to the unit for a cardiac catheterization. Which of the following can be
delegated to nursing assistive personnel (NAP)? (Select all that apply.) A) Obtaining admission vital signs B) Preparing the patient’s room C) Gathering and securing personal care items D) Orienting patient and family to the nursing unit ANS: B, C, D
The nursing assessment conducted during admission to a health care facility cannot be delegated to NAP. You cannot delegate admission vital signs as they provide a baseline for all further comparisons. The nurse directs NAP to (1) prepare the patient’s room with necessary equipment before admission; (2) gather and secure the patient’s personal care items; (3) escort and orient the patient and family to the nursing unit; and (4) collect ordered specimens. DIF: Cognitive Level: Analysis REF: Text reference: p. 15 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Delegation Considerations KEY: Nursing Process Step: Implementation
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Safe and Effective Care Environment 4. Which of the following are considered “advance directives”? (Select all that apply.) A) Living will B) Power of attorney for health care C) Notarized handwritten document D) Nursing progress note ANS: A, B, C
Advance directives may include a living will, power of attorney for health care, or a notarized handwritten document. DIF: Cognitive Level: Analysis REF: Text reference: p. 14 OBJ: Explain the purpose and importance of advance directives. TOP: Advance Directives KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. The patient is being transferred from the intensive care unit to the acute care unit. The nurse
must ensure that the following activities are completed: (Select all that apply.) A) providing the receiving nurse with a report before the transfer. B) determining any equipment needs for the patient during the transfer. C) providing an updated report after transferring the patient to the receiving unit. D) making sure a registered nurse accompanies the patient. ANS: A, B, C
When providing a “handoff” of a patient to another unit, it is essential that information about the patient’s care, treatment, services, and current condition and any recent or anticipated changes are communicated aN ccurR atelI y toGmeB et.pC atieM nt safety goals. The nurse first provides a U nurse. S NThis T allows O the receiving nurse to prepare for the telephone report to the receiving patient (e.g., preparing the room, securing necessary equipment). As clinically appropriate, a nurse or technician accompanies the patient during transport, providing the receiving nurse with the patient’s medical record; introducing the patient to the receiving nurse; and providing an updated report, including any changes in clinical status or plan of care. DIF: Cognitive Level: Application REF: Text reference: p. 19 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Continuum of Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment COMPLETION 1. Completing and documenting an accurate medication history from the patient is the important
first step in the
process.
ANS:
medication reconciliation Medication reconciliation compares the patient’s home medication list versus the medication orders at admission, transfer, or discharge to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Knowledge REF: Text reference: p. 17 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Medication Reconciliation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 2. If a patient is having acute physical problems, postpone routine admission procedures until the
patient’s immediate needs are met. A
assessment is needed at this point.
ANS:
focused If a patient is having acute physical problems, postpone routine admission procedures until you meet the patient’s immediate needs. Complete a focused assessment at this point. DIF: Cognitive Level: Analysis REF: Text reference: p. 15 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Admission Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. When transferring a patient, the nurse must ensure that the patient will receive ANS:
continuity of nursing care When patients transfer, you need to ensure continuity of nursing care. The aim is to continue health care so as to avoid therapeutic interruptions that may hinder progress toward recovery. DIF: Cognitive Level: Synthesis REF: Text reference: p. 19 OBJ: Describe the nurse’s roleNin m ain tain ing co. ntC inuiM ty of care through a patient’s admission, I G TB UR S transfer, and discharge from an acute careN facility. O TOP: Continuity of Care KEY: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment 4. The greatest challenge in effective discharge planning is
.
ANS:
communication The greatest challenge in effective discharge planning is communication. The communication problem is minimized when an organization has a discharge coordinator or a case manager who is responsible for discharge planning. DIF: Cognitive Level: Comprehension REF: Text reference: p. 22 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. A document that provides a patient’s instructions in terms of future medical care or that
designates another person(s) to make medical decisions if the individual loses decision-making capacity is known as an . ANS:
advance directive
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.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank An advance directive is a document that provides a patient’s instructions about future medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity. An advance directive conveys the patient’s choice in continuing medical care when the patient is unable to speak or make decisions. DIF: Cognitive Level: Knowledge REF: Text reference: p. 14 OBJ: Explain the purpose and importance of advance directives. TOP: Advance Directives KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
NURSINGTB.COM
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 3: Communication MULTIPLE CHOICE 1. The patient is a 54-year-old man who has made a living as a construction worker. He dropped
out of high school at age 16 and has been a laborer ever since. He never saw any need for “book learning,” and has lived his life “my way” since he was a teenager. He has smoked a pack of cigarettes a day for 40 years and follows no special diet, eating a lot of “fast food” while on the job. He now is admitted to the coronary care unit for complaints of chest pain and is scheduled for a cardiac catheterization in the morning. Which of the following would be the best way for the nurse to explain why he needs the procedure? a. “The doctor believes that you have atherosclerotic plaques occluding the major arteries in your heart, causing ischemia and possible necrosis of heart tissue.” b. “There may be a blockage of one of the arteries in your heart, causing the chest discomfort. He needs to know where it is to see how he can treat it.” c. “We have pamphlets here that can explain everything. Let me get you one.” d. “It’s just like a clogged pipe. All the doctor has to do is ‘Roto-Rooter’ it to get it cleaned out.” ANS: B
To send an accurate message, the sender of verbal communication must be aware of different developmental perspectives as well as cultural differences between sender and receiver, such as the use of dialect or slang. DIF: Cognitive Level: Application REF: Text reference: p. 28 OBJ: Explain the communication process. TOP: Verbal Communication N R I G B.C M O KEY: Nursing Process Step: ImpU lemS entaN tionT MSC: NCLEX: Psychosocial Integrity 2. The nurse is assessing a patient who says that she is feeling fine. The patient, however, is
wringing her hands and is teary eyed. The nurse should respond to the patient in which of the following ways? a. “You seem anxious today. Is there anything on your mind?” b. “I’m glad you’re feeling better. I’ll be back later to help you with your bath.” c. “I can see you’re upset. Let me get you some tissue.” d. “It looks to me like you’re in pain. I’ll get you some medication.” ANS: A
When assessing a patient’s needs, assess both the verbal and the nonverbal messages and validate them. In this case, if you see a patient wringing her hands and sighing, it is appropriate to ask, “You seem anxious today. Is there anything on your mind?” It is not enough to accept only the verbal message if nonverbal signals conflict, and it is inappropriate to jump to conclusions about what the nonverbal signals mean. DIF: Cognitive Level: Application REF: Text reference: pp. 36-37 OBJ: Explain the communication process. TOP: Nonverbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. Nonverbal communication incorporates messages conveyed by:
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
touch. cadence. tone quality. use of jargon.
