lOMoARcPSD|9647167 Test bank for fundamentals of nursing 10th edition potter 925 Fundamentals of Nursing (Miami Dade College) StuDocu is not sponsored or endorsed by any college or university Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 FUNDAMENTALS OF NURSING 10TH EDITION POTTER PERRY TEST BANK Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Fundamentals of Nursing 10th Edition Potter Perry Test Bank Chapter 1. Nursing Today MULTIPLE CHOICE 1. Contemporary nursing practice is based on knowledge generated through nursing theories. Florence Nightingales theory introduced the concept that nursing care focuses on: 1 2 Psychological needs A maximal level of wellness 3 Health maintenance and restoration 4 Interpersonal interactions with the client ANS: 3 Florence Nightingale believed the role of the nurse was to put the clients body in the best state in order to remain free of disease or to recover from disease. Although Florence Nightingale may have addressed meeting the psychological needs of her clients, it is not the focus of her theory. The goal of Nightingales theory is to facilitate the bodys reparative processes by manipulating the clients environment. Florence Nightingale thought the human body had reparative properties of its own if it was cared for in a way to recover from disease. Her theory did not focus on achieving a maximal level of wellness. Florence Nightingale believed the nurse was in charge of the clients health. Although she interacted with her clients by reading to them, her theory of nursing care did not focus upon interpersonal interactions. DIF: A REF: 2 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 2. Nursing education programs in the United States may seek voluntary accreditation by the appropriate accrediting commission council of the: 1 National League for Nursing 2 American Nurses Association 3 Congress for Nursing Practice International Council of Nurses 4 ANS: 1 The National League for Nursing (NLN) is the professional nursing organization concerned with nursing education. The NLN provides accreditation to nursing programs that seek and meet the NLN accreditation requirements. The American Nurses Association (ANA) is concerned with the nursing profession and issues affecting health care, including standards of care. Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 The Congress for Nursing Practice is the part of the ANA concerned with determining the legal aspects of nursing practice, the public recognition of the importance of nursing, and the impact of trends in health care on nursing practice. The International Council of Nurses (ICN) is concerned about issues of health care and the nursing profession, including the provision of an international power base for nurses. DIF: A REF: 8 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 3. The minimum educational requirement for a nurse practitioner is: 1 Diploma in nursing 2 3 Masters in nursing Doctorate in nursing 4 Baccalaureate in nursing ANS: 2 A masters degree is nursing is required to become a nurse practitioner. Diploma programs in nursing require 3 years of education after which the graduate may become a registered nurse, but not a nurse practitioner. Doctoral programs focus on the application of research findings to clinical practice. The doctoral degree is beyond the masters degree. The baccalaureate degree program generally requires 4 years of study in a college or university, after which the graduate may become a registered nurse, not a nurse practitioner. DIF: A REF: 8 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 4. A group that lobbies at the state and federal level for advancement of nursings role, economic interest, and health care is the: 1 State Board of Nursing 2 American Nurses Association 3 American Hospital Association 4 National Student Nurses Association ANS: 2 The American Nurses Association (ANA) hires lobbyists at the state and federal level to promote the advancement of health care and the economic and general welfare of nurses. State Boards of Nursing primarily focus on licensure of nurses within their own state. The American Hospital Association does not focus on nurses economic issues and the advancement of the role of nurses. The National Student Nurses Association focuses on issues of importance for nursing students. Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 DIF: A REF: 8 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 5. A nurse moves from Seattle to Boston and begins working in a hospital. The most important factor for the nurse to consider when moving to another state is the: 1 2 Massachusetts Nurse Practice Act Standard for nursing practice in Boston 3 Clinical ladder of mobility in the new hospital 4 Requirement for continuing education units (CEU) in Massachusetts ANS: 1 Although most states have similar practice acts, each individual state has its own Nurse Practice Act that regulates the licensure and practice of nursing within that state. Knowledge of the Nurse Practice Act is necessary to provide safe and legal nursing care. Standards of nursing practice are not specific to a city, but rather to the profession itself. Although the clinical ladder of mobility may be of interest in regard to professional advancement, it is not the most important factor when practicing nursing in another state. Knowledge of the Nurse Practice Act in order to provide safe and legal nursing care is of higher importance. Regardless of where a nurse practices, the nurse should strive to remain current. DIF: C REF: 8 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 6. A nurse is caring for a client who has chronic renal failure. The nurse states, We will do everything possible to return you to the optimum level of self-care possible. In coordinating an approach to best meet the needs of this client, the nurse is fulfilling the role of: 1 Manager 2 Educator 3 Counselor Communicator 4 ANS: 1 The nurse, in caring for this client, will coordinate the activities of other members of the health care team. This client may require the assistance of a nursing assistant to provide personal care until the client is less fatigued. A nutritionist may be necessary for diet evaluation, planning, and teaching. A nurse may provide education on the dialysis therapy and perform the skill necessary until the client is able to do so independently. Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 The nurse may include patient teaching in the clients care, but more is required to meet the needs of this client. The nurse is not performing in the role of counselor. Clear communication will be necessary for the client to understand self-care measures regarding dialysis. The role of communicator does not, however, entirely meet the clients physical needs at this time. DIF: A REF: 10 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 7. Nurses have the opportunity to work in a wide variety of health care agencies around the world. The practice setting where the majority of nurses continue to work is: 1 Acute care 2 3 Home care Long-term care 4 Ambulatory care ANS: 1 Most nurses provide direct client care in the hospital setting. Although opportunities for providing patient care in the clients home are increasing, the majority of nurses are not employed in this setting. The majority of nurses do not work in nursing homes or extended care settings. Significantly fewer nurses work in an ambulatory care setting. DIF: A REF: 10 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 8. A client is receiving Dilantin to prevent seizure activity. To which allied health care professional should the nurse refer this client in order to minimize the challenges this condition creates? 1 Physical therapist 2 Physicians assistant 3 Respiratory therapist 4 Occupational therapist ANS: 4 An occupational therapist is a person who provides assessment and intervention to ameliorate physical and psychological deficits that interfere with the performance of activities and tasks of living, including ones employment. A physical therapist is responsible for the patients musculoskeletal system. A physical therapist may use exercises as an intervention to improve a clients mobility. Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 A respiratory therapist provides treatment to preserve or improve pulmonary function. A physicians assistant performs tasks usually done by physicians and works under the direction of a supervising physician. DIF: C OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 9. The Goldmark Report concluded that: 1 Nursing roles and responsibilities required clarification 2 A theory-based curriculum was necessary for accreditation 3 Nursing education programs must be affiliated with universities 4 Increased financial support should be provided for nursing education ANS: 4 In 1923 the Goldmark Report identified the need for increased financial support to universitybased schools of nursing. The National Commission on Nursing and Nursing Education Report of 1965 recommended that nursing roles and responsibilities be clarified in relation to other health care professionals. In 1975 the National League for Nursing required theory-based curriculum for accreditation. The Brown Report of 1948 concluded that all nursing education programs should be affiliated with universities and should have their own budgets. DIF: A REF: 3 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 10. In 1893 Lillian Wald and Mary Brewster made significant contributions to the nursing profession through their work involving the: 1 Henry Street Settlement in New York 2 First training school in Toronto, Canada 3 Training school at Johns Hopkins in Baltimore 4 Development of the American Journal of Nursing ANS: 1 In 1893 Lillian Wald and Mary Brewster opened the Henry Street Settlement, which was the first community health service for the poor. The first nurses training school in Canada was founded in St. Catherines, Ontario, in 1874. In 1894 Isabel Hampton Robb was the first superintendent of the Johns Hopkins Training School in Baltimore, Maryland. Isabel Hampton Robb was one of the original founders of the American Journal of Nursing. DIF: A REF: 3 OBJ: Comprehension Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 11. To obtain a certification in a specialty area, the nurse will have to complete: 1 A request for state approval 2 3 A graduate degree in nursing An examination and the minimum practice requirements 4 A general examination given to all nurses seeking certification ANS: 3 Set minimum practice requirements are based on the certification the nurse is seeking. After passing the initial examination, the nurse maintains certification by ongoing continuing education and clinical or administrative practice. Individual states do not grant certification by request. Certification in a specialty area requires passing the examination for certification in that area and meeting minimum practice requirements. A masters degree in nursing is not required for certification in a specialty area. A specialized examination is given according to the specific area of nursing practice in which certification is being sought. DIF: A REF: 9 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 12. In the ANA Standards of Professional Performance, which one of the following is a specific measurement criterion for The nurses decisions and actions on behalf of clients are determined in an ethical manner? 1 Acts as client advocate 2 Participates in the collection of client data 3 Seeks experiences to maintain clinical skills 4 Consults with appropriate health care providers ANS: 1 As a client advocate, the nurse protects the clients human and legal rights and provides assistance in asserting those rights if the need arises. Performing in the role of patient advocate fulfills a measurement criterion for the professional performance standard of ethics. Participating in data collection is a measurement criterion for the professional performance standard of quality of practice. The nurse who seeks experiences to maintain clinical skills is fulfilling a measurement criterion for the professional performance standard of education. Consulting with health care providers is a measurement criterion for the professional performance standard of collaboration. Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 DIF: A REF: 7 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 13. In looking at the nineteenth century, the growth of professional nursing was stimulated by: 1 2 3 4 The Civil War Federal legislation Florence Nightingale The womens suffrage movement ANS: 1 The Civil War stimulated the growth of nursing in the United States. Nurses were in demand to tend to the soldiers of the battlefield. Throughout history, nurses and their professional organizations have lobbied for health care legislation to meet the needs of clients. However, legislation was not responsible for the growth of nursing in the nineteenth century. Although Florence Nightingale had great impact on the practice of nursing, she was not the cause for the growth of nursing in the United States during the nineteenth century. The womens movement has encouraged nurses to seek greater autonomy and responsibility in providing care, and has caused female clients to seek more control of their health and lives. The womens movement was not responsible for the growth of nursing in the nineteenth century. DIF: A REF: 3 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 14. Which of the following educational activities is an example of in-service education? 1 A workshop given at a nursing convention on malpractice 2 A program on new cardiac medications provided at a local hospital 3 Credit courses in communication offered at the community college Noncredit courses on nursing issues available through the internet 4 ANS: 2 An in-service education program is instruction or training provided by a health care agency or institution for its employees. A workshop at a nursing convention is an example of a continuing education program. Credit courses at a college are examples of continuing education that could possibly by applied toward furthering ones degree. Noncredit courses offered via the internet are an example of a continuing education program. WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 DIF: A REF: 8 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 15. Nurses need to be aware of current trends in the health care delivery system in order to respond in educational preparation and practice. A major trend that is influencing nursing practice today is: 1 Decreased client acuity 2 Increased hospital stays 3 Decreased emphasis on health promotion 4 Increased incidence of chronic disease processes ANS: 4 In recent decades, there is a higher incidence of chronic, long-term illness. With shortened hospital stays, client acuity has increased, not decreased. Hospital stays have decreased, not increased. Lengths of stay have shortened with a trend toward home care, and health promotion and illness prevention. With increased public awareness and rising health care costs, greater emphasis has been placed on health promotion and illness prevention. DIF: A REF: 4 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 16. The nurse assists the client in a health promotion activity that also reduces the cost of health care delivery when: 1 Administering medication 2 Treating a diabetic foot ulcer 3 Obtaining an operative consent 4 Discussing exercise and nutrition ANS: 4 The nurse may educate the client in such areas as exercise, nutrition, and healthy lifestyles to assist the client in health promotion and illness prevention. By administering medication, the nurse is assisting to restore a person to health or maintain ones health. A nurse who treats a foot ulcer is assisting a client to restore their health, rather than promoting healthy behaviors. Obtaining an operative consent pertains to legal aspects of care and is not considered a health promotion activity. DIF: A REF: 5 OBJ: Comprehension TOP: Nursing Process: Planning WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 MSC: NCLEX test plan designation: Health Promotion and Maintenance/Programs 17. The nurse is best able to provide quality care that benefits both client and family by: 1 Incorporating caring into the practice 2 Making the client the center of the practice 3 Integrating the science and art of nursing into the practice 4 Being knowledgeable of the institutions standards of practice ANS: 3 Nursing is an art and a science. As a professional nurse you will learn to deliver care artfully with compassion, caring, and a respect for each clients dignity and personhood. As a science, nursing is based on a body of knowledge that is continually changing with new discoveries and innovations. When you integrate the science and art of nursing into your practice, the quality of care you provide to your clients is at a level of excellence that benefits clients and their families. Caring is one part of the art of nursing. While the client is the focus of nursing practice, this focus is not the main contributor to quality care. Standards of care provide guidelines for the delivery of client care. Awareness of the standards does not guarantee quality care. DIF: C REF: 2 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 18. Which of the following statements best reflects Nightingales nursing philosophy on health maintenance and restoration? 1 Did all the clients eat a good breakfast? 2 What is the client rating his pain level after his medication? 3 Have any clients developed a nosocomial infection last month? Is anyone interested in volunteering to mentor our new graduates? 4 ANS: 3 Florence Nightingale studied and implemented methods to improve battlefield sanitation, which ultimately reduced illness, infection, and mortality (Cohen, 1984). Today nurses are active in determining the best practices for skin care management, pain control, nutritional management, and care of older adults. Infection control and its impact on disease prevention was a major outcome of her contributions to nursing. Awareness of the connection between hospital-acquired infections (nosocomial) and nursing practice is the best example of her nursing philosophy. Nutritional management and its impact on client health, while important does not reflect the best option offered. Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Pain management while a vital client concern does not represent the best option offered While volunteering is certainly reflected in Nightingales practice it is not the best option offered. DIF: C REF: 2-3 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Disease Prevention 19. The twentieth century is recognized for which of the following nursing concepts? 1 Code of Nursing Ethics 2 Hospital-based nursing care 3 Specialized nursing textbooks were adopted. 4 Formalized university-based nursing education ANS: 4 In the early twentieth century a movement toward a scientific, research-based defined body of nursing knowledge and practice was evolving. Nurses began to assume expanded and advanced practice roles. Mary Adelaide Nutting was instrumental in the affiliation of nursing education with universities. In 1990 the American Nurses Association established the Center for Ethics and Human Rights. Nursing in hospitals expanded in the late nineteenth century. Isabel Hampton Robb helped found the Nurses Associated Alumnae of the United States and Canada in 1896. This organization became the American Nurses Association (ANA) in 1911. She authored many nursing textbooks, including Nursing: Its Principles and Practice for Hospital and Private Use (1894), Nursing Ethics (1900), and Educational Standards for Nurses (1907), and was one of the original founders of theAmerican Journal of Nursing (AJN). DIF: A REF: 4 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. The best example of the impact of the womens movement on health care is: 1 Improvement in breast cancer survival rates 2 Insurance coverage for well-woman check-ups 3 Women subjects to be included in all appropriate health research projects 4 A single, teenage mother receiving Women, Infants, and Children (WIC) benefits ANS: 3 The womens movement brought about many changes in society as women increasingly demanded economic, political, occupational, and educational equality. As a result, there is greater sensitivity to the health care needs of women and the role of women in health care research. There are emerging health care specialties dealing with the needs of women. These new WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 specialties expand from the traditional obstetrical specialty and address issues ranging from wellwomens examinations, to oncological subspecialties, to the management of menopause. Because of the prior lack of female subjects in biomedical research, the federal government now requires studies to routinely include women in research, unless specific exception criteria are met. For example, research focusing on management of prostatic cancer is an exception. Improved survival rates for female-oriented cancers is evident because of emphasis being placed on research. While important, increased insurance coverage is not the best option available because this action would be directly driven by research findings. While important, increased federal funding for female-oriented benefits does not represent the best option available because this action would be directly driven by research findings. DIF: C REF: 4 OBJ: Analysis TOP: Nursing Process: Comprehension MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. The human rights movement most directly impacts nursing practice because: 1 Nurses act as advocates for all clients 2 3 Clients require someone to focus on their needs Caring for clients is the focus of nursing practice 4 Everyone deserves to be treated fairly and with respect ANS: 1 Client advocacy is a nursing responsibility. The human rights movement changed the way society views the rights of all of its members, including minorities, clients with terminal illness, pregnant women, and older adults. Many groups have special health care needs, and nursing responds by respecting the human rights of all clients and their right to quality care. Nurses advocate the rights of all clients. Clients do require someone to focus on their needs; advocacy is a responsibility of the nurse but the concept of the nurse as an advocate was established well before the human rights movement. Caring for clients is the focus of nursing practice, but caring physically and emotionally for a client as a nursing responsibility was established well before the human rights movement. Everyone deserves to be treated fairly and with respect. The realization of that truth was impacted by the human rights movement; however, this option does not directly relate to nursing. DIF: C REF: 4-5 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordinated Care 22. Nurses are caring for clients from a variety of cultures primarily as a result of: 1 Increased ease of travel and mobility 2 Political unrest in many foreign countries 3 Increased incidence of contagious diseases Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 4 Poor health care in underdeveloped countries ANS: 1 Because the worlds population is more mobile, both immigration and travel have shown an increase over the last decades. Nursing practice will require the management and delivery of care for clients from many different cultures. Although immigration to this country has been impacted by political strife in other countries, it is not the primary factor in an increasingly culturally diverse client population. Increased incidence of contagious diseases has little impact on the cultural diversity of the client population. Although poor health care services may contribute to some influx of foreign clients, it is not the primary factor in an increasingly culturally diverse client population. DIF: C REF: 5 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 23. Risk for injury during client transfer is minimized most effectively by: 1 Implementation of lift teams 2 Yearly personnel training sessions 3 Using mechanical lifts when possible Use of evidence-based techniques 4 ANS: 4 Injuries to both caregiver and client occur during client transfer. The caregiver is at risk for musculoskeletal injuries. The client is at risk for falls as well as musculoskeletal injuries. There is a shift from ineffective, injury-prone client transfer techniques to evidence-based practices for safe client handling. The implementation of a lift team is directly supported by evidence-based research (EBR). Yearly training sessions are important but the specific training is determined first by EBR. The use of mechanical lifts is directly supported by evidence-based research (EBR). DIF: C REF: 6 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Accident Prevention MULTIPLE RESPONSE 1. Which of the following activities reflect the nurses role in health promotion and wellness? (Select all that apply.) 1 2 3 4 Screening the local homeless population for head lice Monitoring blood pressures at a community health fair Organizing a foot race to benefit national cancer research Consulting a teenage mother on breast-feeding techniques WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 5 Providing literature on smoking cessation to client families 6 Presenting a nursing workshop on the care of diabetic ulcers ANS: 1, 2, 4, 5 Nursing responds to this greater concern for health promotion by providing programs in the community such as health fairs and wellness programs; educational programs for specific diseases; and client and family teaching activities in hospitals, clinics, primary care facilities, and other health care settings. While admirable, organizing a benefit for cancer research is not an activity directed towards health promotion and wellness but rather towards research that will benefit the population as a whole rather than specific individuals. Presenting a workshop on a specific nursing intervention is not an activity directed toward health promotion and wellness but rather towards professional development of the nurses. DIF: A REF: 5 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Programs 2. Changes in recent population demographics that have impacted the delivery of nursing care include the following: (Select all that apply.) 1 2 Increased birth rates Increased life expectancy 3 Decreasing rural population 4 Expanding urban settlement 5 Advances in medical modalities Availability of free public education 6 ANS: 2, 3, 4 Demographic changes affect the population. Changes influencing health care in recent decades include the population shift from rural areas to urban centers; the increased life span; the higher incidence of chronic, long-term illness; and the increased incidence of diseases such as alcoholism and lung cancer. Nursing responds to such changes by exploring new methods to provide care, by changing educational emphases, and by establishing practice standards. Recent birth rates have declined. Advances in medical modalities and availability of free public education do not reflect changes in population demographics but rather health care advances and social services. Chapter 2. Health Care Delivery System MULTIPLE CHOICE 1. Regulatory interventions were initiated to reduce the rise in health care costs. These interventions include: 1 Prospective payment systems WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 State limits on health care fees 3 Federal guidelines for treatment Court review of insurance coverage 4 ANS: 1 As a means to reduce health care costs, in 1983 Congress established the prospective payment system in which hospitals are reimbursed a set dollar amount for each diagnosis-related group, regardless of the length of stay or use of services in the hospital. State limits on health care fees have not been used nationwide to reduce health care costs. Federal guidelines for treatment have not been used to reduce the cost of health care. Rather, the focus has been on financial reimbursement. Court review of insurance coverage has not been a primary intervention to lower health care costs. DIF: A REF: 16 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 2. Levels of prevention are used by the nurse to provide a framework or guide for nursing interventions. Focus is based on the clients needs and the care or service that is provided. An example of a true health promotion service is a(n): 1 Aerobic dance class 2 Immunization clinic 3 Diabetic support group 4 Smoking cessation clinic ANS: 1 Examples of health promotion activities include exercise classes, prenatal care, well-baby care, nutrition counseling, and family planning. An immunization clinic is an example of an illness prevention service. A diabetic support group may be an example of a rehabilitation service to adapt to a change in lifestyle. A smoking cessation clinic may be a part of rehabilitation or offered as an illness prevention service. DIF: A REF: 19 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 3. There are many types of health care delivery agencies. An example of a secondary level care agency is a: 1 School 2 Nursing home WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Drug rehabilitation center 4 State-owned psychiatric hospital ANS: 4 A state-owned psychiatric hospital is an example of the secondary level of care in which clients who present with signs and symptoms of disease are diagnosed and treated. A school is an example of preventive or primary care. A nursing home is an example of continuing care. A drug rehabilitation center is an example of restorative care. DIF: A REF: 20 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 4. Which of the following fits within the occupational safety and health categories? 