ANS: A
Nonverbal communication describes all behaviors that convey messages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch. Cadence, tone quality, and the use of jargon are all part of verbal communication. DIF: Cognitive Level: Knowledge REF: Text reference: p. 28 OBJ: Explain the communication process. TOP: Nonverbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. The patient is an elderly male who had hip surgery 3 days ago. He states that his hip hurts, but
he does not like how the medicine makes him feel. He believes that he can tolerate the pain better than he can tolerate the medication. What would be the best response from the nurse? a. Explain the need for the pain medication using a slower rate of speech. b. Explain the need for the pain medication using a simpler vocabulary. c. Explain the need for the pain medication, but ask the patient if he would like the doctor called and the medication changed. d. Explain in a loud manner the need for the pain medication. ANS: C
Suggesting, which is presenting alternative ideas for patient consideration relative to problem solving, can be effective in hN elpi ngStI heNpGatie UR TBnt.mCain OMtain control by increasing the patient’s perceived options or choices. Nurses often use elder-speak, which includes a slower rate of speech, greater repetition, and simpler grammar than normal adult speech, when caring for older adults. However, many older patients perceive this type of communication as patronizing. DIF: Cognitive Level: Application REF: Text reference: p. 31 OBJ: Identify the purpose of therapeutic communication, communication in various phases of the nurse-patient relationship, and special issues related to communication. TOP: Communication with the Elderly KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. When comparing therapeutic communication versus social communication, the professional
nurse realizes that therapeutic communication: a. allows equal opportunity for personal disclosure. b. allows both participants to have personal needs met. c. is goal directed and patient centered. d. provides an opportunity to compare intimate details. ANS: C
Therapeutic communication empowers patients to make decisions but differs from social communication in that it is patient centered and goal directed with limited disclosure from the professional. Social communication involves equal opportunity for personal disclosure, and both participants seek to have personal needs met. Nurses do not share with patients intimate details of their personal lives.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 30 OBJ: Develop skills for therapeutic communication in various phases of the nurse-patient relationship. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. The nurse is explaining a procedure to a 2-year-old child. Which is the best approach to use? a. Showing the needles and bandages in advance b. Telling the patient exactly what discomfort to expect c. Using dolls and stories to demonstrate what will be done d. Asking the child to draw pictures of what he or she thinks will happen ANS: C
Some age-appropriate communication techniques for a 2-year-old child include storytelling and drawing. Showing the child needles or telling the child about discomfort would increase anxiety. Having a child draw what he expects does not explain what is going to happen. DIF: Cognitive Level: Application REF: Text reference: p. 36 OBJ: Develop skills for therapeutic communication in various phases of the nurse-patient relationship. TOP: Establishing the Nurse-Patient Relationship—Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. The nurse is about to go over the patient’s preoperative teaching per hospital protocol. She
finds the patient sitting in bed wringing her hands, which are sweaty, and acting slightly agitated. The patient states, “I’m scared that something will go wrong tomorrow.” How should the nurse respond? NURSINGTB.COM a. Redirect her focus to dealing with the patient’s anxiety. b. Tell the patient that everything will be all right and continue teaching. c. Tell the patient that she will return later to do the teaching. d. Give the patient antianxiety medication. ANS: A
Anxiety interferes with comprehension, attention, and problem-solving abilities and thus interferes with the patient’s care and treatment. To ensure the effectiveness of treatment, the nurse should try to help the patient understand the source of the anxiety. Ignoring the anxiety, medicating for it, and postponing the discussion are all inappropriate. DIF: Cognitive Level: Application REF: Text reference: p. 36 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 8. The nurse is attempting to teach the patient and his family about his care after discharge. The
patient and the family demonstrate signs of anxiety during the teaching session. The nurse should consider doing what? a. Using more gestures or pictures b. Focusing on the physical complaints c. Getting another staff member to speak to the patient d. Repeating information to the patient and the family at a later time
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: D
Remember that patients and their family members who are under stress often require repeated explanations. Increasing gestures and pictures is additional stimulation that may increase anxiety. Physical complaints should be acknowledged, but dwelling on them can also increase the patient’s anxiety. Involving another staff member would cause a break in the continuity of care. DIF: Cognitive Level: Application REF: Text reference: p. 38 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 9. The patient is an elderly man who was brought to the hospital from an assisted-living
community with complaints of anorexia and general malaise. The nurse at the assisted-living community reported that the patient was very ritualistic in his behavior and fastidious in his dress and always took a shower in the evening before bed. The patient became very angry and upset when the patient care technician asked him to take his bath in the morning. What does this behavior tell the nurse? a. The patient is exhibiting anxiety because of a change in his rituals. b. The patient is suffering from sensory overstimulation. c. The patient is basically an angry person. d. The patient has to follow hospital protocol. ANS: A
Patients often become ritualistic and intent on performing activities a certain way. Anxiety develops as a result of a specN ificR eveI nt oG r a gBe. neCral M pattern of change.
U S N T
O
DIF: Cognitive Level: Analysis REF: Text reference: p. 38 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Gerontological Considerations—Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 10. The nurse is preparing to give an intramuscular injection to the patient in room 320. The
patient care technician comes to the medication room and tells the nurse that the patient in room 316 is very angry with his roommate and is threatening to hit him. How should the nurse respond? a. Tell the patient care technician to calm the patient down until she can get there. b. Have the angry patient’s roommate moved to another location. c. Tell the angry patient to calm down until she can get there. d. Tell the angry patient that he has to act civilized in the hospital, and that’s that. ANS: B
A potentially violent patient needs to be in an environment with decreased stimuli and to have protection from injury to self and against others. Encourage other people, particularly those who provoke anger, to leave the room or area. De-escalation is a skill that cannot be delegated to nursing assistive personnel (NAP). DIF: Cognitive Level: Application REF: Text reference: pp. 39-40 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Communicating With the Angry Patient
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 11. Which behavior should the nurse who is communicating with a potentially violent patient
employ? a. Sit closer to the patient. b. Speak loudly and firmly. c. Use slow, deliberate gestures. d. Always block the door to prevent escape. ANS: C
Make sure that gestures are slow and deliberate rather than sudden and abrupt. There is less chance for misinterpretation of the message, and slow, deliberate gestures are less threatening. Keep an adequate distance between yourself and the patient to reduce your risk of injury and to avoid making the patient feel pressured. Try to talk in a comfortable, reassuring voice. Position yourself closest to the door to facilitate escape from a potentially violent situation. Do not block the exit; if the patient feels unable to escape, this may cause a violent outburst. DIF: Cognitive Level: Application REF: Text reference: p. 40 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Communicating With the Angry Patient KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 12. The patient is sitting at the bedside. He has not been eating and is just staring out of the
window. The nurse approaches the patient and asks, “What are you thinking about?” What type of communication technique is this? a. Restating NURSINGTB.COM b. Clarification c. Broad openings d. Reflection ANS: C
Broad openings encourage patients to select topics for discussion. They affirm the value of the patient’s initiative. Restating is repeating a main thought that the patient has expressed. Clarification is attempting to put into words vague ideas or asking the patient to explain what he or she means. Reflection is directing back to the patient ideas, feelings, questions, or content. DIF: Cognitive Level: Knowledge REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 13. A patient tells the nurse, “I want to die.” Which response is the most appropriate for the nurse
to make? a. “Why would you say that?” b. “Tell me more about how you are feeling.” c. “The doctor should be told how you feel.” d. “You have too much to live for to think that way.” ANS: B
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Broad openings encourage the patient to select topics for discussion and indicate acceptance by the nurse and the value of the patient’s initiative. “Why” questions can cause defensiveness and can hinder communication. Saying you will inform the doctor leads the conversation away from the patient’s feelings. Saying the patient has too much to live for is false reassurance and negates the patient’s feelings. DIF: Cognitive Level: Application REF: Text reference: p. 31 |Text reference: p. 42 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 14. The patient states, “I don’t know what my family will think about this.” The nurse wishes to
use the communication technique of clarification. Which of the following statements would fit that need best? a. “You don’t know what your family will think?” b. “I’m not sure that I understand what you mean.” c. “I think it would be helpful if we talk more about your family.” d. “I sense that you may be anxious about something.” ANS: B
The definition of clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding, or asking the patient to explain what he or she means. Repeating main thoughts expressed by patients is known as “restating.” Using questions or statements that help patients expand on a topic of importance is known as “focusing.” Asking a patient to verify the nurse’s understanding of what the patient is thinking or feeling is known as “sharing perceptions.” DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 15. A patient tells the nurse, “I think that I must be really sick. All of these tests are being done.”