1 Noise exposure 2 3 Firearms safety Swimming lessons 4 Motorcycle helmets ANS: 1 Exposure to environmental hazards within the workplace, such as noise exposure, is one aspect of occupational safety and health. Firearms do not fit within the occupational safety and health category. Swimming lessons do no fit within the occupational safety and health category. Motorcycle helmets do not fit within the occupational safety and health category. DIF: A REF: 20 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 5. A contractual agreement between a hospital and a corporation to pay the health care expenses of the corporations employees is an example of a(n): 1 PPO 2 HMO 3 Private insurance 4 Third-party payment ANS: 1 A preferred provider organization (PPO) is characterized by a contractual agreement between a set of providers (e.g., hospitals, physicians, or clinics) and a purchaser (e.g., the corporations insurance plan). Comprehensive health services are provided at a discount to the companies WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material under contract. Enrollees are limited to a list of preferred hospitals, physicians, and providers. An enrollee pays more out-of-pocket expenses for using a provider not on the list. A Medicare HMO is the same as a managed care organization (all care provided by a primary care physician) but designed to cover costs of senior citizens. Private insurance is the traditional fee-for-service plan where payment is computed after services are provided based on the number of services used. Third-party payment is when an entity (other than the client or health care provider) reimburses health care expenses. Third-party payers include insurance companies, governmental agencies, and employers. DIF: A REF: 18 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 6. The Medicaid insurance program is best described as: 1 Acute care hospital insurance for the older adult population 2 A funded health care program for older and disabled persons 3 A state-regulated health care program for persons of low income 4 A fee-for-service insurance plan that supports preventive health care ANS: 3 Medicaid is a federally funded, state-operated program of medical assistance to people with low incomes. Individual states determine eligibility and benefits. This option describes Medicare. This option describes Medicare Part A. This option does not describe Medicaid. DIF: A REF: 18 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 7. Quality health care is an innovative approach to delivering health care. The major factor for its success is that it: 1 Focuses on the nursing process 2 Uses outcomes to manage client care 3 Is used exclusively in the acute care setting 4 Allows a high degree of flexibility delivering the care ANS: 2 Health care providers are defining and measuring quality in terms of outcomes. An outcome is a measure of what actually does or does not happen as a result of a process of care. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The focus in quality health care is on the outcome, not the process. Quality health care is not used exclusively in the acute care setting. It may be used in various health care settings. Because quality health care is based on achieving outcomes, it does not allow a high degree of flexibility for the nurse in delivering care. DIF: A REF: 27 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 8. Case management is one strategy for coordinating health care services. What best describes this caregiving approach? 1 2 3 4 Continuity of care is the primary concern. This focus of care may be more expensive. The physician is the coordinator of client care. It is designed to provide minimal to moderate levels of care. ANS: 1 With the case management model of care, the case manager coordinates the efforts of all disciplines to achieve the most efficient and appropriate plan of care. Continuity of care is of primary importance. If the efforts of all disciplines are well managed, repetition or delays may be avoided with a resultant shortened hospital stay. Therefore this focus of care may not be more expensive. The physician may or may not be the coordinator of client care. The case manager typically is a nurse or social worker. Case management is not entirely based on the level of care required. DIF: A REF: 21 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care/ Case Management 9. The payment mechanism that Medicare uses within its health care financing is: 1 Capitation 2 Fixed payments 3 Direct contracting 4 Prospective payment ANS: 2 Inpatient hospital services for Medicare clients are reimbursed a set amount for each DRG, regardless of the clients length of stay or use of services in the hospital. Capitation is the payment mechanism in which providers receive a fixed amount per enrollee of a health care plan. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The payment mechanism that Medicare uses is not direct contracting. Medicare is not based on fixed payments, but rather on a set dollar amount according to the DRG. DIF: A REF: 27 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 10. A student nurse visiting a nurse-managed clinic should expect to see which of the following services offered? 1 2 3 4 Physical therapy Same-day surgery Family support services Ongoing psychiatric therapy ANS: 3 Nurse-managed clinics focus on health promotion and health education, disease prevention, chronic disease management, and support for self-care and caregivers. Physical therapy is not typically offered in a nurse-managed clinic. Same-day surgery is not offered in a nurse-managed clinic. Psychiatric therapy is not offered in a nurse-managed clinic. DIF: A REF: 21 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 11. A disabled client requiring restorative care should be referred to a(n): 1 Nursing home 2 Subacute care unit 3 Home health care agency Ambulatory health center 4 ANS: 3 A home health care agency provides health services to individuals and families in their home to promote, maintain, or restore health, or to maximize the level of independence while minimizing the effects of disability and illness. A nursing home is a long-term care setting in which clients receive 24-hour intermediate and custodial care. A subacute care unit is not the best referral for restorative care. An ambulatory health center is not the best referral for restorative care. DIF: A REF: 16 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 12. Which of the following is an appropriate referral for an older client who requires some assistance with daily activities within a partially protective environment? 1 2 3 4 Respite care Extended care Assisted living Rehabilitative care ANS: 3 The appropriate response is assisted living. A group of residents live together, each resident having his or her own room, yet sharing dining and social activity areas. Respite care is a service that provides short-term relief for persons providing home care to the ill or disabled. An extended care facility provides intermediate medical, nursing, or custodial care for clients recovering from acute or chronic illness or disabilities. Rehabilitative care includes physical, occupational and speech therapy, and social services to help restore clients to their fullest ability. DIF: A REF: 20 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 13. Discharge planning for clients begins: 1 After a diagnosis has been established 2 Once the long-term needs are identified 3 Upon admission to a health care facility When the acute care therapies are completed 4 ANS: 3 Discharge planning should begin at the time of admission to the hospital, using the strengths and resources of the client, providing resources to meet the clients limitations, and focusing on improving the clients long-term outcomes. The clients diagnosis does not have to be established before discharge planning can begin. Discharge planning should include preparation for long-term needs of the client. Acute care therapies may impact a clients discharge and should be a part of the plan from the beginning. DIF: A REF: 23 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 14. A client states that she does not understand managed care organization (MCO) health insurance. The nurse responds most appropriately by explaining that the MCO: 1 Reimburses nursing home funding WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Focuses on health maintenance and primary care 3 Allows the individual to go to any physician that he desires 4 Requires a contractual agreement between the health provider and clients employer ANS: 2 In a managed care organization (MCO), a primary care physician provides all care and the focus is on health maintenance and primary care. Medicaid reimburses nursing home funding. In a managed care organization, referral by the primary care physician is necessary for access to specialists and for hospitalization. A PPO is limited to a contractual agreement between a set of providers and one or more purchasers. DIF: A REF: 25 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 15. Which form of health care is of primary importance when dealing with managed care? 2 Health promotion Disease prevention 3 Tertiary treatment 4 Secondary treatment 1 ANS: 1 If people stay healthy, the cost of medical care declines. Systems of managed care focus on containing or reducing costs, increasing client satisfaction, and improving the health or functional status of the individual (Sultz and Young, 2004). Health promotion: Activities that develop human attitudes and behaviors to maintain or enhance well-being. Disease prevention: Activities that protect people from becoming ill because of actual or potential health threats. Tertiary prevention: Care that prevents further progression of disease. Secondary prevention: Early diagnosis and treatment of illness (e.g., screening for hypertension). DIF: C REF: 21 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Management of Care 16. A nurse is consulting with a homeless family who has a 12-year-old disabled child. The nurse suggests which of the following services to best assist with the childs health care needs? 1 2 Medicare Medicaid WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Long-term care insurance 4 An extended care faculty ANS: 2 Medicaid is a federally funded, state-operated program that provides (1) health insurance to lowincome families and (2) health assistance to low-income people with long-term care (LTC) disabilities. Chapter 3. Community-Based Nursing Practice MULTIPLE CHOICE 1. The student nurse is investigating different types of practice settings. In looking at community health nursing, the student recognizes that it: 1 Is the same as public health nursing 2 3 Focuses on the incidence of disease Requires graduate-level educational preparation 4 Includes direct care and services to subpopulations ANS: 4 Community health nursing strives to safeguard and improve the health of populations in the community as well as providing direct care services to subpopulations within a community. Public health nursing is concerned with trends and patterns influencing the incidence of disease within populations. A community health nurse may be involved in direct client care for disease within a community. Public health nursing focuses on the needs of populations. Community health nursing has a broader focus, with an emphasis on the health of a community. The community health nurse merges public health knowledge with nursing theory. The community health nurse considers the needs of populations and is prepared to provide direct care services to subpopulations within a community. Nurses who become expert in community health practice may have advanced nursing degrees, yet the baccalaureate-prepared generalist also can become quite competent in formulating and applying population-focused assessments and interventions. DIF: A REF: 34 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. As a community health nurse assisting the client and family with nutritional needs the nurse should first: 1 Identify for the client the best foods to buy 2 Purchase foods at the lowest cost for the client 3 Ask the client and family what they think they should eat 4 Provide information on stores with the most reasonable pricing ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material With the goal of helping clients assume responsibility for their own health care, the community health nurse must assess a clients learning needs and readiness to learn within the context of the individual, the systems the individual interacts with, and the resources available for support. Asking the client about what foods he or she thinks should be eaten may help the nurse assess the clients level of knowledge regarding nutrition as well as the clients food preferences. It also enables the client to become a participant in his or her care. Telling the client what foods to buy does not encourage the client to assume responsibility for managing his or her health care. The nurse should first assess the resources available, and then encourage the client to do his or her own shopping. Providing information on food sources and stores with reasonable pricing may be appropriate after the nurse has determined what information the client requires to meet nutritional needs. DIF: C REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. Which one of the following clients from a vulnerable population currently appears to be at the greatest risk? 1 2 3 4 A physically abused client in a shelter A schizophrenic client in outpatient therapy An older adult taking medication for hypertension A substance abuser who shares drug paraphernalia ANS: 4 A client with substance abuse has health and socioeconomic problems. These clients frequently may avoid health care for fear of judgmental attitudes by health care providers and concern over being turned in to criminal authorities. An abused client in a shelter has sought protection so currently should be at less risk. Although considered to be a member of a vulnerable population, the older adult who takes medication for a chronic disease, such as hypertension, is taking measures to maintain health. A schizophrenic client in outpatient therapy is currently at less risk because he or she is receiving treatment. DIF: C REF: 36 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. A client with a history of a gastrointestinal disorder eats a well-balanced diet that keeps his GI symptoms suppressed. Which level of prevention corresponds to his dietary management? 1 Health promotion 2 Primary prevention 3 Tertiary prevention 4 Secondary prevention WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 3 The goal of tertiary prevention is to preclude further deterioration of physical and mental function in a person who has an existing illness, and to have the client use whatever residual function is available for maximum enjoyment of and participation in lifes activities. Health promotion is aimed at reducing the incidence of disease and its impact on people. Primary prevention is aimed at general health promotion. Secondary prevention is aimed at early recognition and treatment of disease. DIF: A REF: 37 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. Which of the following statements by the home health nurse best reflects client advocacy in response to the clients concern over the expense of the therapy? 1 2 Have you considered the possibility of a renal transplant? This peritoneal dialysis is less expensive than hemodialysis. 3 You must feel awful about this situation, but this is the best course of treatment for you. 4 Lets call the regional dialysis center and explore options for reducing the cost of your home dialysis. ANS: 4 Calling the regional dialysis center and exploring options for reducing cost demonstrates the nurse acting as client advocate by identifying and assisting the client in contacting the appropriate agency for information and resources to meet the clients needs. Asking the client whether he has considered renal transplantation does not demonstrate client advocacy. Pointing out the difference in cost for dialysis in the home versus the hospital does not meet the clients need to reduce the expenses of his therapy. The nurse is not demonstrating patient advocacy. Telling the client that this is the best treatment for him does not address his financial concerns. The nurse is not demonstrating patient advocacy with this response. DIF: C REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. In assessing the structure of the community in order to identify the needs of its population, the nurse will focus on: 1 Collecting demographic data on age distribution 2 Visiting neighborhood schools to review health records 3 Interviewing clients to determine the cultural composition of the subgroups WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Observing locations where services, such as water sanitation, are provided ANS: 4 When assessing the structure or locale of a community, the nurse should travel around the neighborhood or community and observe its design; the location of services, such as water and sanitation; and the locations where residents congregate. Collecting demographic data on age distribution would be an assessment of the communitys population. Visiting neighborhood schools to review health records is an example of assessing a social system within a community. Interviewing clients to determine the cultural composition of subgroups is an example of assessing the population within a community. DIF: A REF: 41 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. To facilitate change within a community, the nurse working as an effective change agent should: 1 Inform community members how to effectively manage their health needs 2 Work with clients and groups to select alternative health care sites and treatments 3 Formulate decisions for individual clients regarding their health care options 4 Provide instruction in the way the community should address health issues ANS: 2 As a change agent, the nurse seeks to implement new and more effective approaches to problems. The nurse creates change by working with and empowering individuals and their families to solve problems or to become instrumental in changing aspects affecting their health care. Telling community members how to manage their health care needs may meet resistance. It also does not enable clients and their families to take responsibility for their health care. Making decisions for clients does not enable individuals to assume responsibility for their health care decisions. The community-based nurse acting as a change agent may be an excellent resource for health information to members of the community. Ultimately; however, the community members will take an active role to create change for themselves and will assume responsibility for their health care decisions. DIF: A REF: 39-40 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 8. The client is being discharged from an acute care facility following a total hip replacement. She will need follow-up for her rehabilitation and exercise plan. In addition to a home health care nurse, what referral should be discussed? 1 Dietitian 2 3 Social worker Physical therapist 4 Respiratory therapist ANS: 3 Directing clients to appropriate resources and improving continuity of care require the nurse to know those resources well. A physical therapist is responsible for the clients movement system and is likely to be needed following hip replacement surgery. A social worker may or may not be necessary. A dietitian may or may not be necessary. A respiratory therapist would not be necessary unless the client experienced a respiratory complication or had a preexisting respiratory condition. DIF: A OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. The nurse recognizes which of the following as the largest contributing factor for the rise in the need and use of home care? 1 Government funding of the home care setting has increased greatly. 2 Clients are more acutely ill when discharged from the acute care facility. There are 7 days/week services for the elderly in home care agencies. 3 4 The existence of more single-income families has increased the need for their elderly relatives to receive care in the home. ANS: 2 Because hospital stays are being shortened to control health care costs, clients are returning home more acutely ill. This is the largest contributing factor for the rise in the need and use of home care. Government funding of home care is not the largest contributing factor for the rise in the need and use of home care. There are 7 days/week services for the elderly in a variety of settings, such as in acute care or long-term care, not just in the home care setting. Being able to provide daily services for the elderly in the home care setting is not the largest contributing factor for the rise in the need and use of home care. The existence of more single-income families is not the largest contributing factor for the rise in the need and use of home care. DIF: C REF: Chapter 2, 22 OBJ: Analysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. One of the overall goals of Healthy People 2010 is to: 1 Increase life expectancy 2 3 Decrease health care costs Promote managed care organizations 4 Establish the credentials of service providers ANS: 1 The overall goals of Healthy People 2010 are to increase the life expectancy and quality of life and to eliminate health disparities. The initiative of Healthy People 2010 is to improve the delivery of health care services to the general public. The overall goal did not focus on reducing health care costs. Although managed care organizations may increase in number, this was not a goal of the Healthy People 2010 initiative. Establishing the credentials of care providers was not a goal of Healthy People 2010. DIF: A REF: 33 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. When assessing members of a vulnerable population, the community health nurse should realize that the primary need is to: 1 Provide culturally competent assessment. 2 Organize in your mind exactly what you need to ask. 3 Create a comfortable, nonthreatening environment. 4 Be alert for indications of mental and physical abuse. ANS: 3 In order to be successful in assessing a member of a vulnerable population, the nurse must first create an environment that is encourages the client to cooperate with and actively participate in the assessment process While it is important that the nurse be cultural considerate of the client, it is not the primary need of those offered as options. While organization to thought is important to the effective use of time needed for an assessment, it is not the primary need of those offered as options. While vulnerable populations may be more susceptible to both mental and physical abuse making observation for signs of abuse important, it is not the primary need of those offered as options DIF: C REF: 35 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 12. The nurse working in a free clinic often utilized by Hispanic immigrants is assessing a client who reports a cough and malaise. The client is hearing impaired, speaks very little English and is currently living in a homeless shelter. The nurses primary concerns should be the clients: 1 Language barrier 2 3 Risk for tuberculosis Hearing impairment 4 Lack of health care resources ANS: 2 Risk for tuberculosis presents the greatest risk since it is supported by the physical signs, is highly contagious and a risk factor among the homeless and some immigrant populations. The language barrier is a concern since it impacts the communication between the nurse and the client but it is not the primary concern among the options offered. The clients hearing impairment is a concern because it has an impact on the communication between the nurse and the client but it is not the primary concern among the options offered. The clients lack of insurance is a concern because it affects the treatment plan necessary for the clients recovery, but it is not the primary concern among the options offered. DIF: C REF: 36 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. A nurse is planning interventions for the clients of a homeless shelter. Which of the activities represents a primary level intervention regarding sexually transmitted diseases? 1 HIV screening for all residents 2 Sex education for teenage residents 3 Treatment for residents diagnosed with AIDS Gynecological referrals for female residences 4 ANS: 2 Primary level interventions are directed a preventing the disease. Educational programming is generally considered a primary intervention. Screening a disease is generally considered a secondary level intervention. Treatment of the disease is generally considered a tertiary level intervention. Referrals are generally considered a secondary intervention. DIF: A REF: 36 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. The nurse working in a free clinic is caring for a homeless client diagnosed with paranoid schizophrenia who has reported that, I hurt my foot running away from them. It hurts so bad I can hardly walk now. On assessment the nurse notices bruising on the clients back, arms, and WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material thighs, a red rash on both neck and face, and poor personal hygiene, in addition to edema of the left ankle. The nurse should first realize that this client is at risk for: 1 2 3 4 Physical abuse and assault Drug addiction relating to pain Communicable immune disorders Hospitalization due to mental disorder ANS: 1 When a client has a severe mental illness such as schizophrenia there are multiple health and socioeconomic problems you will need to explore. Many clients with pervasive mental illnesses are homeless or live in poverty. In addition, mentally ill clients are at greater risk of abuse and assault. This clients reported foot injury and observable bruising support the possibility of abuse/ assault. While drug abuse may be a consideration, it does not represent the best option offered for this item because there is not indication that the client is drug seeking. Contacting communicable diseases is a risk factor for such a client but it does not represent the best option offered for this item because there are several factors that may indicate abuse/assault. Hospitalization may be required but it does not represent the best option offered for this item because there is no indication that the client is experiencing a psychiatric crisis. DIF: C REF: 37 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. A community nurse has identified a need for educational programming among the residents of an assistive living facility dealing with osteoarthritis. The best example of such programming is: 1 Planning the best exercise program for you. 2 Recognizing how arthritis has affected your life. 3 Proper self administration of antiinflammatory medication Be an informed consumerdont fall for false arthritis cures. 