Which response by the nurse uses the specific communication technique of reflection? a. “I sense that you are worried.” b. “I think that we should talk about this more.” c. “You think that you must be very sick because of all the tests.” d. “I’ve noticed that this is an underlying issue whenever we talk.” ANS: C
Reflecting is directing back to the patient ideas, feelings, questions, or content, validating the nurse’s understanding of what the patient is saying, and signifying empathy, interest, and respect for the patient. Asking the patient to confirm your sense of his or her anxiety is “sharing perceptions.” Stating that “we should talk about this more,” that is, putting forth questions or statements to expand on a topic, is “focusing.” Pointing out underlying issues or problems that occur repeatedly is known as “theme identification.” DIF: Cognitive Level: Application REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 16. The patient is admitted to the hospital with complaints of headache, nausea, and dizziness.
She states that she has a final exam in the morning and needs to do well on it to pass the course, but she can’t seem to get into it. She appears nervous and distracted, and is unable to recall details. She most likely is showing manifestations of anxiety. a. mild b. moderate c. severe d. panic state of ANS: C
Severe anxiety manifests as a focus on fragmented details, as well as headache, nausea, dizziness, inability to see connections between details, and poor recall. Mild anxiety manifests as increased auditory and visual perception, increased awareness of relationships, and increased alertness and ability to problem-solve. Moderate anxiety manifests as selective inattention, decreased perceptual field, focus only on relevant information, muscle tension, and diaphoresis. Panic state of anxiety manifests as an inability to notice surroundings, feelings of terror, and inability to cope with any problem. DIF: Cognitive Level: Analysis REF: Text reference: p. 36 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Manifestations of Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 17. The patient is admitted to the emergency department for trauma received in a fist fight. He
states that he could not control himself. He says that his wife left him for another man. He thinks it was because he was always too tired after working to do things. He says he has to work, and there is nothing he could do to change things. He says that he feels trapped in his N. Wh RSatIwNas GTthe B.C M job, but he knows nothing elseU alteO rcation with the other man probably a manifestation of? a. Mild anxiety b. Depression c. Severe anxiety d. Moderate anxiety ANS: B
Symptoms of depression include apathy, sadness, sleep disturbances, hopelessness, helplessness, worthlessness, guilt, anger, fatigue, thoughts of death, decreased libido, ruminations of inadequacy, psychomotor agitation, verbal berating of self, spontaneous crying, dependency, and passiveness. Mild anxiety manifests as increased auditory and visual perception, increased awareness of relationships, increased alertness, and an increased ability to problem-solve. Moderate anxiety manifests as selective inattention, decreased perceptual field, focus only on relevant information, muscle tension, and diaphoresis. Severe anxiety manifests as a focus on fragmented details, headache, nausea, dizziness, an inability to see connections between details, and poor recall. DIF: Cognitive Level: Analysis REF: Text reference: p. 42 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Manifestations of Depression KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
1. Verbal communication includes which of the following? (Select all that apply.) a. Speech b. Personal space c. Body movement d. Writing ANS: A, D
Verbal communication includes both spoken word and written word. Nonverbal communication describes all behaviors that convey messages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch. DIF: Cognitive Level: Analysis REF: Text reference: p. 28 OBJ: Explain the communication process. TOP: Verbal Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 2. In caring for patients of different cultures, it is important for the nurse to: (Select all that
apply.) a. use appropriate linguistic services. b. display empathy and respect. c. use accurate health history-taking techniques. d. use patient-centered communication. ANS: A, B, C, D
The following factors are essential in providing effective care for culturally and linguistically diverse patients: (1) use of appropriate linguistic services (e.g., interpreter or bilingual health care workers) and/or other coNmm onTsB tr. atC egie URuni SIcati NG OMs, (2) display of empathy and respect for culturally and linguistically diverse patients, (3) use of accurate health history-taking techniques for diagnostic and treatment purposes and health teaching, and (4) use of patient-centered communication behaviors, including participatory decision making. It also is helpful to speak plainly and to avoid mimicking a patient’s accent or dialect. DIF: Cognitive Level: Comprehension REF: Text reference: p. 30 OBJ: Identify the purpose of therapeutic communication, communication in various phases of the nurse-patient relationship, and special issues related to communication. TOP: Cultural Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. In establishing the nurse-patient relationship, personal self-disclosure by the nurse is useful
for which of the following goals? (Select all that apply.) a. To educate the patient b. To build the therapeutic alliance c. To encourage the patient’s independence d. To offer opinions that may influence the patient’s decisions ANS: A, B, C
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Personal self-disclosure is used with caution and only in selected situations. Personal self-disclosure by the nurse is useful for the following goals: (1) to educate the patient, (2) to build a therapeutic alliance with the patient, and (3) to encourage the patient’s independence. Barriers to therapeutic communication include giving an opinion, offering false reassurance, being defensive, showing approval or disapproval, stereotyping, and asking “Why?” The use of “why” questions causes increased defensiveness in the patient and hinders communication. DIF: Cognitive Level: Application REF: Text reference: p. 30 OBJ: Develop skills for therapeutic communication in various phases of the nurse-patient relationship. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. In dealing with angry patients, the nurse realizes that anger: (Select all that apply.) a. may be important to recovery. b. may be a means to cope with grief. c. often hides a specific problem. d. should not be allowed to compromise care. ANS: A, B, C, D
It is important for you to understand that in many cases the patient’s ability to express anger is important for recovery. For example, when a patient has experienced a significant loss, anger becomes a means to help cope with grief. Some patients express anger toward the nurse, but the anger often hides a specific problem or concern. Allow patients to express anger openly, and do not feel threatened by their words. However, do not allow a patient’s anger to threaten or compromise care. DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: p. 38 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. The nurse observes that the patient is pacing in his room with clenched fists. When asked
“What’s wrong?” the patient states, “There’s nothing wrong. I just want out of here.” He then bangs his fist on the table and yells, “I’ve had it!” How should the nurse respond? (Select all that apply.) a. Tell the patient that he needs to calm down. b. Pause to collect her own thoughts. c. Block the doorway. d. Notify the proper authorities. ANS: B, D
Awareness and control of your own reaction and responses will facilitate more constructive interaction. Maintain an open exit. Position yourself closest to the door to facilitate escape from a potentially violent situation. Do not block the exit so the patient feels escape is unattainable; this may cause a violent outburst. An angry patient loses the ability to process information rationally and therefore may impulsively express anger through intimidation. If a strong likelihood of imminent harm to another is present upon discharge, notify the proper authorities (e.g., nurse manager).
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Synthesis REF: Text reference: pp. 39-41 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Communicating With the Angry Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 1. The nurse is starting her first set of morning rounds. As she interacts with the patient, her
questions revolve around his reactions to his disease process. She also asks if there is anything that she can do to make him more comfortable. This type of interaction is known as . ANS:
therapeutic communication Therapeutic communication is an application of the process of communication to promote the well-being of the patient. DIF: Cognitive Level: Analysis REF: Text reference: p. 29 OBJ: Identify guidelines to use in therapeutic communication. TOP: Therapeutic Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. An active process of receiving information that nonverbally communicates to the patient the
nurse’s interest and acceptance is classified as
.
ANS:
NURSINGTB.COM listening Definition: An active process of receiving information and examining one’s reaction to messages received. Therapeutic value: Nonverbally communicates to the patient the nurse’s interest and acceptance. DIF: Cognitive Level: Knowledge REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 3. The patient is talking about his fear of having surgery but is being vague and is using a lot of
jargon. The nurse states, “I’m not sure what you mean. Could you tell me again?” This is an example of . ANS:
clarification Clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding, or asking the patient to explain what he or she means. This may help to clarify the patient’s feelings, ideas, and perceptions, and may provide an explicit correlation between them and the patient’s actions. DIF: Cognitive Level: Application REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Diagnosis
MSC: NCLEX: Psychosocial Integrity
4. Directing the conversation back to patient ideas, feelings, questions, or content is known as
. ANS:
reflection Reflection or directing back to the patient ideas, feelings, questions, or content validates the nurse’s understanding of what the patient is saying and signifies empathy, interest, and respect for the patient. DIF: Cognitive Level: Knowledge REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 5. The patient tells the nurse that his mother left him when he was 5 years old. The nurse
responds by saying, “You say that your mother left you when you were 5 years old?” This is an example of . ANS:
restating Restating is a technique whereby the nurse repeats the main thought that the patient has expressed. It indicates that the nurse is listening, and validates, reinforces, or calls attention to something important that has been said. DIF: Cognitive Level: Application REF: Text reference: p. 31 OBJ: Explain the communicatN ioU nR prS ocI esN s.GTB.COM TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. The patient has been agitated for the entire morning but refuses to say why he is angry.
Instead, whenever the nurse speaks to him, he smiles at her while clenching his fist at the same time. The nurse states, “I can see that you’re smiling, but I sense that you are really very angry.” This is an example of . ANS:
sharing perceptions Sharing perceptions is asking the patient to verify the nurse’s understanding of what the patient is thinking or feeling. It conveys to the patient the nurse’s understanding and has the potential for clearing up confusing communication. DIF: Cognitive Level: Application REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. Lack of verbal communication for a therapeutic reason is known as ANS:
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.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank therapeutic silence Lack of verbal communication for a therapeutic reason is known as therapeutic silence. It allows the patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse’s support, understanding, and acceptance. DIF: Cognitive Level: Comprehension REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Silence KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 8. Anxiety that is the source of inattention, decreased perceptual field, and diaphoresis is
classified as
.
ANS:
moderate anxiety Moderate anxiety is characterized by selective inattention, decreased perceptual field, the ability to focus only on relevant information, muscle tension, and/or diaphoresis. DIF: Cognitive Level: Comprehension REF: Text reference: p. 36 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 4: Documentation and Informatics MULTIPLE CHOICE 1. The patient is a 24-year-old man who is diagnosed with possible HIV infection while being
treated for active pneumonia. He has stated that the nurse may share test result information with his significant other but nothing else at this time. With whom may the nurse communicate regarding this information? a. The patient’s parents b. The patient’s significant other only c. No one in the hospital until the patient says so d. The patient’s physician, significant other, and laboratory personnel ANS: D
All members of the health care team are legally and ethically obligated to keep patient information confidential. Do not discuss the patient’s examinations, observations, conversations, or treatments with other patients or staff not involved in the patient’s care, unless permission is granted by the patient. DIF: Cognitive Level: Application REF: Text reference: p. 49 OBJ: Describe measures to maintain confidentiality of patient information. TOP: Confidentiality KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following is the best example of objective charting? a. “The patient states that he has been having severe chest discomfort.” b. “The patient is lying in bN edUaR ndSsI eeNmGsTtoBb.eCinOcM onsiderable pain.” c. “The patient appears to be pale and diaphoretic and complains of nausea.” d. “The patient’s skin is ashen and respiratory rate is 32 and labored.” ANS: D
A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as “respiratory rate 20 and unlabored.” Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient’s exact words whenever possible. For example, you record, “Patient states, ‘my stomach hurts.’” Avoid terms such as appears, seems, and apparently, which are often subject to interpretation. For example, the description “the patient seems to be in pain” does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts. DIF: Cognitive Level: Analysis REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Objective Documentation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 3. Which of the following is the best example of accurate documentation? a. “Abdominal wound is 5 cm in length without redness, edema, or drainage.”