4 ANS: 4 Thorough assessment and appropriate community based interventions provide an opportunity to improve the lifestyle and quality of life of older adults in general. The focus is on broad-based needs not specific client needs. Answer 4 offers information applicable to the entire resident population diagnoses with osteoarthritis. DIF: C REF: Chapter 2, 19 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. A homeless client has presented in the ED with a bacterial infection in a hand wound. The nurse has cleansed and dressed the wound, and an initial dose of an antibiotic has been WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material administered. The client will need the antibiotic prescription filled and a dressing change in 3 days. In order to ensure that the client will receive the appropriate follow-up care, the nurse must first act as the clients: 1 Educator 2 3 Advocate Caregiver 4 Counselor ANS: 2 Client advocacy perhaps is more important today because of the confusion surrounding access to health care services. Your clients often need someone to help them walk through the system, identify where to go for services and tell them how to reach the individuals with the appropriate authority, what services to request, and how to follow through with the information they received. The role of the educator is to help the client assume responsibility for his or her own health care. This client has been educated to the needs related to caring for the infection but needs the nurse advocate to assist with facilitating the care. As caregiver, the nurse manages and cares for the clients health. You apply the nursing process (see Unit III) in a critical thinking approach to ensure appropriate, individualized nursing care for specific clients and their families. This clients nursing care has been appropriated delivered and so that nursing role has been fulfilled. A counselor assists clients in identifying and clarifying health problems and in choosing appropriate courses of action to solve those problems. The client is first in need of assistance in dealing with the obstacles to the care of the identified probleminfection. DIF: C REF: 37-38 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. A nurse is discussing the need to use a specific cleansing agent when redressing an infected hand. The client prefers using, plain old soap and water. The nurse knows that the primary factor that will affect client compliance is: 1 The ease with which the client can use the special agent 2 The clients acceptance of the need for the specialized care 3 The availability and cost of the prescribed cleansing agent 4 The introduction of an incentive to prompt client to comply ANS: 2 Client must perceive the innovation or change as more advantageous than other alternatives or they will not make the change. Client education is essential in bringing about the change in attitude necessary for change. While the client is more likely to adapt the change if it is perceived as being easy, it is not the primary factor in achieving client compliance provided among the options available because client compliance is primarily a result of the clients understanding of WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material the need for change. While cost to the client is a factor, it is not the primary factor in achieving client compliance provided among the options available since client compliance is primarily a result of the clients understanding of the need for change. An incentive is sometimes necessary, but it is not the primary factor in achieving client compliance provided among the options available, because client compliance is primarily a result of the clients understanding of the need for change. DIF: C REF: 39 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. The nurse is assessing a client diagnosed with chronic bronchitis who has been experiencing an increase in dyspnea. The client lives within 2 blocks of a factory that emits pollution into the air. In light of this information, the nurse is primarily concerned with: 1 Performing a complete client health history and physical assessment 2 Providing the client with assess to all the required breathing treatments 3 Identifying a correlation between the pollution and the clients increased dyspnea 4 Determining the availability of alternate housing for the client away from the factory ANS: 3 There may be many factors that are affecting the clients breathing. Determining the clients exposure to the pollution and its affects of the clients breathing would be the nurses primary concern for this client. The assessment and history is important but is not the best option available regarding the effects of air pollution on the clients respirations. The availability of required breathing treatments is important but it is not the best option regarding the effects of air pollution of the clients respirations. It may be necessary for the client to consider moving but only if it is determined that the pollution is responsible of the increase in the dyspnea. DIF: A REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which of the following clients is a concern for the community health nurse? (Select all that apply.) 1 The homeless woman with a history of congestive heart failure 2 The elderly gentleman who fell while disembarking from a bus WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 The child of itinerant workers who has a developed asthma 4 A client diagnosed with HIV who recently lost her insurance 5 A 15-year-old who was injured while at a public swimming pool 6 A retired service veteran who has a chronic psychiatric disorder ANS: 1, 3, 4 Community-based health care occurs outside traditional health care institutions, such as hospitals. It provides services for acute and chronic conditions to individuals and families with in the community (Stanhope and Lancaster, 2006). Some of these problems include an increase in homeless and immigrant populations, an increase in sexually transmitted diseases, underimmunization of infants and children, and life-threatening diseases (e.g., clients living with HIV and other emerging infections). All of these clients possess risk factors that are community based DIF: C REF: 40 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. A nurse working with clients at or below the poverty level recognizes that the life expectancy of these clients is lower than the general population because of: (select all that apply.) 1 Inadequate nutritional diets 2 High-risk work environments 3 Hazardous living environments Addictive and abusive lifestyles 4 5 6 Predisposition to chronic diseases Ineffective decision making abilities ANS: 1, 2, 3, 4 People who live in poverty are more likely to live in hazardous environments, work at high-risk jobs, eat less nutritious diets, abuse substances, and have multiple stressors in their life. When researchers compared the life expectancies of European Americans and African-Americans, the causes of the differences were related to low socioeconomic status rather than ethnicity. Predisposition to chronic disease in part is genetic in nature and research has confirmed no such link between poverty and chronic disease. Decision-making ability is not the only factor affecting decision making. Poverty negatively affects the individuals ability to access recourses and adds stressors such as finding shelter that can alter the decision-making process. Chapter 4. Theoretical Foundations of Nursing Practice MULTIPLE CHOICE WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. In preparing to review different theories, the nurse reviews basic information to assist in understanding the material. Theories are defined as: 1 2 Mental formulations of objects or events Aspects of reality that can be consciously sensed 3 Statements that describe concepts or connect concepts 4 Concepts or propositions that project a systematic view of phenomena ANS: 4 A theory is a set of concepts, definitions, relationships, and assumptions that project a systematic view of phenomena. Mental formulations of objects or events are called concepts. Aspects of reality that can be consciously sensed are called phenomena. Statements that describe concepts or connect concepts are called assumptions. DIF: A REF: 46 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. There are different types of theories that may be used by nurses seeking to study the basis of nursing practice. When the goal of a theory is to speculate on why phenomena occur, it is termed a: 1 Grand theory 2 Prescriptive theory 3 Descriptive theory Middle range theory 4 ANS: 3 Descriptive theories describe phenomena, speculate on why phenomena occur, and describe the consequences of phenomena. Grand theories provide the structural framework for broad, abstract ideas about nursing. Prescriptive theories address nursing interventions and predict the consequence of a specific nursing intervention. Middle range theories address specific phenomena or concepts and reflect practice. DIF: A REF: 47 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3. Which one of the four linkages of interest in the nursing paradigm refers to factors in the home or school? 1 2 3 4 Person Health Nursing care Environment ANS: 4 Environment/situation includes all possible conditions affecting the client and the setting in which health care needs occur, such as the home, school, workplace, or community. Person refers to the recipient of nursing care, including individual clients, families, and the community. Health is the goal of nursing care. Nursing care refers to the diagnosis and treatment of human responses to actual or potential health problems (ANA, 1995). DIF: A REF: 45 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. The nurse is working within a health care system that employs Neumans theory. A client is having difficulty breathing and requires oxygen and medication. Within Neumans theory, the nurse approaches the client to: 1 Achieve the 14 basic needs 2 Promote attainment of biological self-care requisites 3 Assist in physiological adaptation to internal changes Strengthen the line of defenses at the secondary level of prevention 4 ANS: 4 Neumans framework for practice included nursing actions as primary, secondary, or tertiary levels of prevention in caring for clients holistically. Secondary prevention strengthens internal defenses and resources by establishing priorities and treatment plans for identified symptoms. In Hendersons theory, nurses help the client to perform 14 basic needs. The goal of Orems theory is to promote attainment of self-care. Roys theory focuses on adaptation. DIF: A REF: 49 OBJ: Comprehension WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. Although there are similarities in the different nursing theories, there are key elements that distinguish one from another. The emphasis of Jean Watsons conceptual model is that: 1 2 3 4 Self-care maintains wholeness Stimuli disrupt an adaptive system Subsystems exist in dynamic stability Caring is central to the essence of nursing ANS: 4 Like Benner and Wrubels theory, Watson emphasized caring in her theory. Watsons model is designed around the caring process, assisting clients in attaining or maintaining health or in dying peacefully. The key emphasis of her theory is that caring is the moral ideal: mind-bodysoul engagement with another. Self-care is central to Orems theory. The key emphasis of Roys theory is that stimuli disrupt an adaptive system. The key emphasis of Johnsons theory is that subsystems exist in dynamic stability. DIF: A REF: 50-51 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. A community health nurse is working with a variety of clients and decides to use a systems theory approach to assist them to meet their health care needs. In using this approach, the nurse focuses on the: 1 Hierarchy of the clients human needs 2 Clients interaction with the environment 3 Clients attitudes toward health behaviors Response of the client to the process of growth and development 4 ANS: 2 According to systems theory, a system is made up of parts that rely on one another, are interrelated, share a common purpose, and together form a whole. A clients interaction with the environment is an example of an open system. The nurse understands factors that change the environment can also have an impact on the system. Maslows hierarchy of human needs is an interdisciplinary theory useful in planning individualized care. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Determining a clients attitudes toward health behaviors follows a health-and-wellness theoretical model. Focusing on the response of a client to the process of growth and development is consistent with developmental theories. DIF: A REF: 47 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. While working on a postoperative unit, the nurse is applying the elements of the self-care theory. The nurse who assists the client to manage or attain self-care in wound management is using the theory developed by: 1 2 Imogene King Dorothea Orem 3 Virginia Henderson 4 Florence Nightingale ANS: 2 The goal of Orems theory is to help the client perform self-care. The goal of Kings theory is to use communication to help the client reestablish positive adaptation to the environment. The goal of Hendersons theory is to work independently with other health care workers assisting the client to gain independence as quickly as possible. The goal of Nightingales theory is to facilitate the bodys reparative processes by manipulating the clients environment. DIF: A REF: 50 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. Martha Rogers theory has a framework for practice that includes the: 1 Manipulation of the clients environment 2 21 nursing problems within 4 major client needs 3 Seven categories of behavior and behavioral balance 4 Unitary human being in continuous interaction with the environment ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The framework for practice according to Martha Rogers theory is the unitary human continuously changing and coexisting with the environment. Nightingales theory includes manipulation of the clients environment (i.e., appropriate noise, nutrition, hygiene, light, comfort, socialization, and hope) in the framework for practice. Abdellahs nursing theory includes 21 nursing problems within 4 major client needs in the framework for practice. Johnsons theory includes seven categories of behavior and behavioral balance in the framework for practice. DIF: A REF: 50 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. The nurse plans to apply a theory that focused on stress reduction. A theory proposed by which one of the following individuals should be selected? 1 2 3 4 Parse Peplau Neuman Orlando ANS: 3 Stress reduction is the goal of the systems model of nursing practice according to Neumans theory. Parses theory focuses on indivisible beings and the environment co-creating health. Peplaus theory focuses on the interpersonal process as the maturing force for personality. Orlandos theory focuses on the interpersonal process to alleviate distress. DIF: A REF: 49 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. A similarity between the theories of Leininger and of Benner and Wrubel is: 1 Caring as a central focus 2 The clients adaptation to demands 3 An emphasis on the maximum level of wellness 4 Dynamic interpersonal communication ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Leininger states that care is the essence of nursing and the dominant, distinctive, and unifying feature of nursing. Caring is also central to the theory of Benner and Wrubel, depicting personal concern as an inherent feature of nursing practice. The theories of Roy and Johnson focused on the clients adaptation to demands. Neumans theory places emphasis on achieving a maximum level of wellness. Abdellahs theory also addressed the person as a whole. Kings theory and Peplaus theory share a similarity with a focus on interpersonal communication. DIF: A REF: 50-51 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. The nurse is working with a client diagnosed with multiple sclerosis. The goal is that the client will be capable of living independently. The nursing theory that best supports this clients situation is: 1 2 3 4 Orems theory Neumans theory Abdellahs theory Hendersons theory ANS: 1 According to Orem, the goal of nursing is to increase the clients ability to independently meet biological, psychological, developmental, or social needs. Neumans theory is concerned with the whole person. According to Neuman, the focus of nursing is on the variables affecting the clients response to a stressor. Abdellahs theory emphasizes the delivery of nursing care for the whole person. According to Henderson, nurses help clients to perform 14 basic needs. DIF: A REF: 50 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. While the nurse realizes that the definition of health is unique to the client, the most universal factor is that health is: 1 Dynamic and ever-changing 2 Affected and managed by the nurse 3 Determined by internal and external forces 4 Perceived and defined by the individual WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 1 Health has different meanings for each client, the clinical setting, and the health care profession (see Chapter 6). Health is dynamic and continuously changing. Your challenge is to provide the best possible care based on the clients level of health and health care needs at the time of care delivery. While the other options may be true, they are not universally true to all individuals because not everyone is involved in a nurse-client relationship, wellness can be affected by internal factors, external factors, or a combination of both, and not everyone is capable of perceiving and defining their own wellness. DIF: C REF: 45 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. Which of the following statements by the nurse best defines nursing diagnoses for a client? 1 It is the basis for a clients care plan. 2 It is what we nurses use to plan your care. 3 It is one of a set of standardized client oriented problems. 4 It is the way nurses identify what specific needs a client has. ANS: 4 In medicine, physicians diagnose and treat disease. In contrast, nursing is the diagnosis and treatment of human responses to actual or potential health problems (ANA, 2003). The scope of nursing is broad. For example, a nurse does not medically diagnose the clients heart condition but instead assesses the clients response to the disease and may develop nursing diagnoses of fatigue, change in body image, and altered coping. From these nursing diagnoses, the nurse creates an individualized plan of care for each of the clients health problems. Although the other statements are correct, they are not the best options available because they do not fully explain the function of a nursing diagnosis. DIF: C REF: 45 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. The nurse is caring for a client newly diagnosed with type 2 diabetes mellitus. Which of the following nursing interventions best reflects Orems nursing theory? 1 Arranging for a consult with a certified diabetic nurse educator 2 Demonstrating proper documentation of glucose testing results 3 Explaining the role of A1C values in the management of glucose levels WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Preparing discharge teaching to reinforce proper finger-stick technique ANS: 4 If a nurse uses Orems theory in practice, the nurse assesses and interprets the data to determine the clients self-care needs, self-care deficits, and self-care abilities in the management of a disease. The theory then guides the design of individualized nursing interventions. While the other interventions are appropriate and will ultimately affect effective client self-care/ management of the diabetes, they are not the correct option because they are not directly involved in determining client self-care needs. DIF: C REF: 50 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. Swansons theory of caring is best demonstrated when the nurse: 1 Demonstrates efficiency when performing ordered treatments 2 Offers to stay with the client during a painful bedside procedure 3 Administers the clients pain medication promptly when requested Frequently updates a family regarding a clients status during surgery 4 ANS: 2 Swansons theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief. These components provide a foundation of knowledge for the direction and delivery of caring nursing practice. This theory provides a basis for identifying and testing nurse caring behaviors to determine if caring improves client health outcomes. Offering to stay with the client is an intervention directly reflected of being with the client. Efficiency is a component of caring but it is not the best option available because it is not exclusively directed toward Swansons theory. Administering pain medication promptly reflects effective nursing care as well as a clients right. It is a component of caring but it is not the best option available because it is not exclusively directed towards Swansons theory. Effective nursing care and caring for the family is important, but it is not the best option available because it is not directed towards the client. DIF: C REF: 46 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 16. Which of the following responses observed in a client recently diagnosed with lung cancer is most directly addressed by the Neuman System Model? 1 The client asks for a consult with the hospital clergy. 2 The client is observed crying after his family has left for the day. 3 The client asks for pictures of his children to be brought to him in the hospital. 4 The client is heard saying, I trust my health team, and Ill do what they suggest. ANS: 2 Examples of phenomena of nursing include caring, self-care, and client responses to stress. In the Neuman Systems Model (1995), phenomena include all client responses, environmental factors, and nursing actions. Crying is reflective of a clients response to stress to a second level need (Maslows) and so is directly related to Neumans model. While consulting with clergy is reflective of a client need, it is higher on Maslows hierarchy and so not the best option available. While requesting family photos is reflective of a client need, it is higher on Maslows hierarchy and so not the best option available. The client stating that he/she will trust the health team is reflective of a client response, it is less reflective of a need and so not the best option available. DIF: C REF: 49 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. A client diagnosed with type 2 diabetes mellitus reports poor glucose control since starting her new stressful job. The nurse uses Neumans theory to focus on the: 1 Identification of new stressors and improve dietary choices 2 Acquisition of appropriate interpersonal communication skills 3 Learning of effective coping methods and relaxation techniques 4 Implementation of both aerobic and anaerobic exercise routines ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The Neuman Systems Model uses a systems approach to describe how clients deal with stressors in their internal or external environments. Nurses using Neumans theory in practice focus their care on client responses to the stressors (Meleis, 2006). For example, when a client takes on a new role within their employment, they may react to the stress by eating an improper diet. In this situation the nurse focuses on the client response to the stressors and designs interventions related to improving nutritional intake, both actions directed towards improving glucose control. While acquiring good interpersonal communication skills may help minimize the stress the client is currently experiencing, it does not address identifying the source of the stress or the management of the type 2 diabetes. While acquiring effective coping and relaxation skills may help manage the stress the client is currently experiencing, it does not address identifying the source of the stress or the management of the type 2 diabetes. While implementing effective exercise routines may help in the management of the type 2 diabetes, it does not address identifying the source of the stress or the thorough management of the type 2 diabetes. DIF: C REF: 46 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. The best example of an appropriate nursing assumption is: 1 Clients will make their needs and wants known to the staff 2 Clients require a quiet, darkened environment in which to sleep 3 Prompt administration of pain medication is an expectation of a postoperative client 4 A client recently diagnosed with cancer will want family present when discussing treatment options ANS: 3 Assumptions are the taken for granted statements that explain the nature of the concepts, definitions, purpose, relationships, and structure of a theory (Meleis, 2006; Chinn and Kramer, 2004). It is a reasonable assumption that a client who recently underwent surgery would require and expect prompt administration of medications to manage that pain. Not all clients will openly communicate their needs/wants to the staff so this option is not the best example offered. While most clients will rest effectively in a quiet, darken environment, it is not required by all clients so this option is not the best example offered. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material While many clients will want family present in this situation, not all will. Therefore this option is not the best example offered because an incorrect assumption would result in a violation of a clients right to privacy. DIF: C REF: 46 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 19. An example of a nursing activity directed towards providing input to the nursing process is: 1 Assessing a client who has just reported being nauseated 2 Discussing various ways to increase calcium intake with a client 3 Asking the client to identify when she would like to be ambulated 4 Documenting a clients pain level 30 minutes after being medicated ANS: 1 Input for the nursing process is the data or information that comes from a clients assessment (i.e., how the client interacts with the environment and the clients physiological function). This is an example of the nursing process content: the information about the nursing care for clients with specific health care problems. Feedback serves to inform a system about how it functions: how the client responds to the intervention. Output is the end product of a system and in the case of the nursing process it is whether the clients health status improves or remains stable as a result of nursing care. DIF: C REF: 47 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 20. The nurse realizes that which of the following stated client needs has the highest priority? 1 A clients reaction to facial scarring after an automobile accident 2 A client who is crying hysterically upon hearing of her sons death A homeless clients fear that his belongings will be stolen while he is hospitalized 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 An asthmatic clients concern regarding the lack of insurance to pay for her medications ANS: 4 The second level of Maslows hierarchy includes safety and security needs, which involve physical and psychological security. The clients concern about securing the medication needed to minimize the potential for breathing problems has the highest priority of the options available. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. Although important, a clients concern regarding her appearance would not have priority over the other options available. The third level contains love and belonging needs, including friendship, social relationships, and sexual love. Although important, a clients reaction to the loss of a loved one does not have priority over the other options available. The second level of Maslows hierarchy includes safety and security needs, which involve physical and psychological security. While the clients concern for the safety of his belongs is on the same level, it does not take priority over the client whose concern relates to potential breathing problems. DIF: C REF: Chapter 6, 72 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. Which of the following statements best expresses the primary goal of nursing practice? 1 To identify client needs in order to facilitate improved health and wellness 2 To tend to the physical and psychosocial needs of both the client and his family 3 To provide effective, research-based nursing care specifically tailored to each clients needs To perform the required treatments and interventions directed towards client recovery from illness 4 ANS: 3 Providing excellent, evidenced-based nursing care is an expectation for all nurses and the care they provide. Although other options are reflective of an appropriate nursing outcome, they are not the best descriptions of nursings primary goal. Chapter 5. Evidence-Based Practice MULTIPLE CHOICE WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. Which of the following research approaches is an example of an exploratory type of research? 