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. “OD to be irrigated qd with NS.” c. “No complaint of abdominal pain this shift.” d. “Patient watching TV entire shift.” ANS: A
The use of exact measurements in documentation establishes accuracy. For example, charting that an abdominal wound is “5 cm in length without redness, edema, or drainage” is more descriptive than “large wound healing well.” It is essential to know the institution’s abbreviation list, and to use only accepted abbreviations, symbols, and measures (e.g., metric), so that all documentation is accurate and is in compliance with standards. For example, the abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word “daily” or “every day” on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). The term “no complaint” may indicate stoicism on the part of the patient. He may have been in excruciating pain but never complained of it. It also creates a question related to the assessment skills of the nurse. It is essential to avoid unnecessary words and irrelevant details. For example, the fact that the patient is watching TV is only necessary to report when this activity is significant to the patient’s status and plan of care. DIF: Cognitive Level: Evaluation REF: Text reference: pp. 51-52 OBJ: List guidelines for effective communication and reporting. TOP: Accurate Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Patients on the unit have their vital signs taken routinely at 0800, 1200, 1600, and 2000. At
1000, a patient complains of feeling “light-headed.” The nurse takes the patient’s vital signs and finds blood pressure to be lower than usual. Within 15 minutes, the patient says that he NU RSblo INod GTpressur B.CO M finds that it is now back to normal. feels better. The nurse recheck s the e and How should the nurse handle documentation for this episode? a. Document the 1000 vital signs in the graphic record only. b. Not report the incident because it was a transient episode. c. Document the vital signs in the graphic and progress record. d. Document the vital signs as 12 o’clock signs. ANS: C
When documenting a significant change on a flow sheet, you describe the change, including the patient response to nursing interventions, in the progress notes. For example, if a patient’s blood pressure becomes dangerously low, record the blood pressure in the progress notes, as well as relevant assessment such as pallor and dizziness and any interventions performed to raise the blood pressure. Common issues in malpractice caused by inadequate or incorrect documentation include failing to give a report or giving an incomplete report to an oncoming shift and failing to document the correct time of events. DIF: Cognitive Level: Application REF: Text reference: pp. 53-54 OBJ: Identify the purpose of the patient record. TOP: Flow Sheets and Graphic Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. The nurse manager is attempting to determine the staffing needs of the unit. One tool that she
may use to determine the level of care needed would be: a. the standardized care plan.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. the acuity record. c. the patient care summary. d. flow sheets. ANS: B
Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. An acuity recording system determines the hours of nursing care and the number of staff required for a nursing unit. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: Cognitive Level: Analysis REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Acuity Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 6. A preprinted guideline used to care for patients with similar health problems is known as the: a. acuity record. b. standardized care plan. c. patient care summary. NURSINGTB.COM d. flow sheet. ANS: B
Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines that are used in caring for patients with similar health problems. Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: Cognitive Level: Analysis REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Standardized Care Plans KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. The patient is ready to go home from the hospital. What does the nurse provide to the patient
and his family before he leaves the facility? a. Discharge summary b. Standardized care plan
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. Patient care summary d. Flow sheet ANS: A
When a patient is discharged from a health care institution, the members of the health care team prepare a discharge summary. A discharge summary provides important information related to the patient’s ongoing health problems and need for health care after discharge. You enhance discharge planning when you are responsive to changes in patient condition and involve the patient and family in the planning process. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: Cognitive Level: Application REF: Text reference: p. 55 OBJ: Identify the purpose of the patient record. TOP: Discharge Summary Forms KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 8. Which is a delivery model that coordinates and links health care services to patients and
families? a. Critical pathways b. Charting by exception c. SOAP d. Case management
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ANS: D
Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. Critical pathways state the goals and important elements of care based on best practice and patient expectations by documenting, monitoring, and evaluating variances and providing resources and outcomes. This system involves completing a flow sheet that incorporates those standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal findings and routine interventions. The logic for SOAP (IE) notes is similar to that for the nursing process: Collect data about the patient’s problems, draw conclusions, and develop a plan of care. DIF: Cognitive Level: Analysis REF: Text reference: p. 57 OBJ: List guidelines for effective communication and reporting. TOP: Case Management KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 9. The patient has been in the hospital for a hip replacement. According to his critical pathway,
he should have his Foley catheter discontinued on the fourth day after surgery. Instead, the patient has it removed on the third day and is voiding normally with no problems. This would be a sign of: a. a negative variance.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. positive case management. c. a positive variance. d. use of SBAR. ANS: C
Variances are unexpected occurrences, unmet goals, and interventions not specified within the critical pathway time frame that reflect a positive or negative change. A positive variance occurs when a patient progresses more rapidly than is anticipated in the case management plan (e.g., use of a Foley catheter is discontinued a day early). A negative variance occurs when activities on the critical pathway do not happen as predicted, or outcomes are unmet (e.g., oxygen therapy is necessary for a new-onset breathing problem). Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. SBAR is a technique that provides a framework for communication between members of the health care team about a patient’s condition. SBAR is a concrete mechanism used for framing conversations, especially critical ones, requiring a nurse’s immediate attention and action. DIF: Cognitive Level: Analysis REF: Text reference: p. 59 OBJ: Describe the role of critical pathways in multidisciplinary documentation. TOP: Variances KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 10. Which is a primary difference between home care and hospital care? a. Documentation systems need to provide information for the home health nurse
only. b. Documentation no longer affects reimbursement. c. Services are assumed and need less documentation. NwR I G stB.C M d. The patient and the family U itnSessNmoT of theOcare provided. ANS: D
One primary difference is that the patient and the family rather than the nurse witness most of the care provided. Documentation systems need to provide the entire health care team with the necessary information to work together effectively, supply quality control, and justify reimbursement from Medicare, Medicaid, or private insurance companies. DIF: Cognitive Level: Analysis REF: Text reference: p. 59 OBJ: Explain guidelines used in documentation of home care and long-term care. TOP: Home Care Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 11. The patient has been transferred to the nursing home from the acute care hospital. A report
was called from the hospital and was received by the RN in charge of the nursing home unit. Upon arrival, which approach is used to assess the patient? a. The Long-Term Care Facility Resident Assessment Instrument b. The case management model c. Collaborative pathways d. The charting by exception model ANS: A
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Each resident in long-term care is assessed using the Long-Term Care Facility Resident Assessment Instrument as mandated by the Omnibus Budget Reconciliation Act of 1989 (OBRA) and updated in 1998. Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. The collaborative pathways are multidisciplinary care plans that include key interventions provided and expected outcomes within an established time frame. The charting by exception model involves completing a flow sheet that incorporates those standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal findings and routine interventions. DIF: Cognitive Level: Analysis REF: Text reference: p. 60 OBJ: Explain guidelines used in documentation of home care and long-term care. TOP: Long-Term Care Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nursing assistant tells the RN that when the patient’s vital signs were taken, the patient
complained that she was in a lot of pain. The nursing assistant then tells the nurse that she charted the patient’s complaint when she charted the vital signs. What instruction does the nurse need to provide to the nursing assistant? a. The nursing assistant needs to make sure she uses the SBAR format when entering notes. b. Nursing assistants are not allowed to chart vital signs. c. Only the nurse can write in the progress notes. d. The nursing assistant needs to write using blue ink to distinguish from the RN note. ANS: C
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The task of writing a progress note may not be delegated to nursing assistive personnel (NAP). The nurse instructs the NAP about what repetitive care activities should be documented on flow sheets, including vital signs, intake and output (I&O), and routine care related to ADLs. DIF: Cognitive Level: Analysis REF: Text reference: p. 61 OBJ: Identify the purpose of the patient record. TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 13. The patient was in bed with all side rails up. During the night, the patient tried to get up to go
to the bathroom and fell while trying to climb over the side rails. After meeting the patient’s needs and assessing that the patient was not harmed, what step should the nurse take (if any)? a. Complete an incident report and put it in the medical record. b. Chart what happened and state that an incident report has been filled out. c. Do nothing because the patient was not harmed. d. Document what happened in the patient record without mentioning the incident report. ANS: D
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Document in the patient’s record an objective description of what you observed and follow-up actions taken without reference to the incident report. Incident reports are not a part of the permanent medical record but are an important source of risk management data for identifying and addressing the causes of errors made in health care organizations. You complete the report even if an injury does not occur or is not apparent. DIF: Cognitive Level: Analysis REF: Text reference: p. 62 OBJ: Complete an incident report accurately. TOP: Incident Reports KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Nursing documentation: (Select all that apply.) a. ensures continuity of care. b. provides legal evidence. c. evaluates patient outcomes. d. increases the risk of litigation. ANS: A, B, C
Nursing documentation ensures continuity of care, provides legal evidence, and evaluates patient outcomes. Effective documentation ensures continuity of care, maintains standards, and reduces errors. DIF: Cognitive Level: Knowledge REF: Text reference: p. 47 OBJ: List guidelines for effective communication and reporting. TOP: Communication Y: Nursing Process Step: Assessment N R I GKEB .C M NnviTronmentO MSC: NCLEX: Safe and EffectivU e CS are E 2. What is the goal of information management? (Select all that apply.) a. Support decision making. b. Improve patient outcomes. c. Ensure patient safety. d. Improve health care documentation. ANS: A, B, C, D
The goal of information management is to support decision making and improve patient outcomes, improve health care documentation, ensure patient safety, and improve performance in patient care, treatment and services, governance, management, and support processes. DIF: Cognitive Level: Knowledge REF: Text reference: p. 49 OBJ: Identify the purpose of the patient record. TOP: Information Management KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Nursing documentation must have which of the following characteristics? (Select all that
apply.) a. Factual b. Organized c. Public d. Complete
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: A, B, D
Quality documentation and reporting have six characteristics: they are factual, accurate, complete, current, organized, and confidential. DIF: Cognitive Level: Comprehension REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Guidelines for Reporting and Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment COMPLETION 1. A patient’s private health information is legally protected by the
.