1 Establishing facts and relationships of past events 2 3 Testing how well a program, practice, or policy is working Refining a hypothesis on the relationships among phenomena 4 Portraying the characteristics of persons, situations, or groups ANS: 3 An example of an exploratory type of research is to develop or refine a hypothesis about the relationships among phenomena. An example of a historical type of research is to establish facts and relationships concerning past events. An example of an evaluation type of research is to test how well a program, practice, or policy is working. An example of a descriptive type of research is to accurately portray characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur. PTS: 1 DIF: A REF: 62 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The Health Information Portability and Accountability Act (HIPAA), implemented in 2003, may influence nursing research in the area of: 1 The cost of the study 2 Where the study may be published 3 What type of study may be conducted 4 How the data will be obtained and protected ANS: 4 HIPAA regulations identify how protected health information of potential research subjects is to be managed. The researcher must be able to ensure that the data will be protected and used only by the researcher. HIPAA regulations should not influence the area of cost in nursing research. The focus of HIPAA regulations is not on where a study may be published. HIPAA regulations should not influence the type of study conducted. PTS: 1 DIF: A OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3. The expected research role for the baccalaureate-prepared nurse is to: 1 Assume the role of a clinical expert 2 3 Acquire funding for research projects Identify clinical nursing problems in practice 4 Develop methods of inquiry relevant to nursing ANS: 3 Nurses with a baccalaureate degree are prepared to read research critically and use existing standards to determine the readiness of the findings for clinical practice. They also participate in research activities through identification of clinical problems in nursing practice. Nurses with a masters degree assume the role of clinical expert and are able to create a climate in which research-based change can be implemented into practice. Doctorally-prepared nurses are responsible for acquiring funding for research from public and private sources. Doctorally-prepared nurses are prepared to design studies independently including the development of methods of inquiry relevant to nursing. PTS: 1 DIF: A REF: 55 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. When a nurse researcher distributes an explanatory information sheet to subjects solicited for participation in her study, which of the following ethical principles that guide research is this researcher using? 1 Informed consent 2 Freedom from harm 3 Protection of subjects 4 Confidentiality of subjects ANS: 1 As a component of informed consent, research subjects are given full and complete information about the purpose of the study, procedures, data collection, potential harm and benefits, and alternative methods of treatment. Research aspects such as minimizing the risk to participants, allowing reasonable risk to participants in relation to anticipated benefits, and monitoring the research to ensure the safety of participants follow the ethical standard of freedom from harm. In the case of research, institutions have Health Information Portability and Accountability Act (HIPAA) regulations that identify how protected health information of research subjects is to be WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material managed. The nurse researcher who follows HIPAA guidelines is following the principle of protection of subjects. Confidentiality guarantees that any information provided by the subject will not be reported in any manner that identifies the subject and will not be made accessible to people outside the research team. Describing how confidentiality is maintained is a component of informed consent. PTS: 1 DIF: A REF: 63 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. The nurse takes on ethical responsibilities when conducting research with human subjects. Which of the following violates an ethical responsibility associated with informed consent? 1 2 Adhering to verbal and written agreements Using data obtained before the initiation of the study 3 Explaining the possibility of unknown risks when appropriate 4 Providing alternatives, including the right of refusal and standard practices ANS: 2 Using data obtained before the initiation of the study would be a breach of privacy because the participant has not yet given informed consent for use of those data. Adhering to verbal and written agreements is central to informed consent and the implementation of ethical research. One component of informed consent is the inclusion of informing the research subject of the potential harm and benefits. This would include the risks to the subject (including financial risks) and the potential for no benefit. Within the consent document, the researcher must outline alternative methods of treatment and alternatives to participation, including the right to withdraw from the study at any given time. PTS: 1 DIF: A REF: 63 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. Nurses need to become familiar with the elements of a research publication. A brief explanation of the type of measurement to be used is found in which section of a study? 1 Results 2 Methods 3 Conclusion Introduction 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 The methods section of a study includes the description of the sample (what or who was studied), type of data collected, and the device or instrument used to measure empirical information. The results section contains a description of the results obtained in the study, including appropriate statistical tests used to analyze the data. The conclusion consists of the author summarizing implications that can be drawn from the study. The introduction section presents the purpose, a summary of literature used to formulate the study, and the hypothesis tested or the research questions posed. PTS: 1 DIF: A REF: 59 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. After identifying the problem, the next step in the research process is to: 1 Select the population 2 3 Review the literature Obtain approval to conduct the study 4 Identify the instrument to use for data analysis ANS: 2 After identifying the problem, the next step in the research process is to review the literature to determine what is known about the problem. Following identification of the problem and review of the literature, the researcher will design the study protocol. Selecting the population is a component of this phase of the research process. Obtaining necessary approvals is part of conducting the study, which follows the design phase in the research process. Identifying the instrument to use for data analysis occurs during the process of designing the study protocol. This step would occur during the study design phase of the research process after problem identification and literature review have taken place. PTS: 1 DIF: A REF: 58 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. A sample of orthopedic clients varies greatly in their requests for postsurgical analgesics. Which type of nursing research would best examine a prospective group of clients in determining what factors affect their alterations in comfort? 1 Historical research 2 Evaluation research WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Correlational research 4 Experimental research ANS: 3 Correlational research explores the interrelationships among variables of interest (such as factors affecting client comfort) without any active intervention by the researcher. Historical research is designed to establish facts and relationships concerning past events. It would not use prospective groups of clients. Evaluation research tests how well a program, practice, or policy is working. In experimental research, the investigator controls the study variable and randomly assigns subjects to different conditions. PTS: 1 DIF: A REF: 62 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. Which of the following research topics best lends itself to the experimental research process method? 1 The effects of therapeutic touch on a geriatric client diagnosed with Alzheimers disease 2 Prioritizing three nursing diagnoses for a newly admitted client with diabetes mellitus 3 Employing humor as an intervention with clients who are recovering from orthopedic surgery 4 Determining the blood pressure patterns of a client who recently experienced a cerebrovascular accident (i.e., stroke) ANS: 3 In experimental research, the investigator controls the study variable (use of humor) and randomly assigns subjects to different conditions (those who receive humor as an intervention, and those who do not). The effect of therapeutic touch on a geriatric client with Alzheimers disease lends itself to the nursing process as a nursing intervention to perhaps assist a client in meeting a goal of preventing social isolation. To use the experimental research process, there would have to be other clients involved (i.e., a group of clients with Alzheimers disease who receive therapeutic touch, and a group of clients with Alzheimers disease who do not receive therapeutic touch) to determine whether or not therapeutic touch had any effect. Prioritizing nursing diagnoses for client care is an example of using the nursing process. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Determining the blood pressure patterns of a client who recently had a cerebrovascular accident is a part of the assessment phase of the nursing process. In contrast to an experimental research study, no variable is being controlled by the nurse. PTS: 1 DIF: A REF: 62 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. The nurse is looking at different strategies for learning and incorporating new information into practice. A strategy that uses problem-solving is demonstrated by: 1 Repeatedly practicing vital signs until competence is achieved 2 Seeking information from the nurse manager on the clients status Reviewing Maslows hierarchy either in a textbook or on the internet 3 4 Trying different types of colostomy dressings for maximum therapeutic effect ANS: 4 Trying various ways of resolving clients health care needs or evaluating health care products, as in trying different types of colostomy dressings for maximum effect, is an example of the problem-solving strategy for knowledge acquisition. Practicing skills is an example of gaining experience to increase ones knowledge. Information-seeking is a strategy used to obtain knowledge from experts in a particular field. Reviewing Maslows hierarchy in a reference textbook or on the internet is another example of acquiring knowledge through information-seeking. PTS: 1 DIF: A REF: 55 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. A nurse researcher has completed a study involving the use of intravenous analgesics for postsurgical discomfort. The description of the 16 clients used for the study would best be written in which part of the research report? 1 Results section 2 Methods section 3 Discussion section 4 Introduction section WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 A description of the clients used is found in the methods section of the research study. The results section contains a description of the results obtained in the study, including appropriate statistical tests used to analyze the data. The discussion section presents the authors interpretation of the results, including conclusions and implications that can be drawn from the study. The introductory section presents the purpose of the study, a summary of literature, and the hypotheses tested or questions posed. PTS: 1 DIF: A REF: 59 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. A nurse reads about a case study involving the potential positive effects of the early stimulation of posthead-injury clients. Which of the following questions should be a priority consideration before use of the research results? 1 What was the cost of the study? 2 3 Were ethical principles maintained? Were the results of this study published in other journals? 4 Are the clients in the study similar to clients I work with? ANS: 4 Determination of whether the subjects and environment in the study are similar to the clients for whom the nurse provides care in the particular practice setting is necessary before research can be considered for use in practice. Although cost may be a consideration in determining the feasibility of applying research findings, it is not the priority consideration for research utilization. The research findings would first have to be applicable to the practice setting and client population. Even though research may indicate ethical principles were maintained, it does not necessarily mean that it is feasible to apply the findings in practice. For example, cost issues may limit the use of research findings. The number of journals that published the research results of the study should not be the priority consideration in implementation of its findings. To judge the scientific worth of the study; however, it is important to examine the amount of supportive evidence provided by other scientific studies that have obtained similar results. PTS: 1 DIF: C REF: 59 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. An example of a predictive type of question that a nurse might use for research is which of the following? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 What creates an increase in stress levels? 2 3 How often does the stress reaction occur? What does guided imagery mean to clients? 4 If guided imagery is used, will stress levels be reduced? ANS: 4 Questioning whether stress will be reduced is an example of a predictive type of question because it connects stress reduction with the use of guided imagery. Asking what increases stress explores factors that impact a phenomenon. It is not a predictive type of question. Asking how often stress increases does not predict any outcome, but rather focuses on frequency of a response, which could be used in data collection. Asking what guided imagery means does not predict any type of outcome, but rather explores meaning in order to gain understanding. PTS: 1 DIF: A REF: 55 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. A nurse routinely uses therapeutic touch when caring for postoperative clients with incisional pain. Occasionally a client will show reluctance when the intervention is offered. The nurses best response in such a situation is to: 1 Research for alternative interventions that will be better received by the client 2 Suggest that the client allow the intervention just once before making a final decision Respect the clients wishes and rely on pain medication to help with managing the pain 3 4 Inform the client that the intervention has been found to be effective during several research projects ANS: 1 Evidence-based practice is a problem-solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinicians expertise and client preferences and values in making decisions about client care. If the client is not receptive to an intervention, the best nursing response is to search for an alternative evidence-based therapy that the client will accept. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Suggesting the client allow intervention once before making a decision may be considered as long as there is no pressure placed on the client to accept the intervention, but it is not the best option provided because there is no guarantee that the client will be receptive to the intervention, and the problem regarding incisional pain would then go unaddressed. Chapter 6. Health and Wellness MULTIPLE CHOICE 1. When formulating a definition of health, the nurse should consider that health, within its current definition, is: 1 2 3 4 The absence of disease A function of the physiological state The ability to pursue activities of daily living A state of well-being involving the whole person ANS: 4 When formulating a definition of health, a person should consider the total person, as well as the environment in which the person lives. Health generally implies a state of well-being that is ultimately defined in terms of the individual. Health is considered to be more than merely the absence of disease. The definition of health has broadened beyond the physiological state to include mental, social, and spiritual well-being. An individual who has the ability to pursue activities of daily living may not define himself or herself as being healthy. Life conditions such as environment, diet, and lifestyle practices may negatively impact ones health long before the person is unable to perform activities of daily living. DIF: A REF: 69 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. Which one of the following is the main, overarching goal for Healthy People 2010? 1 Reduction of health care costs 2 Elimination of health disparities 3 Investigation of substance abuse Determination of acceptable morbidity rates 4 ANS: 2 Two overarching goals for Healthy People 2010 are (1) to increase quality and years of healthy life and (2) to eliminate health disparities. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Reducing health care costs was not a goal for Healthy People 2010. Investigation of substance abuse was not one of the main, overarching goals for Healthy People 2010. Determining acceptable morbidity rates was not one of the main, overarching goals for Healthy People 2010. DIF: A REF: 69 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. A nurse is using a holistic approach when caring for a client. To incorporate all of the factors that may influence the client, which of the following nursing responses is most therapeutic? 1 2 I would like you to perform this exercise once a day. Your physician has left orders that you are to follow. 3 The laboratory tests reveal the need to reduce your daily percentage of fat intake. 4 Adapting to a low-fat diet and increasing your activity will help lower your blood glucose levels. ANS: 4 Using a holistic approach involves consideration of all factors that may impact a clients level of well-being in all dimensions, not just physical health. Factors such as diet and exercise can influence ones level of health. Directing the client to exercise does not address the many factors that may impact ones level of health. This response does not facilitate the client in seeing the connection between lifestyle choices and well-being. Directing the client to follow physicians orders, though important, does not describe a holistic approach of nursing care. A holistic approach may include a discussion of diet and exercise and the effect these factors have on blood glucose level. The aim is for the client to take responsibility for their health and choices that may impact their health. Viewing laboratory test results is a part of the nursing assessment. To approach the client holistically, the nurse would need to also assess the clients diet and activity level. DIF: C REF: 72 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. The client states, Heart disease runs in our family. My blood pressure has always been high. The nurse determines that this is an example of the clients: 1 Risk factors WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Active strategy 3 Health beliefs Negative health behavior 4 ANS: 1 Risk factors are anything that increases the vulnerability of an individual or group to an illness or accident. This client is identifying the physical risk factor of genetic predisposition to heart disease. An example of an active strategy would be weight reduction or smoking cessation, where the client is actively involved in measures to improve their present and future levels of wellness. Health beliefs are a persons ideas, convictions, and attitudes about health and illness. An example of a health belief would be if the client stated, Heart disease runs in our family. I know I will have heart disease anyway, so why exercise? A negative health behavior is a behavior that may negatively impact ones health. An example of a negative health behavior would be consistently drinking alcohol in excess. DIF: A REF: 77 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. A client is discharged following a heart attack. In using the Stages of Health Behavior Change as a guide, the nurse recognizes that the client is most likely to begin to accept information on diet changes and an exercise program during which stage? 1 Action 2 Preparation 3 Maintenance 4 Contemplation ANS: 4 During the contemplation stage, the client is considering a change within the next 6 months. The client may be ambivalent initially, but will more likely accept information as he or she develops more belief in the value of change. During the action stage, the client is actively engaged in strategies to change behavior. During the preparation stage, the client is making small changes in preparation for a change in the next month. At this point, the client believes advantages outweigh disadvantages in behavior change. During the maintenance stage, the client has sustained change over time. DIF: A REF: 78 OBJ: Knowledge WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. When assessing the external variables that influence a clients health beliefs and practices, the nurse must consider his: 1 2 3 4 Income status Religious practices Educational background Reaction to the heart disease ANS: 1 External variables influencing a persons health beliefs and practices include family practices, cultural background, and socioeconomic factors, such as income. Economic variables may affect a clients level of health by increasing the risk for disease and influencing how or at what point the client enters the health care system. A persons compliance with the treatment to maintain or improve health is also affected by economic status. Religious practices are one way that people exercise spirituality. Spirituality is considered to be an internal variable. Educational background is an internal variable that can influence the health beliefs and practices of a client. An example of an internal variable that can influence health beliefs and practices of a client includes emotional factors, such as the reaction to heart disease. DIF: A REF: 74 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. A paraplegic client is admitted for an electrolyte imbalance. Based on the levels of prevention, the client is receiving care at the level of: 1 Health promotion 2 Primary prevention 3 Tertiary prevention Secondary prevention 4 ANS: 4 The secondary prevention level focuses on early diagnosis and prompt treatment as well as disability limitations. Adequate treatment for the electrolyte imbalance is sought to prevent further complications. Health promotion is a focus of the primary prevention level. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The primary prevention level focuses on health promotion and specific protection measures such as immunizations and personal hygiene. The tertiary prevention level focuses on restoration and rehabilitation. DIF: A REF: 75 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. Which of the following nursing activities is an example of tertiary level caregiving? 1 2 3 4 Teaching a client how to irrigate a new colostomy Providing a class on hygiene for an elementary school class Informing a client that her infant can be immunized at the health department Arranging for a hospice nurse to visit with the family of a client with lung cancer ANS: 4 Tertiary prevention occurs when a defect or disability is permanent and irreversible. Care of the hospice nurse at this level aims to help the client and the clients family achieve as high a level of functioning as possible despite the limitations caused by the cancer. Teaching a client how to irrigate a new colostomy would be an example of secondary prevention. If the colostomy is to be permanent, care may later move to the tertiary level of prevention. Providing a class on hygiene for an elementary school class would be an example of the primary level of prevention. Informing a client about available immunizations would be an example of primary prevention. DIF: A REF: 75-76 OBJ: Comprehension TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. Which one of the following client assessment findings indicates a lifestyle risk factor to the nurse? 1 Obesity 2 Sunbathing 3 Overcrowded housing Industrial-based occupation 4 ANS: 2 Excessive sunbathing is a lifestyle risk factor for skin cancer. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Obesity is a physiological risk factor. Overcrowded housing is an environmental risk factor. An industrial-based occupation is an environmental risk factor. DIF: A REF: 77-78 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. In the Health Belief Model, the nurse recognizes that the focus is placed on the: 1 2 Basic human needs for survival Functioning of the individual in all dimensions 3 Relationship of perceptions and compliance with therapy 4 Multidimensional nature of clients and their interaction with the environment ANS: 3 In the Health Belief Model, the nurse focuses on the relationship between a persons beliefs and health behaviors. By focusing on the clients perceptions of health, the nurse is better able to understand and predict how a client will comply with health care therapies. Basic human needs for survival is a component of Maslows hierarchy of needs model. The nurse who focuses on the functioning of the individual in all dimensions is following a holistic health model. In the health promotion model, the nurse focuses on the multidimensional nature of clients and their interaction with the environment. DIF: A REF: 70 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. The client who recently received a kidney transplant is worried about her husband since he has taken over the physical tasks of running their home. The client is in the process of adapting to a change in: 1 Body image 2 Self-concept 3 Illness behavior 4 Family dynamics ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The effects of illness on the client and family have created a change in family dynamics. Family dynamics is the process by which the family functions, makes decisions, gives support to individual members, and copes with everyday changes and challenges. Body image is the subjective concept of physical appearance. The client did not express concerns regarding body image. Self-concept is a mental self-image of strengths and weaknesses in all aspects of personality. The client did not express a change in self-concept. Illness behavior refers to how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the health care system. The client did not express change in illness behavior. DIF: A REF: 81 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. Client assessment provides the nurse with necessary information for the development of an effective plan of care. When determining the influence of an internal variable on the clients health status, the nurse will specifically look for: 1 Anxiety level present 2 3 Family remedies used Location and type of occupation 4 Available health insurance coverage ANS: 1 Emotional factors, such as the clients degree of anxiety, is an internal variable that can influence the clients health status. An example of an external variable that can influence the clients health status is the use of family remedies. Socioeconomic factors, such as location and type of occupation, are external variables that can influence the clients health status. Available health insurance coverage is an example of an external socioeconomic factor that can influence the clients health status. DIF: C REF: 73-74 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. A nurse understands that illness behavior means: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 2 3 4 Each distinct illness will cause the client to behave in a specific manner Nursing care provides interventions that are behavior oriented The clients behaviors will have a direct impact on his illness When ill, a clients perception of illness will result in unique behaviors ANS: 4 Medical sociologists call the reaction to illness, illness behavior. Nurses who understand how clients react to illness can minimize the effects of illness and assist clients and their families in maintaining or returning to the highest level of functioning. While the other options may be true, they do not define illness behavior. DIF: A REF: 79 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. A client tells the nurse that his illness is a result of his failure to live a good life. The nurse recognizes this statement as an example of the clients: 1 Risk factor 2 Health belief 3 Illness behavior Negative health behavior 4 ANS: 2 Health beliefs are a persons ideas, convictions, and attitudes about health and illness. A risk factor is any situation, habit, social or environmental condition, physiological or psychological condition, developmental or intellectual condition, or spiritual or other variable that increases the vulnerability of an individual or group to an illness or accident. Illness behavior is the unique manner in which a client reacts to illness. Negative health behaviors include practices actually or potentially harmful to health, such as smoking, drug or alcohol abuse, poor diet, and refusal to take necessary medications. DIF: A REF: 70 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. Which of the following client statements best relates to the third component of the Health Belief Model? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 My blood cholesterol is only a little high. 2 3 No one in my family is susceptible to the flu. Ill just avoid the food that causes the problem. 4 By losing weight my blood pressure may come down. ANS: 4 The third componentthe likelihood that a person will take preventive actionresults from the persons perception of the benefits of and barriers to taking action. Preventive action may include lifestyle changes, increased adherence to medical therapies, or a search for medical advice or treatment. The second component is the individuals perception of the seriousness of the illness. The first component of this model involves the individuals perception of susceptibility to an illness. Increased incidence of chronic disease processes. DIF: C REF: 70 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. The goal of Penders Health Promotion theory is best reflected in which of the following nursing interventions? 1 Suggesting the client experience a variety of exercise routines before settling on the one to adapt 2 Arranging for a client to attend a support group for individuals who also have severe burn scars 3 Playing soft, classical music when a client diagnosed with Alzheimers becomes physically agitated Providing a client with a history of stress-induced respiratory problems with detailed explanations regarding her care 4 ANS: 1 Health-promoting behaviors should result in improved health, enhanced functional ability, and better quality of life. According to the Basic Human Needs model, certain human needs are more basic than others; that is, some needs must be met before other needs (i.e., fulfilling the physiological needs before the needs of love and belonging). Self-actualization is the highest expression of ones individual potential and allows for continual discovery of self. Maslows model takes into account individual experiences, always unique to the individual. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions, such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery, because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care. The holistic nursing model considers the emotional and spiritual well-being, as well as other dimensions of an individual, as important aspects of physical wellness. DIF: C REF: 71 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. The nurse knows that the greatest internal factor to consider when educating an adult client concerning health promotion activities is the clients: 1 Emotional wellness 2 Developmental stage 3 Professed spirituality 4 Intellectual background ANS: 4 A persons beliefs about health are shaped in part by the persons knowledge, lack of knowledge, or incorrect information about body functions and illnesses; educational background; and past experiences. These variables influence how a client thinks about health. In addition, cognitive abilities shape the way a person thinks, including the ability to understand factors involved in illness and to apply knowledge of health and illness to personal health practices. The clients ability to understand and accept the importance of the teaching is the primary nursing consideration. The clients degree of stress, depression, or fear, for example, can influence health beliefs and practices. The manner in which a person handles stress throughout each phase of life will influence the way the person reacts to illness, but this option is not the best choice available. A persons thought and behavior patterns change throughout life. The nurse must consider the clients level of growth and development when using his or her health beliefs and practices as a basis for planning care, but the client has been identified as being adult and so the developmental stage has been determined. Spirituality is reflected in how a person lives his or her life, including the values and beliefs exercised, the relationships established with family and friends, and the ability to find hope and meaning in life. However, this is not the best option available. DIF: C REF: 23 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 18. The nurse is caring for a terminally ill client who recently immigrated to the United States. To provide quality end-of-life care, the nurse must initially: 1 Make every effort to involve the client and his family in the end-of-life care 2 Understand the clients personal and cultural views regarding death and dying 3 Arrange for end-of-life care to be provided by personnel familiar with the clients culture 4 Share the clients concerns regarding the dying process with his interdisciplinary care team ANS: 2 Differences in beliefs, values, and traditional health care practices are relevant when planning end-of-life care. It is the nurses responsibility to become familiar with the clients personal and cultural views so as to provide the most effective and appropriate end-of-life care. While this is important, it is not the best available option because understanding the clients cultural and personal views will facilitate all other offered options. This may not be either practical or possible. While this is important, it is not the best available option because understanding the clients cultural and personal views will facilitate all other offered options. DIF: C REF: 74 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 19. Which of the following nursing interventions is the best example of a primary care prevention strategy regarding the flu? 1 Staffing a flu immunization clinic at a senior citizens center 2 Providing flu prevention literature for distribution to visitors 3 Reminding client care personnel of the importance of the flu shot 4 Getting a drug manufacturer to donate flu vaccine for the homeless ANS: 4 Primary prevention is true prevention; it precedes disease or dysfunction and is applied to clients considered physically and emotionally healthy. Primary prevention aimed at health promotion WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material includes health education programs, immunizations, and physical and nutritional fitness activities. This option is the best example because it facilitates the availability of a service to clients to whom it might otherwise be unavailable. This is a good example of primary care, but it is not the best one available because it facilitates a service that is already available. While this is an example of primary care, it is not the best because it does not ensure the facilitation of the needed service. While this is an example of primary care, it is not the best because it does not ensure the facilitation of the needed service. DIF: C REF: 75 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 20. The nurse can best discuss the impact of a known risk factor on a clients health by stating: 1 It doesnt mean youll get the disease just that the odds are greater for you. 2 Now you know that the possibility is there, you can take steps to prevent it. 3 The risk factor can be managed by making a change in your lifestyle. 4 Youre lucky because you have the benefit of being able to do something about it. ANS: 1 The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. While this response is not incorrect, it does not address the impact of a risk factor on the clients health. This is not always true, and so it is not the best option. This option minimizes the clients concern and does not address the impact of a risk factor on the clients health. DIF: C REF: 77 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. When caring for a client with a spouse and two adolescent children, the nurse knows that the family unit must first: 1 Be viewed as a client WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Change traditional roles 3 Provide support for the ailing mother Seek help to fulfill day-to-day needs 4 ANS: 1 The nurse must view the whole family as a client under stress, planning care to help the family regain the maximal level of functioning and well-being. While the illness of a family member requires role reassignment in order for the family to continue to function, the initial focus is to be viewed as a unit in need of care. While the family should provide support to the ailing member, the initial focus is to be viewed as a unit in need of care. Chapter 7. Caring in Nursing Practice MULTIPLE CHOICE 1. The nurse recognizes that the client symptomatology typical of the acute cancer survival phase includes: 1 Fear and anxiety 2 Despair and anger 3 Lethargy and alopecia 4 Dyspnea and tachycardia ANS: 1 The acute survival phase starts with the diagnosis of cancer. Diagnostic and therapeutic efforts dominate. Fear and anxiety are constant elements of this phase. Despair and anger are more representative of the stages of grief and loss according to KblerRoss. Extended survival is the period during which a client has ended the basic, rigorous course of treatment and is dealing with the physical side effects of the treatment, such as lethargy and alopecia. Dyspnea and tachycardia may represent a clients unique individualized symptomatology but they are not recognized as general signs of the acute phase. DIF: A REF: 85 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 2. Since being treated for leukemia in her early twenties, a client has experienced bilateral mastectomies and has been diagnosed with osteoporosis and hypothyroidism. This health history best reflects the lifelong impact of: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Cancer on a clients health and wellness 2 3 Cancer treatments on future health status Specific cancers on the health status of survivors 4 Genetic susceptibility on the reoccurrence of cancer ANS: 2 The impact of cancer treatment on future health status is the correct response. The increased risk for developing a second cancer is due to cancer treatment, genetic or other susceptibility, or an interaction between treatment and susceptibility. The risk for treatment related problems is associated with the complexity of the cancer itself (e.g., type of tumor and stage of disease); the type, variety, and intensity of treatments used; and the age and underlying health status of the client. While cancer itself affects the clients immediate health and wellness status, it is secondary to the long-term effects of the cancer treatments used. Although some health effects are related to specific forms of cancer, this is not the best option available because it is much less likely to be the cause of lifelong health issues. While genetic predisposition is a factor in cancer development it is not the most likely factor affecting lifelong health issues for the cancer survivor. DIF: C REF: 86 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 3. In the geriatric population, the primary reason cancer is diagnosed in its later stage is: 1 Health care benefit coverage is often inadequate 2 Symptoms are often masked by the effects of aging 3 Clients are reluctant to seek help for the early symptoms Symptoms are often attributed to the aging process 4 ANS: 4 Most cancer survivors (61%) are over the age of 65 (IOM, 2006). Often health care providers wrongly attribute the symptoms of cancer or the symptoms from the side effects of treatment to aging. This often leads to late diagnosis or a failure to provide aggressive and effective treatment of symptoms. While the geriatric population may have a problem with adequate health care coverage, it is not the primary cause of delayed cancer diagnosis in that population. While symptoms may be masked by the effects of aging, it is not the primary cause of delayed cancer diagnosis in this population. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material While symptoms can be attributed to the aging process for individual geriatric clients, it is not the primary cause of delayed cancer diagnosis in this population. DIF: C REF: 86 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 4. Which of the following clients is most likely to experience cancer treatment-related problems in the future? 1 2 3 4 A 73-year-old client with heart problems An otherwise healthy 6-year-old child A 25-year-old professional tennis player A 39-year-old with a history of depression ANS: 2 The risk for treatment-related problems is associated with the complexity of the cancer itself (e.g., type of tumor and stage of disease); the type, variety, and intensity of treatments used; and the age and underlying health status of the client. The 6-year-old child is at greatest risk because the primary cancer occurred at such a young age and during a critical physiological developmental stage. Because the pivotal factors for cancer treatment-related problems are age and development, the 73-year-old with heart problems does not present the greatest risk. Because the pivotal factors for cancer treatment related problems are age and development, 25year-old professional tennis players chronic health issues do not present the greatest risk. While depression may have a negative health effect, a 39-year-old with a history of depression does not present the greatest risk for cancer treatment related problems since the pivotal factors are age and developmental stage. DIF: C REF: 86-87 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 5. Eleven months after being treated for breast cancer, a client reports difficulty sleeping and the associated fatigue while denying any other signs/symptoms. The nurse recognizes that the client may be experiencing: 1 Situational depression 2 Normal remission symptoms 3 Post-traumatic stress disorder Delayed effects of chemotherapy drugs 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 1 Survivors feelings of distress range along a continuum from sadness to disabling depression (Vachon, 2006). The long-term presence of fatigue and sleep disturbances, for example, is often associated with anxiety and depression in many cancer survivors (Barton-Burke, 2006). Sleep disorders and fatigue would not necessarily be expected at this point in the remission stage. Posttraumatic stress disorder (PTSD) is a psychiatric disorder characterized by an acute emotional response to a traumatic event or situation. Cancer survivors experience symptoms of PTSD (e.g., grief, nightmares, panic attacks, or fear) at a rate of 4% to 19%, as a result of their diagnosis, treatment, or a past traumatic episode. While chemotherapy drugs can produce side effects, sleep disorders are not a typical complaint. DIF: C REF: 88 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 6. A client, who recently completed treatment for cancer, shares with the nurse that she is, a little depressed, but I guess I will be OK. The foremost reason the nurse encourages the client to discuss this situation with her primary health care provider is that the nurse realizes that: 1 The depression will not improve by itself 2 The medications can help resolve the depression 3 Depression can decrease the clients chances of recovery 4 The depression is a result of concerns about the cancer reoccurring ANS: 3 Research has associated depression with decreased cancer survivorship. A study conducted by Brown and colleagues (2003) suggested that a cancer diagnosis and its effects predispose people to distress, which if maintained over time will enhance disease progression. While depression may not improve by itself, it is not the primary reason for the nurse to encourage the client in cancer remission to seek medical advice. Chronic depression can adversely affect the chances of long-term survivorship. While medications can help resolve depression, it is not the primary reason for the nurse to encourage the client in cancer remission to seek medical advice. Chronic depression can adversely affect the chances of long-term survivorship. While may be a result of concerns about the cancer reoccurring, it is not the primary reason for the nurse to encourage the client in cancer remission to seek medical advice. Chronic depression can adversely affect the chances of long-term survivorship. DIF: C REF: 87 OBJ: Analysis TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 7. The nurse knows that the primary factor affecting a cancer survivors quality of life is: 1 The clients precancer physical and mental health status 2 The presence of a strong support system 3 The quality and type of cancer treatment received 4 The type and number of cancer-related risk factors the client possesses ANS: 2 Mellon and colleagues (2006) interviewed cancer survivors and their family caregivers, finding that two of the strongest predictors for cancer survivors quality of life (enjoyment of life) were family stressors and social support. Precancer physical and mental health status may affect the survivors physical recovery regarding the treatment but not their quality of life (enjoyment of life). The quality and type of cancer treatment received may affect the survivors chances of survival but not their quality of life (enjoyment of life). The type and number of cancer-related risk factors the client possesses may affect the survivors chances of survival but not their quality of life (enjoyment of life). DIF: C REF: 85-86 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 8. A client, who is a 7-year breast cancer survivor, tells the nurse, My husband will help me bathe when he gets here. The nurse interprets this statement to mean that the client: 1 Is reluctant to have the staff see her chest scar 2 Prefers to protect her modesty and privacy 3 Has a healthy self-image regarding her husband 4 Is not comfortable with the care she is receiving ANS: 3 Self-image and intimacy may be negatively affected after cancer surgery. It is a positive sign that the client is comfortable having her husband perform this task for her. Although the client may be reluctant to have staff see her chest scar, the clients history of cancer surgery should direct you to the more related option. While the client may prefer to protect her modesty and privacy, the clients history of cancer surgery should direct you to the more related option. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Although the client may not be comfortable with the care she is receiving, it is not as likely as the other options and the clients history of cancer surgery should direct you to the more related option. DIF: C REF: 88 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 9. The nurse understands the primary focus of education for a client who has just received a diagnosis of cancer is to: 1 Introduce self-care measures to support health 2 3 Discuss the management of treatment-related side effects Reinforce the explanation of the risks of proposed treatments 4 Formulate long-term lifestyle changes to minimize risk factors ANS: 3 When caring for clients with an initial diagnosis of cancer, the immediate focus of client education should be the reinforcement of their health care providers explanations of the risks related to their cancer as well as the benefits and risks related to the proposed treatment options. This should then be followed by instructions on what they need to self-monitor (i.e., appetite and weight, effects of fatigue and sleeplessness), and what to discuss with health care providers in the future. Potential for treatment effects; such as pain, neuropathy, or cognitive change; also should be addressed since clients are more likely to report their symptoms if they are educated on their likelihood. Survivors need to learn how to manage problems related to persistent symptoms. Because survivors are at an increased risk for developing a second cancer and/or chronic illness, it is important to educate them about lifestyle behaviors that will improve the quality of their life. While introducing self-care measures to support health is an appropriate topic for client education, it should be addressed after the client is informed of the risks related to their cancer as well as the benefits and risks related to the proposed treatment options. Although discussing the management of treatment-related side effects is an appropriate topic for client education, it should be addressed after the client is informed of the risks related to their cancer as well as the benefits and risks related to the proposed treatment options. While formulating long-term lifestyle changes to minimize risk factors is an appropriate topic for client education, it should be addressed after the client is informed of the risks related to the cancer as well as the benefits and risks related to the proposed treatment options. DIF: C REF: 91 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. Which of the following assessment data best confirms the possibility of cognitive impairment in a client with a diagnosis of lung cancer? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Client is observed writing questions to ask his oncologist. 2 3 Client states, I seem to be a little more forgetful lately. Clients wife states, I have to remind him of everything. 4 Client overheard asking son, Where did I put my glasses? ANS: 2 Cognitive changes are a set of physical symptoms very common in survivors that develop from their disease, treatment, the complications of treatment, underlying medical conditions, and psychological responses to the diagnosis of cancer (Nail, 2006). Cognitive changes can occur during all phases of the cancer experience, from small deficits in information processing to acute delirium. Often the cognitive impairments survivors experience are not evident to someone else but are apparent to the person experiencing them, especially in relation to work performance with high cognitive demands (Anderson-Hanley and others, 2003). The clients personal evaluation of his memory is the best indicator of cognitive impairment. While writing down questions to ask the oncologist may be motivated by poor memory, it is not uncommon for clients to prepare a list of questions before a meeting with their health care provider. Although the clients spouse reminding the client of things may indicate impaired cognitive ability, it is not as strong an indicator as a statement from the client. Although not being able to locate an item may indicate impaired memory, it is not uncommon for individuals to misplace personal items. DIF: C REF: 86-87 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 11. Which of the following cancer survivors is at greatest risk for post-treatment symptoms and poor treatment outcomes? 1 An Asian dishwasher 2 A Hispanic truck driver 3 A Caucasian factory worker 4 An African-American carpenter ANS: 1 There is evidence to suggest that survivors among racial and ethnic minorities and other underserved populations have more post-treatment symptoms and poorer treatment outcomes than Caucasians (CDC, 2004). The disparities in health among ethnic groups are related to a complex interplay of economic, social, and cultural factors, with poverty being a key factor. The WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Asian dishwasher is both a member of a racial minority and likely the poorest paid of the survivors. While being a member of an ethnic group is a risk factor, a Hispanic truck driver is not likely to be the poorest of the survivors. The Caucasian factory worker has the least risk because he is not a member of an ethnic or racial minority nor is there a likelihood of him being the poorest of the survivors. While being a member of a racial minority is a risk factor, an African-American carpenter is not likely to be the poorest of the survivors. DIF: C REF: 85 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 12. When assessing cancer survivors regarding the stressors of cancer, the nurse should first ask clients: 1 2 If they feel they are stressed by the cancer How they believe cancer has affected their life 3 What they are doing to cope with the stress of having experienced cancer 4 What assistance they need to successfully manage the stressors of dealing with cancer ANS: 2 As a nurse, learn to assess the many ways in which cancer affects the lives of clients who are survivors. It is through their perception of how cancer impacts their lives, that therapeutic nursing interventions can be implemented. Clients may not be comfortable identifying themselves as being stressed. An open-ended question regarding the effects of cancer on the clients life is likely to be more informative. Asking a client what they are doing to cope with stress assumes the client is experiencing stress, and it may be uncomfortable for the client to answer. An open-ended question regarding the effects of cancer on the clients life is likely to be more informative. Asking a client about assistance needed to manage stress assumes the client is experiencing stress, and it may be uncomfortable for the client to answer. An open-ended question regarding the effects of cancer on the clients life is likely to be more informative. DIF: C REF: 91 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Illness Management 13. A 78-year-old woman presents at the emergency department with complaints of shortness of breath. She has a history of radiation therapy for a lung mass 7 years ago. When the client asks the nurse if it could be cancer again, the most therapeutic response would be: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 At your age, shortness of breath could be a result of any number of things. 2 That is a possibility but it could also be a result of your radiation therapy. What makes you think that? Shortness of breath can have many different causes. 3 4 I wouldnt jump to that conclusion. Lets just see what your health care provider thinks. ANS: 2 Cancer survivors are at increased risk for cancer (either a recurrence of the cancer for which they were treated or a second cancer) and for a wide range of treatment-related problems (IOM, 2006). While shortness of breath could be caused by many things, it does not address the clients concern regarding reoccurring cancer. While shortness of breath could be caused by many things, it does not address the clients concern regarding reoccurring cancer. Telling the client not to jump to conclusions minimizes the clients concern. Chapter 8. Caring for Patients with Chronic Illness MULTIPLE CHOICE 1. When caring for an older patient with hypertension who has been hospitalized after a transient ischemic (TIA), which topic is the most important for the nurse to include in the discharge teaching? a. Effect of atherosclerosis on blood vessels b. Mechanism of action of anticoagulant drug therapy c. Symptoms indicating that the patient should contact the health care provider d. Impact of the patients family history on likelihood of developing a serious stroke ANS: C One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to take if these symptoms occur. The other information also may be included in patient teaching but is not as essential in the patients self-management of the illness. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: Cognitive Level: Apply (application) REF: 63 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse performs a comprehensive geriatric assessment of a patient who is being assessed for admission to an assisted living facility. Which question is the most important for the nurse to ask? a. Have you had any recent infections? b. c. How frequently do you see a doctor? Do you have a history of heart disease? d. Are you able to prepare your own meals? ANS: D The patients functional abilities, rather than the presence of an acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted living situation. The other questions will also provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient. DIF: Cognitive Level: Apply (application) REF: 71 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. An older patient who takes multiple medications for chronic cardiac and pulmonary diseases is alert and lives with a daughter who works during the day. During a clinic visit, the patient verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. Which nursing diagnosis should the nurse assign as the priority for this patient? a. Risk for injury related to drug interactions b. Social isolation related to weakness and fatigue c. Compromised family coping related to the patients many care needs d. Caregiver role strain related to need to adjust family employment schedule ANS: A The patients age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. Problems with social isolation, caregiver role strain, or compromised family coping are not physiologic priorities. Drug-drug interactions could cause the most harm to the patient and is therefore the priority. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: Cognitive Level: Apply (application) REF: 73-74 TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 4. The nurse plans to complete a thorough assessment of an older patient. Which method should the nurse use to gather the most complete information? a. Use a geriatric assessment instrument to evaluate the patient. b. Ask the patient to write down medical problems and medications. c. Interview both the patient and the primary caregiver for the patient. d. Review the patients medical record for a history of medical problems. ANS: A The most complete information about the patient will be obtained through the use of an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the medical record, interviews with the patient and caregiver, and written information by the patient are all included in a comprehensive geriatric assessment. DIF: Cognitive Level: Apply (application) REF: 71 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. An older patient is hospitalized with pneumonia. Which intervention should the nurse implement to provide optimal care for this patient? a. Use a standardized geriatric nursing care plan. b. Minimize activity level during hospitalization. c. Plan for transfer to a long-term care facility upon discharge. d. Consider the preadmission functional abilities when setting patient goals. ANS: D The plan of care for older adults should be individualized and based on the patients current functional abilities. A standardized geriatric nursing care plan will not address individual patient needs and strengths. A patients need for discharge to a long-term care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process. DIF: Cognitive Level: Apply (application) REF: 71 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to best meet this patients needs? a. Suggest that the patient move to an urban area. b. Assess the patient for chronic diseases that are unique to rural areas. c. Ensure transportation to appointments with the health care provider. d. Obtain adequate medications for the patient to last for 4 to 6 months. ANS: C Transportation can be a barrier to accessing health services in rural areas. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. DIF: Cognitive Level: Apply (application) REF: 66-67 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 7. Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult? a. Teach the patient to have all prescriptions filled at the same pharmacy. b. Instruct the patient to avoid taking over-the-counter (OTC) medications. Make a schedule for the patient as a reminder of when to take each medication. c. d. Have the patient bring all medications, supplements, and herbs to each appointment. ANS: D The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but use of supplements WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material and herbal medications also need to be considered in order to prevent drug-drug interactions. Use of a medication schedule will help the patient take medications as scheduled but will not prevent drug-drug interactions. DIF: Cognitive Level: Understand (comprehension) REF: 74 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation stress syndrome. Which action should the nurse include in the plan of care? a. b. Remind the patient that making changes is usually stressful. Discuss the reason for the move to the facility with the patient. c. Restrict family visits until the patient is accustomed to the facility. d. Have staff members write notes welcoming the patient to the facility. ANS: D Having staff members write notes will make the patient feel more welcome and comfortable at the long-term care facility. Discussing the reason for the move and reminding the patient that change is usually stressful will not decrease the patients stress about the move. Family member visits will decrease the patients sense of stress about the relocation. DIF: Cognitive Level: Apply (application) REF: 70 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9. An older patient complains of having no energy and feeling increasingly weak. The patient has had a 12-pound weight loss over the last year. Which action should the nurse take initially? a. Ask the patient about daily dietary intake. b. Schedule regular range-of-motion exercise. c. Discuss long-term care placement with the patient. Describe normal changes associated with aging to the patient. d. ANS: A In a frail older patient, nutrition is frequently compromised, and the nurses initial action should be to assess the patients nutritional status. Active range of motion may be helpful in improving the patients strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The patients assessment data are not consistent with normal changes associated with aging. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: Cognitive Level: Apply (application) REF: 67 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. The nurse admits an acutely ill, older patient to the hospital. Which action should the nurse take first? a. b. Speak slowly and loudly while facing the patient. Obtain a detailed medical history from the patient. c. Perform the physical assessment before interviewing the patient. d. Ask a family member to go home and retrieve the patients cane. ANS: C When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records. After the initial physical assessment to determine the patients current condition, then the nurse could ask someone to obtain any assistive devices for the patient if applicable. DIF: Cognitive Level: Apply (application) REF: 71 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 11. The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the most appropriate for the nurse to include in the discharge plan for this patient? a. Refer the patient to social services for further assessment. b. Teach the patient how to assess and care for the foot infection. c. Schedule the patient to return to outpatient services for foot care. d. Give the patient written information about shelters and meal sites. ANS: A An interdisciplinary approach, including social services, is needed when caring for homeless older adults. Even with appropriate teaching, a homeless individual may not be able to maintain WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of factors such as fear of institutionalization or lack of transportation. DIF: Cognitive Level: Apply (application) REF: 67 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would best encourage medication compliance? a. b. c. d. Use a marked pillbox to set up the patients medications. Discuss the option of moving to an assisted living facility. Remind the patient about the importance of taking medications. Visit the patient daily to administer the prescribed medications. ANS: A Because forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication compliance. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs). DIF: Cognitive Level: Apply (application) REF: 65 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. The home health nurse visits an older patient with mild forgetfulness. The nurse is most concerned if which information is obtained? a. The patient tells the nurse that a close friend recently died. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patients son uses a marked pillbox to set up the patients medications weekly. ANS: B WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an 86-year-old would have friends who have died. DIF: Cognitive Level: Apply (application) REF: 67 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. Which statement, if made by an older adult patient, would be of most concern to the nurse? a. I prefer to manage my life without much help from other people. b. I take three different medications for my heart and joint problems. c. I dont go on daily walks anymore since I had pneumonia 3 months ago. d. I set up my medications in a marked pillbox so I dont forget to take them. ANS: C Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. Selfmanagement is appropriate for independently living older adults. On average, an older adult takes seven different medications so the use of three medications is not unusual for this patient. The use of memory devices to assist with safe medication administration is recommended for older adults. DIF: Cognitive Level: Apply (application) REF: 73 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 15. The nurse assesses an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first? a. Palpate over the suprapubic area. b. Inspect for abdominal distention. c. Question the patient about hematuria. Invite the patient to use the bathroom. d. ANS: D Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material from the patients ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible. DIF: Cognitive Level: Apply (application) REF: 71 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. Which patient is most likely to need long-term nursing care management? b. 72-year-old who had a hip replacement after a fall at home 64-year-old who developed sepsis after a ruptured peptic ulcer c. 76-year-old who had a cholecystectomy and bile duct drainage d. 63-year-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg) a. ANS: D Osteoarthritis and obesity are chronic problems that will require planning for long-term interventions such as physical therapy and nutrition counseling. The other patients have acute problems that are not likely to require long-term management. DIF: Cognitive Level: Apply (application) REF: 70 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 17. When completing an admission assessment on an older adult, the nurse gives the patient a high fall risk score. Which action should the nurse take first? a. Use a bed alarm system on the patients bed. b. Administer the prescribed PRN sedative medication. c. Ask the health care provider to order a vest restraint. Place the patient in a geri-chair near the nurses station. d. ANS: A The use of the least restrictive restraint alternative is required. Physical or chemical restraints may be necessary, but the nurses first action should be an alternative such as a bed alarm. DIF: Cognitive Level: Apply (application) REF: 75 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 18. An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first? a. Notify an elder protective services agency about the possible abuse. b. Make a referral for a home assessment visit by the home health nurse. c. Have the family member stay in the waiting area while the patient is assessed. d. Ask the patient how the injury occurred and observe the family members reaction. ANS: C The initial action should be assessment and interviewing of the patient. The patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document data before notifying the elder protective services agency. DIF: Cognitive Level: Apply (application) REF: 68-69 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 19. The family of an older patient with chronic health problems and increasing weakness is considering placement in a long-term care (LTC) facility. Which action by the nurse will be most helpful in assisting the patient to make this transition? a. Have the family select a LTC facility that is relatively new. b. Obtain the patients input about the choice of a LTC facility. c. Ask that the patient be placed in a private room at the facility. d. Explain the reasons for the need to live in LTC to the patient. ANS: B The stress of relocation is likely to be less when the patient has input into the choice of the facility. The age of the long-term care facility does not indicate a better fit for the patient or better quality of care. Although some patients may prefer a private room, others may adjust better when given a well-suited roommate. The patient should understand the reasons for the move but will make the best adjustment when involved with the choice to move and the choice of the facility. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: Cognitive Level: Apply (application) REF: 70 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 20. The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Obtain information about food and medication allergies from patients. b. Take blood pressures daily and document in individual patient records. c. Choose social activities based on the individual patient needs and desires. d. Teach family members how to cope with patients who are cognitively impaired. ANS: B Measurement and documentation of vital signs are included in UAP education and scope of practice. Obtaining patient health history, planning activities based on the patient assessment, and patient education are all actions that require critical thinking and will be done by the registered nurse. DIF: Cognitive Level: Apply (application) REF: 72 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient (select all that apply)? a. Observe for depression. b. Review laboratory results. c. Assess teeth and oral mucosa. d. Ask about transportation needs. e. Determine food likes and dislikes. ANS: A, B, C, D The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat/cholesterol intake. Transportation impacts patients ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition. Chapter 9. Cultural Competence MULTIPLE CHOICE 1. The nurse recognizes that ethnicity differs from race in that ethnicity: 1 2 Refers to subgroups within a race Is a unique factor within a cultural group 3 Includes more than biological identification 4 Is the set of conflicting values between races ANS: 3 Ethnicity refers to a shared identity related to social and cultural heritage, such as values, language, geographical space, and racial characteristics. Race refers to biological attributes. Subcultures refer to subgroups within a race. A variant cultural pattern is a unique factor within a cultural group. Ethnocentrism is the root of biases and prejudices comprising beliefs and attitudes associating negative permanent characteristics with people who are perceived to be different from the valued group. DIF: A REF: 107 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 2. Within transcultural nursing, sensitivity to social organization is the recognition of the clients: 1 Language usage 2 Status and expected role in the family 3 Definition of health and health practices 4 Psychological characteristics and coping mechanisms ANS: 2 Cultural groups consist of units of social organization delineated by kinship, status hierarchy, and appropriate roles for their members. Sensitivity to social organization is the recognition of the clients status and role in the family. Sensitivity to communication patterns would be the recognition of the clients language usage. Culture is the framework used in defining social phenomena such as when a person is considered to be healthy or in need of intervention. The way an individual defines health and health practices needs to be understood by the nurse to best meet the needs of the client. Sensitivity to social organization is not met by recognizing the definition of health for an individual. Psychological characteristics and coping mechanisms may be expressed in a variety of ways across cultures. Sensitivity to social organization is not WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material demonstrated by the recognition of psychological characteristics and coping mechanisms of a particular culture. DIF: A REF: 116 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 3. Traditional Western medicine, in contrast to alternative therapy, uses: 1 2 Acupuncture Herbal therapy 3 Spiritual advising 4 Medication administration ANS: 4 Traditional Western medicine uses medication administration as a method of treatment. Acupuncture is an alternative therapy often used in non-Western cultures such as the Chinese and Southeast Asians. Herbal therapy is an alternative therapy often used in non-Western cultures, but not in traditional Western medicine. Spiritual advising is not used in traditional Western medicine, but it may be seen in the African-American cultural group. DIF: A REF: 110 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 4. The nurse is completing an assessment of an Asian-American client. Recognizing that there are commonly seen problems in individuals from this background, the nurse observes for particular signs and symptoms of: 1 Hypertension 2 Tuberculosis 3 Diabetes mellitus 4 Lactose intolerance ANS: 4 Lactose intolerance is frequently observed among Asians, Africans, and Hispanics. Hypertension is commonly seen in African Americans. Aboriginal Canadians descended from native North American Indians and living on reservations have a higher incidence of tuberculosis. Diabetes mellitus is commonly seen among Ute, Pima, and Papago Indians. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A REF: 116 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 5. The nurse recognizes the following as an appropriate strategy for communicating with clients who are not fluent in English? 1 2 3 4 Speaking in a louder tone of voice Incorporating hand gestures and pictures Responding to the client by his or her first name Interacting with an interpreter for all communication ANS: 2 An appropriate strategy for communicating with clients who are not fluent in English is to incorporate hand gestures and pictures. Speaking in a louder tone of voice will not help the client understand the English language. Responding to the client by his or her first name may demonstrate a lack of respect. The nurse should introduce him or herself and then request the client to introduce himself or herself. An interpreter is not necessary for all communication. However, an interpreter must be used for communicating to the client information about his or her medical condition. It is not acceptable for family members to translate health care information, but they can assist with ongoing interaction during the clients care. DIF: A REF: 113 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 6. One aspect of a culture is invisible, or less observable, to others. A nurse wanting to develop an awareness of the practices of different cultures within that community would have which of the following as an example of this component? 1 Wearing an amulet or charm 2 Using prayer beads or candles 3 Using cotton garments for clothing Believing in supernatural influences 4 ANS: 4 An example of an invisible (less observable) component of a culture is having a belief in supernatural influences. An example of a visible (easily seen) component of culture is the wearing of an amulet or charm. An example of a visible (easily seen) component of culture is WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material using prayer beads or candles. Using cotton undergarments for clothing is a visible (easily seen) component of culture. DIF: A REF: 107 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 7. From culture to culture time often takes on different meanings. In exploring the relationship of time to nursing interventions, the nurse should: 1 Avoid using set times to do procedures, if possible 2 Maintain the set times for treatments and inform the client of the schedule 3 Maintain a flexible attitude when the client requests procedures to be done at specific times 4 Encourage clients to set the times when they would like the nurse to perform nursing care activities. ANS: 3 Because time has different meanings from one culture to another, the nurse should maintain a flexible attitude and not become emotionally upset when the client requests procedures to be done at different times. When making appointments and referrals, anticipated barriers to time adherence should be explored and managed with the client. For organizational purposes, nurses should seek clients input and together the nurse and client may set a time to do procedures. Maintaining set times for treatments and informing the client of the schedule do not take into consideration the clients time orientation. Although the clients input should be sought, it is not realistic to have clients set their own times for nursing care activities regardless of the schedule. Some procedures may be required more frequently than the client would set, or the nurse may be unable to meet the needs of several clients on the unit at the same time. DIF: A REF: 118 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 8. The nurse recognizes that changes in demographics have an influence on health care delivery. One of the expectations in the United States by the year 2020 is: 1 Growth of the European-American population 2 Increases in the Hispanic and Latino populations 3 Reduction of the African-American population by 50% WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Equal growth in the Hispanic-, Asian-, and African-American populations ANS: 2 By 2020 the population of Hispanic and Latino populations is predicted to triple. Population projections beyond 2000 show Hispanics/Latinos, Asian-Americans, and African-Americans outpacing the growth of white, European-descended groups. The African-American group is projected to double by 2020. By 2020 the population of African Americans is predicted to double and that of Asian Americans and Hispanics/Latinos to triple. DIF: A REF: 107 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 9. While going through the process of acculturation a client will be: 1 Identifying with 2 or more cultures 2 Adapting to and adopting a new culture 3 Showing favor to the dominant culture Socializing within their primary cultural group 4 ANS: 2 Acculturation is the process of adapting to and adopting a new culture. Biculturalism occurs when an individual identifies equally with two or more cultures. Assimilation occurs when an individual gives up his or her ethnic identity in favor of the dominant culture. Socialization into ones primary culture as a child is known as enculturation. DIF: A REF: 708 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 10. An example of a nurse imposing his/her own cultural beliefs on a client is evident in which of the following examples? 1 2 3 Adaptation of the clients room to accommodate family members Seeking information on gender-congruent care for an Egyptian client Administering less potent pain medication to an outpatient surgery client WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Encouraging family members to assist with the clients feeding and hygiene care ANS: 3 Holding back more potent pain medication for a client who had a minor procedure is an example of a cultural imposition of the nurse on a client. Adaptation of the clients room to accommodate extra family members is not an example of cultural imposition on a client, but rather is meeting the clients need by providing culturally congruent care. Seeking information on gendercongruent care for an Egyptian client is an example of the desire to provide culturally congruent care. Encouraging family to assist with the clients care is not an example of cultural imposition on a client. Western culture tends to follow a pattern of caring that focuses on self-care and selfdetermination, whereas non-Western cultures typically have care provided by others. DIF: A REF: 109 OBJ: Cognitive Level: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 11. Following a surgical procedure, an older Chinese woman refuses to perform the range of motion and breathing exercises requested, in addition is hesitant to complete her hygienic care and grooming. The nurse recognizes that this is most likely related to: 1 Dependence on health care providers for care 2 Reliance upon family members to assist with care 3 Lack of personal motivation to participate in self-care 4 Reluctance to cooperate with traditional Western medical treatment ANS: 2 Non-Western cultures traditionally rely heavily on family members to provide care. Although it may be related to dependence on health care providers for care, it is not as likely because nonWestern cultures depend on family members to assist with care. While it may be related to lack of personal motivation to participate in self-care, the clients behavior is more likely a result of her cultural background rather than a lack of motivation. While the clients behavior may be a result of reluctance to cooperate with Western medical treatments, it is more likely indicative of her cultural dependence on family members. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 12. When faced with a scenario where it is believed that a client from another cultural background is using herbal remedies along with the prescribed medication to treat her arthritis. The nurses first action should be to: 1 Educate the client concerning the danger of taking herbs and the prescribed medication 2 Inquire of the client as to the reason for using herbal remedies along with the prescribed medication Ask the client to identify what herbal remedies are being used along with the prescribed medications 3 4 Alert the physician to the clients use of herbal remedies in addition to the prescribed medications ANS: 3 Rather than first dismissing the practice as dangerous and incompatible with Western medicine, practitioners need to investigate further whether the practice needs changing. Although educating the client may be appropriate, this cannot be determined until the herb has been identified and it is determined to be harmful in this situation. Asking the client why additional remedies are being used may make the client feel defensive. The nurse needs to first determine what herbs are being used. While alerting the physician is appropriate, it is not the first action to be taken by the nurse. The nurse should initially determine what herbs are being used. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 13. Being cared for by a nurse of the opposite gender would be an especially important issue for women from which of the following cultures? 1 Afghan 2 Filipino 3 Native American 4 African American ANS: 1 Modesty is a strong value among Afghan and Arab women. Modesty is not an especially important issue for Filipino women. Modesty is not an especially important issue for Native American women. Modesty is not an especially important issue for African American women. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A REF: 109 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 14. An example of a culture where a male relative will regularly decline to observe the birth process is: 1 2 Pakistani Hispanic 3 Korean 4 Japanese ANS: 1 Religious beliefs may prohibit the presence of males, including husbands, in the delivery room. This may be observed among devout Muslims, Hindus, and Orthodox Jews. Hispanic men typically do not have religious or cultural beliefs that would prohibit them from the delivery room. Korean men typically do not have religious or cultural beliefs that would prohibit them from the delivery room. Asian men typically do not have religious or cultural beliefs that would prohibit them from the delivery room. DIF: A REF: 111 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 15. The nurse observes a religious charm hanging from the wrist of a client being prepared for surgery. The nurses best initial approach is to: 1 Remove the religious charm 2 Securely tape the charm in place 3 Ask the client to leave the charm with family members 4 Clarify whether the charm may remain in place during the procedure ANS: 4 The nurse should first determine if it is permissible for the item to remain in place during the procedure. Removing the bracelet may create unnecessary stress for the client. Initially the nurse should determine if removal is necessary. Taping the bracelet in place may be appropriate after the nurse determines that the item may remain in place during the procedure. Asking the client to WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material remove the item may create unnecessary stress for the client. Initially the nurse should determine if removal is necessary. DIF: B REF: 109 OBJ: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 16. The nurse recognizes that the family of a deceased Buddhist client will: 1 2 3 4 Bury before sundown Decline viewing the body Not move the body until it is cold Select cremation rather than burial ANS: 3 Some Buddhists may refuse to move the dead body after death because of their belief that the spirit of the dead takes some time to leave the body. They define death as the absence of consciousness and loss of body warmth. Among Orthodox Jews, the body is generally buried before sundown. Some Asian Indians regard seeing the deceased as adding to the suffering of the family. Hindus and Buddhists believe that the soul lives on and the dead body without the soul is but an empty shell, and therefore may not want to see the body. Muslims prefer burial rather than cremation. DIF: A REF: 112-113 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity 17. A nurse that has the knowledge of the biocultural history of clients and aware that individuals with a greater potential for and incidence of hypertension are: 1 Asians 2 Hispanics 3 Native Americans African Americans 4 ANS: 4 Malignant hypertension is found more frequently in African Americans. Lactose intolerance is frequently observed among Asians. Hispanics have a higher incidence of lactose intolerance. Native Americans have a higher incidence of tuberculosis and diabetes mellitus. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A REF: 117 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 18. There are cultural context of health and illness differences in comparing Western versus nonWestern cultures. The nurse is aware that in Western culture the overall treatment is: 1 2 3 4 Herbal Holistic Naturalistic Specialty-specific ANS: 4 The overall treatment in Western culture is specialty-specific. The treatment in some nonWestern cultures is herbal. The treatment in non-Western cultures is holistic in nature. Some nonWestern cultures use a naturalistic approach for the method of diagnosis. DIF: A REF: 109 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 19. Regarding a client who is an Orthodox Jew and maintains a Kosher diet, the nurse will make sure that the clients menu does not include: 1 Beef 2 Eggs 3 Milk Shellfish 4 ANS: 4 Jewish clients who follow a Kosher diet will avoid meat from carnivores, pork products, and fish without scales or fins. Therefore shellfish should not be included in the menu of a client who is an Orthodox Jew and maintains a Kosher diet. Beef may be included in a Kosher diet. Eggs may be included in a Kosher diet. Milk may be included in a Kosher diet. DIF: A REF: 117 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 20. For a client who is a Buddhist and maintains a traditional diet, the nurse will make sure that a sufficient quantity of which of the following is included in the menu? 1 2 3 4 Beef Milk Fish Vegetables ANS: 4 Many Buddhists are vegetarians. The nurse should ensure that a sufficient quantity of vegetables is included in the menu when caring for a Buddhist who maintains a traditional diet. Beef is not a traditional component of a Buddhists diet. A sufficient quantity of milk is not necessary for the traditional Buddhists diet. A sufficient quantity of fish is not necessary for the traditional Buddhists diet. DIF: A REF: 117 OBJ: Cognitive Level: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 21. Which of the following factors has the greatest impact on health care available to nonHispanic white minority groups in the United Sates? 1 Significant language barriers 2 Inappropriately high poverty rates 3 Genetically based disease processes 4 Mistrust of Western medical practices ANS: 2 Racial and ethnic minorities are more likely than non-Hispanic whites to be poor or near poor. In addition, Hispanics, African Americans, and some Asian subgroups are less likely than nonHispanic whites to have a high school education. In general, racial and ethnic minorities often experience poorer access to care and lower quality of preventive, primary, and specialty care. While language barriers may have an influence on the amount and type of health care services available to and sought out by minority groups, it is poverty that has the greatest negative influence. While genetically based disease processes may have an influence on the amount and type of health care services available to and sought out by minority groups, it is poverty that has the greatest negative influence. Although mistrust of Western medical practices may have an influence on the amount and type of health care services available to and sought out by minority groups, it is poverty that has the greatest negative influence. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 107 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 22. The nurse who is attempting to practice in a culturally sensitive manner must first realize that recognition of the visible signs of a clients culture: 1 2 Is essential to the establishment of a nurse-client relationship Provides the basis for a sense of trust between client and nurse 3 Does not ensure understanding of the underlying cultural beliefs 4 Has little impact on the nurses ability to provide therapeutic care ANS: 3 Culture has both visible (easily seen) and invisible (less observable) components. Nurses cannot appreciate the meanings and beliefs associated with these artifacts without further assessment. Recognition of visible signs of a clients culture will assist in the formation of a therapeutic nurseclient relationship because it conveys the nurses interest in the client as a person; it is not essential to the relationship process. Recognition of visible signs of a clients culture will assist in the formation of trust (a component of a therapeutic nurse-client relationship) because it conveys the nurses interest in the client as a person; it is not essential to the trust-establishing process. Recognition of visible signs of a clients culture will assist in the formation of a therapeutic nurseclient relationship, which is vital to the nurses ability to provide therapeutic care because it conveys the nurses interest in the client as a person. DIF: C REF: 107 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 23. Which of the following nursing interventions shows the greatest degree of culturally competent nursing care for a Muslim female client? 1 Notifying the chaplain of the clients religious preference 2 Notifying staff that the clients bath will be done by her sister 3 Drawing the curtains around the clients bed during prayer time Facilitating a dietary consult to meet the clients nutritional concerns 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 Cultural competence is the process of acquiring specific knowledge, skills, and attitudes that ensure delivery of culturally congruent care. By arranging for the family to assume responsibility for the clients hygiene, the nurse has shown a specific knowledge of the clients needs and acted upon that need. The other options are not as specific or as directly related to nursing care as notifying the staff that the clients bath will be done by her sister. DIF: C REF: 109 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 24. A nursing care assistant fails to report in a timely manner a request for pain medication from an African-American male client who is recovering from a stab wound. The nurses initial action is to evaluate the care assistants: 1 Feelings regarding this particular client 2 3 Need for administrative disciplinary action Understanding of the need for prompt reporting 4 Employment files for documentation of similar behavior ANS: 1 Personal bias and prejudices when acted upon may interfere with the delivery of appropriate, effective nursing care. While all the options are appropriate, the nurses initial action is to determine the cause of the care assistants negligent behavior. Although all the options are appropriate, the nurses initial action is to determine the cause of the care assistants negligent behavior. DIF: C REF: 109 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 25. An Arab woman arrives in the emergency department reporting vaginal bleeding. It is determined that the client is 5 months pregnant with her second child and has had no prenatal care. The nurse realizes that the most likely reason for this lack of health care is that the client: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Cannot afford to seek health care 2 3 Views pregnancy as a normal life event Typically relies on same-culture healers 4 Lacks an understanding of available services ANS: 2 Culture is the context in which groups of people interpret and define their experiences relevant to life transitions. This includes events such as birth, illness, and dying. It is the system of meanings by which people make sense of their experiences. Culture is how others define social phenomena such as when a person is healthy or requires intervention. Traditionally, in Arab culture, pregnancy is not a medical condition but rather a normal life transition; hence, a pregnant woman does not always go to a doctor unless she has a problem. While the other options may have been a factor, the most likely cause is that the Arab culture views pregnancy as a normal life event and care is sought only when a perceived problem exists. DIF: C REF: 109 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 26. An Asian-American client will accept hygiene care from only family members. The cultural origin of this behavior is most likely: 1 Valued privacy 2 Female modesty 3 Interdependency Mistrust of strangers 4 ANS: 3 In collectivistic cultures that value group reliance and interdependence, such as traditional Asians, Hispanics, and Africans, caring behaviors require actively providing physical and psychosocial support for family or community members. While the other options may be individualized factors, culturally the most likely origin is that of group reliance and interdependency of the Asian culture. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 27. An older Chinese client experienced a stroke that left him with right-sided weakness and now refuses to participate in physical therapy until his son is present. The nurse should initially interpret this behavior as: 1 A sign of post-stroke depression 2 3 An illustration of cultural collectivism A response to the therapy-induced pain 4 An example of a healthy father-son relationship ANS: 2 In collectivistic cultures that value group reliance and interdependence, such as traditional Asians, Hispanics, and Africans, caring behaviors require actively providing physical and psychosocial support for family or community members. The other options may be true; however, the more likely interpretation is the clients cultural inclination toward group reliance and family support systems. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 28. While assessing an older Vietnamese client, the nurse notes several oval-shaped reddened areas on her back and arms. The clients daughter explains them to be the result of a traditional healing practice called cupping. The nurses immediate reaction should be to: 1 Report the finding to the authorities to rule out physical abuse 2 Ask the daughter to explain the practice in detail 3 Notify the clients health care provider to see if treatment is necessary Document the assessment findings in the nursing notes 4 ANS: 2 Many Southeast-Asian cultures practice folk remedies such as coining, cupping, pinching, and burning to relieve aches and pains and remove bad wind or noxious elements that cause illness. These remedies leave peculiar visible markings on the skin in the form of ecchymosis, superficial burns, strap marks, or local tenderness. Cultural ignorance causes a practitioner to call authorities for suspicion of abuse. Nurses need to investigate to determine the details of the practice in order to decide whether the practice needs to be changed. Consultation and collaboration with herbalists and other naturalistic practitioners will prevent unnecessary distress for the client. While reporting the finding to authorities should not be dismissed, the nurse should WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material first discuss the practice with the daughter to learn more of the details regarding the practice. The clients health care provider should be notified, however, the nurses assessment of the areas as reddened areas suggests that other options may have priority. Documentation of the assessment findings is certainly appropriate and is a nursing responsibility, but acquiring an explanation from the daughter who is present would have priority. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 29. The nurse, caring for a comatose Muslim client who is dying, realizes that from a cultural standpoint, the most therapeutic intervention is to: 1 Facilitate the clients peaceful, pain-controlled death 2 Become familiar with Muslim death and dying traditions 3 Approach the family to identify and discuss any needs that exist 4 Arrange for a private room so the family can grieve traditionally ANS: 3 Be aware of religious and cultural preferences when helping clients and families prepare for death. Facilitating the clients peaceful, pain-controlled death is an appropriate intervention; it is not necessarily culturally oriented because nursing strives to facilitate a peaceful, pain-free death for all clients. Becoming familiar with cultural tradition is therapeutic and would have priority if the family were not present to be questioned directly regarding their needs. Arranging for a private room may be a therapeutic intervention because most cultures would prefer some degree of privacy when attending to the death of a loved one, but since the family is present the priority intervention is the one that identifies their needs. DIF: C REF: 112-113 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 30. A Hispanic client is diagnosed with inoperable brain cancer. The clients wife insists that any discussion about treatment options be postponed until all local family members are present. The nurse correctly views this as: 1 The familys attempt to facilitate a good death for the client WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 An invasion of the clients right of confidentiality by the family members 3 Appropriate because the cancer may have affected his decision-making abilities A cultural tradition that relieves the ill family member of the burden of decision making 4 ANS: 4 In some cultures, the group assumes decision making for a family member in these situations and is trusted to make the right decision for the individual. Indeed, some groups such as African Americans, Asian Americans, and Hispanics expect their family to make decisions for them, and family members prefer to protect the individual from unnecessary suffering by knowing the reality of imminent death. These cultures value group interdependence and view individual autonomy as an unnecessary burden for a loved one who is ill (Pacquiao, 2002, 2003a). The means by which the family provides a good death is first established through the process of group decision making. It may appear that the clients confidentiality is being invaded by a member of the Western nursing profession; it is a cultural norm for members of many Hispanic families. Although cancer may affect the clients abilities to make decisions, the origin of this behavior is more likely the cultural tradition of group decision making among Hispanics. DIF: C REF: 111 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 31. The nurse realizes that the primary goal of a cultural assessment is to: 1 Minimize client distress resulting from unmet cultural expectations 2 Provide care that is in concert with the clients cultural expectations 3 Identify cultural beliefs and traditions that are important to the client 4 Blend Western nursing practice with the clients cultural expectations ANS: 2 The goal of cultural assessment is to gather significant information from the client that will enable the nurse to implement culturally congruent care. Minimizing distress is an achieved WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material outcome when the goal of culturally congruent care is met. Identifying beliefs and traditions is an assessment goal that helps identify the criteria for individualized, culturally congruent care. Blending Western nursing practice with cultural expectations will result in individualized, culturally congruent care. DIF: C REF: 108 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 32. The nurse caring for members of the Hispanic community recognizes which of the following situations as the best reflection of the cultures view of family caring? 1 2 A husband calling each evening to tell his wife goodnight Family members taking turns staying with the client at night 3 The daughter bringing her fathers favorite soup to the hospital 4 The eldest son sending a huge floral arrangement to the hospital ANS: 2 In collectivistic groups such as the Hispanic culture, the physical presence of loved ones with the client demonstrates caring. While the other options show caring, it is not the best option reflecting the Hispanic culture. DIF: C REF: 110 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 33. A nurse caring for the Arab community observes a client crying. The woman was recently informed that her radiation treatments may affect her ability to become pregnant. The nurse recognizes that the client is most likely reacting to a cultural attitude regarding: 1 The importance of children to an Arab family 2 The Arab view that infertility is grounds for divorce 3 Infertility is a punishment for unholy living The loss of status among other married Arab women 4 ANS: 2 Infertility in a woman is considered grounds for divorce and rejection among Arabs. Although infertility is grounds for divorce in Arab cultures, it is not the best option for this question. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Infertility as a punishment for unholy living may not be a generally accepted view, it is not the best option for this question. While the loss of status among other married Arab women may be true, it is not the best option for this question. DIF: C REF: 111 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Cultural Diversity; Health Promotion and Maintenance/Health and Wellness 34. The primary problem with using English-speaking children of immigrant families as interpreters is that: 1 The adults may resent their dependence upon the child 2 The subjects discussed may be too disturbing to the child 3 Children can be easily distracted, thus making them unreliable translators 4 There are concerns about the childs ability to convey important information ANS: 1 Assuming that children are ideal interpreters for their parents may in fact be an insult to the authority of the elder who has to take directions from a child. Although the other options may be true, it is not the primary reason for the concerns regarding using children as interpreters Chapter 10. Family Dynamics MULTIPLE CHOICE 1. Which of the following is a current trend in families or family living? 1 People marrying earlier 2 Reduction in the divorce rate 3 People having more children 4 More people choosing to live alone ANS: 4 The number of people living alone is expanding rapidly and represents approximately 26% of all households. People are marrying later, not earlier. The rate of divorce appears to have stabilized, with approximately 55% of marriages ending in divorce. Couples are choosing to have fewer children or none at all. DIF: A REF: 122 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2. Of the following trends, which one represents the greatest current health care challenge to nurses? 1 2 3 4 Homelessness Single parent families Alternative relationship patterns Sandwiched or middle generation ANS: 1 Homelessness is identified as one of the greatest health care challenges to nurses. The trend of single parent families is not the greatest current health care challenge to nurses. The trend of alternate relationship patterns is not the greatest current health care challenge to nurses. The trend of a sandwiched or middle generation is not the greatest current health care challenge to nurses. DIF: A REF: 124 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 3. When working with families, the nurse may view the family as context or client. Which one of the following examples demonstrates the view of the family as context? 1 The familys ability to support the clients dietary and recreational needs 2 The clients ability to understand and manage his own personal dietary needs The familys demands on the client that are based on the clients role performance 3 4 The adjustment of both the client and the family to changes in diet and exercise ANS: 2 When the nurse views the family as context, the primary focus is on the health and development of an individual member existing within the clients family. The clients ability to understand and manage his own dietary needs is an example of viewing the family as context. The familys ability to support the clients dietary and recreational needs is an example of viewing the family as client. The familys demands on the client based on his role performance is an example of viewing the family as client. The adjustment of the client and family to changes in diet and exercise is an example of viewing the family as system. DIF: A REF: 128 OBJ: Comprehension TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 4. What would a nurse expect to find in an assessment of a healthy family? 1 2 Change is viewed as detrimental to the family. There is a passive response to most stressors. 3 The structure is flexible enough to adapt to crises. 4 Minimum influence is being exerted on the environment. ANS: 3 A healthy family has a flexible structure that allows adaptable performance of tasks and acceptance of help from outside the family system. The structure is flexible enough to allow adaptability but not so flexible that the family lacks cohesiveness and a sense of stability. The healthy family is able to integrate the need for stability with the need for growth and change. It does not view change as detrimental to family processes. The healthy family demonstrates control over the environment and does not passively respond to stressors. The healthy family exerts influence on the immediate environment of home, neighborhood, and school. DIF: A REF: 127 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 5. Initially, the nurse should begin by doing what in completing a clients family assessment? 1 Collecting health data from all the family members 2 Testing the familys ability to cope with normal stressors 3 Evaluating the familys interpersonal communication patterns 4 Determining the clients definition of familiar structure and attitudes ANS: 4 The nurse begins the family assessment by determining the clients definition of and attitude toward family and the extent to which the family may be incorporated into nursing care. The nurse also assesses family form and membership. Gathering health data from the family members is not the starting point for a family assessment. Testing a familys ability to cope is not where the nurse should begin a family assessment. Evaluating communication barriers would not be an initial action of the nurse when completing a clients family assessment. DIF: C REF: 126 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 6. Post discharge, the client is returning to their home environment. In assisting the client with that, specifically in implementing family-centered care, the nurse: 1 2 Provides personal beliefs regarding problem-solving Assists the family members to assume dependent roles 3 Works with the client to accept responsibility for role in discourse 4 Offers both client and family information about necessary selfcare abilities ANS: 4 When implementing family-centered care, the nurse adopts the role of educator and offers information about necessary self-care abilities. In family-centered care, the nurse guides the family in problem solving without providing his/her own beliefs. In family-centered care, the nurse assists clients to assume independent roles by increasing family members abilities in certain areas. In family-centered care, the nurse guides the family in problem solving, not in helping them accept blame. DIF: A REF: 129 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 7. A client is unable to independently perform colostomy care due to arthritis. The nurse should first: 1 Offer to assist the client to learn to manage the care 2 Arrange for home care services to care for the colostomy 3 Inquire as to family members who may be able to assist with the care Suggest that the client attend a colostomy self-help support group 4 ANS: 3 The nurse should first find out if there is anyone else in the family or neighborhood who would or could assist with the colostomy care. Informing the client that management of the colostomy must be learned will not change the fact that the client has arthritis and needs assistance. The nurse should first determine whether there is someone else who could perform the task. If not, the nurse arranges for a home care service referral. A colostomy self-help support group may provide emotional support, but it will not meet the clients need for assistance with colostomy care. DIF: C REF: 131 OBJ: Analysis TOP: Nursing Process: Planning WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 8. The optimum goal of effective communication within the family, according to the nurse observing the family members and their interaction, is: 1 2 3 4 Problem solving and psychological support Role development of individual members Socialization among individual members Better financial conditions for the family ANS: 1 The optimum goal of effective communication within the family is to be able to problem solve and provide psychological support for its members. Role development is not the optimum goal of effective communication within the family. Socialization among individual family members is not the optimum goal of effective communication within the family. Improving financial conditions for the family is not the optimum goal of effective communication within the family. DIF: A REF: 129 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 9. Which of the following is a gerontological principle related to families? 1 Later-life families need not work on developmental tasks. 2 The caregivers are often not members of the clients family. 3 Role reversal is usually expected and well accepted by the older client. Support systems are likely to be different than those of younger age-groups. 4 ANS: 4 It is true that social support systems for older adults are likely to be different from those for clients in younger age-groups. Members of later-life families need to be working on developmental tasks. Caregivers for older adults are usually either spouses or middle-age children. Accepting shifting of generational roles is often difficult for the older client. DIF: A REF: 125 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 10. In assessing the roles and power structure of a clients nuclear family, the nurse should specifically ask the client: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Who decides where to go on vacation? 