ANS:
Health Insurance Portability and Accountability Act (HIPAA) Health Insurance Portability and Accountability Act HIPAA HIPAA protects patients’ private health information. This governs all areas of health information management, including, for example, reimbursement, coding, security, and patient records. DIF: Cognitive Level: Application REF: Text reference: p. 49 OBJ: Describe measures to maintain confidentiality of patient information. TOP: Confidentiality KEY: Nursing Process Step: Implementation G MSC: NCLEX: Safe and EffecN tivU eR CS arI eE n vi N TroBnm.eCntOM 2. To limit liability, nursing documentation must clearly indicate that the nurse provided
individualized, goal-directed nursing care to a patient based on the ANS:
nursing assessment To limit liability, nursing documentation must clearly indicate that the nurse provided individualized, goal-directed nursing care to a patient based on the nursing assessment. DIF: Cognitive Level: Application REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Guidelines for Reporting and Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
documentation should include your observations of patient behavior.
3. ANS:
Objective Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. DIF: Cognitive Level: Analysis
REF: Text reference: p. 50
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.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: List guidelines for effective communication and reporting. TOP: Objective Documentation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment 4. The abbreviation for every day (
) is no longer used.
ANS:
qd The abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word “daily” or “every day” on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). DIF: Cognitive Level: Application REF: Text reference: p. 51 OBJ: List guidelines for effective communication and reporting. TOP: Accurate Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. When making written entries in the patient’s medical record, describe the nursing care
provided and the
.
ANS:
patient’s response The information within a recorded entry or a report must be complete, containing appropriate and essential information. Make written entries in the patient’s medical record, describing nursing care that you administer and the patient’s response. DIF: Cognitive Level: Application REF: Text reference: p. 52 OBJ: List guidelines for effectN ive com io. nC andOM reporting. UR SImun NGicat TB TOP: Complete Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
provide a quick, easy reference for health care team members in assessing
6.
the patient’s status. ANS:
Flow sheets Flow sheets provide a quick, easy reference for health care team members in assessing the patient’s status. DIF: Cognitive Level: Application REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Flow Sheets and Graphic Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. Standardized care plans are effective ways to plan care for the patient. To be most effective,
however, the SCP must be
.
ANS:
individualized to meet the patient’s needs Standardized care plans must be individualized for each patient. Most standardized care plans allow for the addition of specific patient outcomes and target dates for achievement of these outcomes.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Standardized Care Plans KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 8. Multidisciplinary care plans that include key interventions and expected outcomes within an
established time frame are known as
.
ANS:
critical pathways Critical pathways are multidisciplinary care plans that include key interventions and expected outcomes within an established time frame. DIF: Cognitive Level: Comprehension REF: Text reference: p. 57 OBJ: Describe the role of critical pathways in multidisciplinary documentation. TOP: Critical Pathways KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
provide a format for documenting a patient’s health status and
9.
progress. ANS:
Progress notes Progress notes provide a format for documenting a patient’s health status and progress. DIF: Cognitive Level: Analysis REF: Text reference: p. 61 TOP: Patient Record OBJ: Identify the purpose of tN he pR atienIt reG cordB U S N T . .C OM KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 5: Vital Signs MULTIPLE CHOICE 1. The patient is brought to the emergency department complaining of severe shortness of
breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient’s respiratory status, the nurse should: a. remove the patient’s nail polish to get a pulse oximetry reading. b. use a forehead probe to get a pulse oximetry reading. c. use a finger probe to get a pulse oximetry reading. d. check the color of the patient’s nail polish before attempting a reading. ANS: B
Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Assess for factors that influence measurement of SpO2 (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish [Cieck et al., 2010]; medications such as bronchodilators). DIF: Cognitive Level: Analysis REF: Text reference: p. 101 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Pulse Oximetry KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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2. A person’s core temperature is considered the most accurate since it is: a. reflective of the surrounding environment. b. the same for everyone. c. controlled by the hypothalamus. d. independent of external influences. ANS: C
The core temperature, or the temperature of the deep body tissues, is under the control of the hypothalamus and remains within a narrow range. Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically. Body tissues and cells function best within a relatively narrow temperature range, from 36° C to 38° C (96.8° F to 100.4° F), but no single temperature is normal for all people. For healthy young adults, the average oral temperature is 37° C (98.6° F). An acceptable temperature range for adults depends on age, gender, range of physical activity, hydration status, and state of health. DIF: Cognitive Level: Analysis REF: Text reference: p. 67 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Core Temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse takes the patient’s temperature using a tympanic electronic thermometer. The
temperature reading is 36.5 C (97.7 F). The nurse knows that this correlates with:
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