2 3 What type of health care insurance do you have? How many family members currently live in your home? 4 What types of social activities do you and your family enjoy? ANS: 1 Asking, Who decides where to go on vacation? enables the nurse to determine the power structure and patterning of roles and tasks of the family. Asking about health insurance does not assess the roles and power structure of the family. Inquiring about family members living at home may be used to help determine family form, not the power structure and roles of the family. Asking about social activities may provide information on the interactive processes of the family and how time is spent, but it does not assess the roles and power structure of the family. DIF: C REF: 126 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 11. Needing assistance with daily living activities, an older adult with two grown children is being discharged home. Although both children live nearby, the daughter is expressing concern about handling her parents physical needs. The nurses initial response is to: 1 Work with the family on delegating responsibility 2 Suggest short-term nursing home placement to the client 3 Arrange for the client to remain hospitalized in the medical center Make decisions for the family on how to manage the care at home 4 ANS: 1 The nurse must consider caregiver strain and work with the family on delegating responsibility. Nursing home placement should not be the nurses initial response to caregiver strain. Arranging for the client to remain in the medical center is not always feasible and does not address the problem of caregiver strain. It should not be the nurses initial response in this situation. The nurse should not make decisions for the family, but rather work with the family to problem solve. DIF: C REF: 126 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 12. The nurse suspects that there is physical abuse present after visiting the client in the home. In recognition of the pattern of family violence, the nurse knows that: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Child abuse is declining in frequency 2 3 Spouses are the most frequent abusers Mental illness is a major cause of abuse 4 Abuse is primarily seen in lower income families ANS: 2 In recognition of the pattern of family violence, the nurse knows that spouses are the most frequent abusers. Child abuse is increasing, not decreasing. Mental illness may increase the incidence of abuse within a family, but is not a major cause of abuse. Emotional, physical, and sexual abuse occurs across all social classes. DIF: A REF: 124 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 13. The primary goal of family-centered nursing is to: 1 Promote the wellness of the family and its members 2 Implement appropriate care for the family and its members 3 Provide support and care for the family and its individual members 4 Identify physical and emotional problems affecting the family as a unit ANS: 3 The goal of family-centered nursing care is to promote, support, and provide for the well-being and health of the family and individual family members. While the other options are appropriate goals, they are not the primary goal because promoting, supporting, and providing for the wellbeing and health of the family and individual family members will result in this option DIF: C REF: 122 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 14. A nurse who is sensitive to the care of families recognizes that the term family is primarily defined: 1 As individuals legally bound to the client 2 As people with biological connections to the client 3 In terms generally accepted by the majority of clients By the client as individuals important to the client 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 4 A nurse can think of the family as a set of relationships that the client identifies as family or as a network of individuals who influence each others lives. People related legally and biologically may be criterion used to determine family. General terms may not be correct in todays diversified world. DIF: C REF: 122 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 15. The nurse is preparing a new mother for discharge when the woman shares that she is worried about going back to work and its effects on my infant. The most therapeutic response by the nurse is: 1 2 3 4 Do you want to go back to work? Just be sure you have an excellent baby sitter. There is no proof that working will harm your baby. Can your husband share in the child care responsibilities? ANS: 3 Balancing employment and family life creates a variety of challenges in terms of child care and household work for both parents. There is no proof maternal employment is damaging for children (Shpancer and others, 2006; Hill, 2005). Although the other options may be true or attempt to offer a solution, they do not address her concerns regarding the effects on her child. DIF: C REF: 123 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 16. The greatest risk to a child of adolescent parents comes from the: 1 Increased family stressors resulting in domestic violence 2 Lack of appropriate parenting resources and role models 3 Statically high potential for physical and emotional abuse Parents inability to provide health care and economic support 4 ANS: 2 The greatest risk to a child of adolescent parents is derived from the parents strong potential to lack good parenting skills. This inability can result in both physical and emotional harm. Increased family stressors resulting in domestic violence and statically high potential for physical and emotional abuse often result from poor parenting and coping skills. The parents inability to provide health care and economic support is more likely in an adolescent-headed family resulting from limited marketable skills. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 123 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 17. Which of the following nursing statements has the greatest therapeutic value when counseling a sandwich generation client caring for a chronically ill parent? 1 2 I can help you in finding assistance with the in-home care. What is the most stressful aspect of caring for your parent? 3 Im sure your children love having grandmother in the house. 4 What do you do for relaxation now that your mom lives with you? ANS: 4 Assess for caregiver stress, such as tension in relationships with family and care recipient, changes in level of health, changes in mood, and anxiety and depression. Asking the caregiver about hobbies or other means of relaxation is a nonthreatening way to assess tension levels. Offering to help find assistance infers a need for help that may insult the caregiver. Assuming the caregiver is stressed or assuming the living situation is good may cause the caregiver to be reluctant to discuss existing problems. DIF: C REF: 133 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 18. The mother of a child receiving immunizations at a health clinic shares with the nurse that she and the child have not eaten today. Which of the following nursing interventions is best directed at impacting the immediate problem while being sensitive to the mothers sense of selfworth? 1 Notifying family services of the problem 2 Taking both mother and child to the cafeteria 3 Informing the mother that she is eligible for food stamps 4 Providing her with contacts at the neighborhood food bank ANS: 4 When caring for these families, the nurse needs to be sensitive to the familys desire for independence, but also help them with obtaining appropriate food, financial, and health care resources. Notifying family services may become necessary, but attempts to provide the mother with available means of assistance has priority. Taking them to the cafeteria would provide immediate food but does not address future needs or show sensitivity to the mother. Informing WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material the mother about local and state aid may become necessary, but it does not address the immediate need, nor does it show sensitivity to the mother. DIF: C REF: 124 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 19. The nurse recognizes that the presence of an alcohol-abusing parent places a child at greatest risk for: 1 2 3 4 Homelessness School truancy Family violence Accident-related injuries ANS: 3 Factors such as alcohol and drug abuse increase the incidence of abuse within a family (Family Violence Prevention Fund, 2006b). While the other options are possible, they are not the greatest negative outcome. DIF: C REF: 124 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 20. The most important impact that truthful, timely communication between the nurse and the family of a critically ill client has is on the familys ability to: 1 Trust the nurse 2 Adjust to bad news 3 Be confident of the care the client is receiving Make appropriate choices regarding client treatment 4 ANS: 1 Provide realistic assurance; giving false hope breaks the nurse-client trust. Being trustful of the information provided by the nurse will aid in the adjustment to bad news. Trust is the basis for confidence in the care being provided and for appropriate decision-making. DIF: C REF: 125 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 21. When caring for a terminally ill client, the nurse must also assess the family, because the primary benefit will be: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Effective use of time and resources in the end-of-life care of the client 2 Appropriate attention to the cultural beliefs and expectations of the family Added information regarding the care needs and preferences of the client 3 4 The ability to respond effectively to the family unit during the dying process ANS: 4 The more you know about your clients family, how they interact with one another, their strengths, and their weaknesses, the better. Each family approaches and copes with end-of-life decisions differently. While the other responses may be true, they are not the primary benefit. DIF: C REF: 125 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 22. When attempting to meet the needs of the family, the nurse recognizes the central concept of the theory of family developmental stages is that: 1 Over time all families progress through developmental stages 2 Needs differ as the family progresses through the various stages 3 While each family is unique, they all tend to progress through similar stages The family will progress only when all the challenges of a particular stage are met 4 ANS: 3 Although families are far from identical to one another, they tend to go through certain stages. Nursing care can be delivered based on the assumption that all families progress through similar stages that present comparable challenges. DIF: C REF: 125 OBJ: Analysis TOP: Nursing Process: Assessment/Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Family Dynamics 23. The nurse can primarily affect the effectiveness of a familys ability to cope with stress by encouraging: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Flexible roles 2 3 Distinct task assignment Individual independence 4 Variable parenting models ANS: 1 A rigid structure specifically dictates who is able to accomplish a task, and may limit the number of persons inside as well as outside the immediate family who can assume these tasks. Sharing tasks allows for reassignment of tasks when the need arises. A rigid structure specifically dictates who is able to accomplish a task, and may limit the number of persons inside as well as outside the immediate family who can assume these tasks. Inability to reassign the tasks will impact the familys ability to adjust to stressors. Chapter 11. Developmental Theories MULTIPLE CHOICE 1. A nurse who wants to apply a theory that relates to moral development should read more from the work of: 1 Gould 2 Freud 3 Erikson 4 Kohlberg ANS: 4 Kohlberg developed a theory on moral development. Gould developed a theory on psychosocial development. Freud developed a theory on psychosexual development. Erikson developed a theory on psychosocial development. DIF: A REF: 144 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 2. The nurse using Eriksons theory to assess a 20-year-old clients developmental status expects to find which of the following behaviors? 1 Coping with physical and social losses 2 Enjoys participating in the community 3 Applying self to learning skills Overcoming a sense of guilt or frustration 4 ANS: 2 According to Erikson, the young adult is in the intimacy versus isolation stage of development. This is the time in which the young adult can become fully participative in the community, WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material enjoying adult freedom and responsibility. Coping with physical and social losses is found in Eriksons integrity versus despair stage (old age) of development. Applying themselves to learning productive skills is a consistent behavior found in Eriksons industry versus inferiority stage (6 to 11 years) of development. According to Erikson, overcoming a sense of guilt or frustration is in the initiative versus guilt stage (3 to 6 years) of development. DIF: A REF: 140 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 3. The nurse recognizes that Freuds theory approaches development by looking at: 1 Moral reasoning. 2 3 Logical maturity Psychosexual aspects 4 Cognitive development ANS: 3 Freuds theory of personality development approaches development by looking at psychosexual aspects. Kohlbergs theory approaches development by looking at moral reasoning. Goulds theory approaches development by looking at logical maturity. Piagets theory approaches development by looking at cognitive development. DIF: A REF: 138 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 4. According to Piaget, a preschool child (3 to 5 years old) who comes to the clinic is expected by the nurse to exhibit which of the following behaviors? 1 Far-reaching problem-solving 2 Exploration of the environment 3 Cooperation and sharing with others Thinking with the use of symbols and images 4 ANS: 4 According to Piaget, the preoperational child (age 2 to 7 years) is learning to think with the use of symbols and mental images. Organization of thoughts and far-reaching problem-solving are noted in Piagets formal operations (11 years to adulthood) stage of cognitive development. According to Piaget, the child explores the environment in the sensorimotor stage (birth to 2 years) of cognitive development. Cooperation and sharing are seen in Piagets concrete operations (age 7 to 11 years) stage of cognitive development. DIF: A REF: 142 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 5. For an older adult client, an example of a common behavioral task or critical event is: 1 Selecting a mate 2 3 Rearing children Finding a congenial social group 4 Adjusting to decreasing physical strength ANS: 4 A common behavioral task of the older adult client is adjusting to decreasing physical strength. Selecting a mate is a developmental task commonly seen in the early adult. Rearing children is a developmental task of the middle-early adult. Finding a congenial social group is a developmental task of the middle-early adult. DIF: A REF: 137 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 6. The nurse working in an adult medical clinic wishes to learn more about a developmental theory that focuses on the adult years. The nurse investigates different possibilities and selects the theory proposed by: 1 Gould 2 Piaget 3 Freud 4 Chess and Thomas ANS: 1 Goulds theory of psychosocial development specifically focuses on the adult years. Piagets theory focused on cognitive development throughout the life span. Freuds psychosexual theory focused on personality development throughout the life span. The theory of Chess and Thomas focused on development from childhood to early adulthood. DIF: A REF: 142 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 7. The nurse recognizes that which one of the following statements about growth and development is correct? 1 Development ends with adolescence. 2 Growth refers to qualitative events. 3 Developmental tasks are age-related achievements. Cognitive theories focus on emotional development. 4 ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Developmental tasks are age-related achievements is a correct statement about growth and development. Human growth and development are orderly, predictable processes beginning with conception and continuing until death. Growth refers to quantitative events. Development refers to qualitative events. Cognitive theories focus on reasoning and thinking processes. DIF: A REF: 137 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 8. In Kohlbergs Moral Development theory, an individual who reaches level II (conventional thought) is expected to exhibit: 1 2 Absolute obedience to authority Reasoning based on personal gain 3 Personal internalization of others expectations 4 Self-chosen ethical principles, universality, and impartiality ANS: 3 At level IIconventional thought, the person sees moral reasoning based on his or her own personal internalization of societal and others expectations. In stage 1, the childs response to a moral dilemma is in terms of absolute obedience to authority and rules. At level Ipreconventional thoughtthe person reflects on moral reasoning based on personal gain. According to Kohlberg, stage 6 is when a person has self-chosen ethical principles, universality, and impartiality. DIF: A REF: 144 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 9. According to Piaget, the infant is in the first period of development, which is characterized by: 1 Concrete operations 2 Preoperational thought 3 Sensorimotor intelligence Identity versus role confusion 4 ANS: 3 According to Piaget, the infant is in the first period of development, which is characterized by sensorimotor intelligence. According to Piaget, children ages 7 to 11 are in the concrete operations period of development, which is characterized by having the ability to perform mental operations, while children ages 2 to 7 are in the preoperational period of development, which is characterized by the child learning to think with the use of symbols and mental images. Identity versus role confusion is a developmental stage (puberty) according to Erikson. DIF: A REF: 142 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 10. A childs understanding of the concept of ice becoming water, Piagets stage of cognitive development, is seen in: 1 2 3 4 Sensorimotor Preoperational Formal operations Concrete operations ANS: 4 During Piagets concrete operations stage of cognitive development, the child is able to understand that objects or quantities remain the same despite a change in their physical appearance, such as when ice becomes water. During Piagets sensorimotor stage of cognitive development, the child is exploring the environment but is unable to understand the concept of ice becoming water. During Piagets preoperational stage of cognitive development, the child is learning to think with the use of symbols and mental images but is not able to understand the concept of ice becoming water. According to Piagets formal operations stage of cognitive development, the individuals thinking moves to abstract and theoretical subjects. DIF: A REF: 142-143 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 11. The nurse in a pediatric health care setting is using Kohlbergs developmental theory. A child is evaluated as having reached level I, the preconventional level, if the child: 1 Makes sure that he or she is not late for school 2 Cleans the blackboards after school for the teacher 3 Runs for school council in order to change policies Stays away from peer groups that harass other children 4 ANS: 1 According to Kohlbergs developmental theory of moral development, at level I, the preconventional level, the childs reasoning is based on personal gain. The moral reason for acting relates to the consequences the person believes will occur. The child who makes sure not to be late for school may do so out of fear of punishment. Cleaning the blackboards after school for the teacher is an example of Kohlbergs stage 3, good boy-nice girl orientation. The child desires to win the teachers approval. Running for school council to change policies is an example of Kohlbergs stage 5 social contract orientation. Staying away from gangs at school that harass other children is an example of Kohlbergs stage 4 society-maintaining orientation. DIF: A REF: 144 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 12. In applying Goulds developmental theory, the nurse anticipates that a client will have a greater concern for ones health within the following theme and age-group: 1 2 3 4 First theme (20s) Second theme (early 30s) Fourth theme (40s) Fifth theme (50s) ANS: 4 During the fifth theme (50s), Gould finds a realization of mortality with a concern for ones state of health. During the first theme (20s), Gould finds individuals wanting to get away from their parents. During the second theme (30s), Gould finds young adults working to accept who they are and to accept their growing children as being unique and separate. During the fourth theme (40s), Gould finds resignation and the belief that possibilities are limited. DIF: A REF: 142 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 13. The nurse is working with a new mother who will require surgery. The follow-up treatment will interfere with bonding. In applying Freuds theory, the nurse recognizes that the stage of development that may be affected is the: 1 Oral stage 2 Anal stage 3 Phallic stage Latent stage 4 ANS: 1 According to Freud, disruption in the physical or emotional availability of the parent for the newborn (e.g., undergoing surgery) will affect the oral stage of development; the anal stage is from 12 to 18 months to 3 years, when the child is toilet-training; the phallic stage is from 3 to 6 years of age, when the child becomes interested in the genital organs; and the latent stage is from 6 to 12 years, when the child represses sexual urges and channels them into productive activities that are socially acceptable. DIF: A REF: 138 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 14. In accordance with Eriksons theory, it is expected by the nurse that a middle-aged adult client will be involved in the process of: 1 Developing a sense of identity 2 Searching for meaning in life WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Enhancing ones capability to love others 4 Expanding personal and social involvement ANS: 4 In accordance with Eriksons theory, the middle-aged adult client is involved in the process of expanding ones personal and social involvement. Middle-aged adults should be able to see beyond their needs and accomplishments to the needs of society. Developing a sense of identity is in accordance with Eriksons identity versus role confusion (puberty) stage of development. Searching for meaning in life is in accordance with Eriksons integrity versus despair (old age) stage of development. Enhancing ones capability to love others is in accordance with Eriksons intimacy versus isolation (young adult) stage of development. DIF: A REF: 140 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 15. The primary purpose for the nurse to understand human growth and development is to be best able to: 1 Identify deviations from normal 2 3 Select effective nursing interventions Be sensitive to age-appropriate needs 4 Enhance nurse-client communication ANS: 1 Understanding normal growth and development helps nurses predict, prevent, and detect any deviations from clients normal expected patterns. While being familiar with the characteristics of the various stages of human growth and development and being able to apply that knowledge to the individual client do have a positive impact on determining the most appropriate nursing interventions, the primary purpose is to predict, prevent, and detect any deviations from the clients normal expected patterns. Although being familiar with the characteristics of the various stages of human growth and development and being able to apply that knowledge to the individual client do have a positive impact on identifying age-appropriate needs, the primary purpose is to predict, prevent, and detect any deviations from the clients normal expected patterns. While being familiar with the characteristics of the various stages of human growth and development and being able to apply that knowledge to the individual client do have a positive impact on the nurses ability to communicate with the client in an appropriate manner, the primary purpose is to predict, prevent, and detect any deviations from the clients normal expected patterns. DIF: C REF: 137 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 16. Which of the following should the nurse consider first when assessing the cognitive ability of an older adult? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 A life-long bachelor 2 3 Orphaned at age 12 History of a chronic disease process 4 Recent immigration to the United States ANS: 4 Cognitive processes comprise changes in intelligence, ability to understand and use language, and the development of thinking that shapes an individuals attitudes, beliefs, and behaviors. Recent immigration to the United States would present language and life experiences that should be considered by the nurse. Socioemotional processes consist of the variations that occur in an individuals personality, emotions, and relationships with others during their lifetime. Being a bachelor and not having experienced a marital relationship should be considered by the nurse. Socioemotional processes consist of the variations that occur in an individuals personality, emotions, and relationships with others during their lifetime. Being orphaned at a young age should be considered by the nurse. Biological processes produce changes in an individuals physical growth and development. A chronic disease process should be considered by the nurse. DIF: C REF: 142 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 17. A nurse caring for a 78-year-old client recently diagnosed with pneumonia will find Eriksons psychosocial development theory most helpful in determining: 1 Which needs the client will typically develop 2 Which coping mechanisms the client will likely use 3 How the client will respond to the respiratory problem 4 How the client and his family will adjust to the stressors ANS: 3 Developmental theories are important in helping nurses assess and treat a persons response to an illness. Understanding and being able to apply the concepts of the theory will enable the nurse to determine a variety of generalized information that will assist in providing appropriate nursing care. The other options are only one area of information that is made available when applying Eriksons psychosocial development theory. DIF: C REF: 140 OBJ: Analysis TOP: Nursing Process: Assessment/Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 18. As described by Freud, the nurse recognizes that a young adult best shows a well-developed superego when he: 1 Tells a friend that hell help him stop smoking WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Returns a lost wallet to a stranger who dropped it 3 Arranges for a cab ride home after consuming alcohol Has 10% of his salary automatically transferred to savings 4 ANS: 3 Components of the human personality develop through Freuds developmental stages. Freud believed that the functions of these components regulate behavior. These components are the id, the ego, and the superego. The superego performs regulating, restraining, and prohibiting actions. Often referred to as the conscience, the superego is influenced by the standards of outside social forces (i.e., the law). The ego represents the reality component mediating conflicts between the environment and the forces of the id. The ego helps us judge reality accurately, regulate impulses, and make good decisions. DIF: C REF: 139 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 19. A nurse is preparing to discharge an 11-month-old child after a hospitalization for a viral infection. The nurse uses anticipatory guidance most effectively when: 1 Encouraging the parents to limit visitors for 14 days 2 Providing the parents with written discharge instructions 3 Arranging the follow-up pediatrician appointment for the parents 4 Informing the parents that the child may cry when taken to daycare ANS: 4 A nurses use of anticipatory guidance (derived from an understanding of the characteristics shown by clients in the trust versus mistrust phase of development) will help parents cope with the hospitalization of an infant and the infants behaviors when discharged to home. The childs sense of trust may be challenged during hospitalization and may need support from parents when returning home. Encouraging the parents to limit visitors for 14 days is more educational and related to the childs physical recovery. Providing the parents with written discharge instructions is more educational and designed to reinforce the information. Arranging the follow-up pediatrician appointment for the parents is an action included in the discharge planning. DIF: C REF: 139 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 20. Which of the following situations/statements best depicts Goulds fourth theme of adult development? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 When I made that decision, I didnt expect it to turn out like it did. 2 I have to take the opportunity to be my own boss and not rely on others. I think you can do anything if only you have your health and good friends. 3 4 As much as Id love to open my own shop, I just cant take that kind of chance. ANS: 4 The fourth theme, identified in the 40s and called the die is cast, indicates resignation and the belief that possibilities are limited. The personality is set. Individuals believe changes in career are less likely to be successful. Parents are blamed for their lack of choices. Individuals face regret for mistakes made with children. The second theme occurs during the early 30s and asks, Is what I am the only way for me to be? This question occurs when young adults experience the consequences of the decisions of their independence. Goulds development themes start when individuals are in their 20s with, I have to get away from my parents. This is challenged in minor ways before the end of high school but ends as young persons begin to live away from home. The move away from parental influence is gradual as young adults establish themselves as adults. During the 50s a decrease in negativism occurs. Gould finds a realization of mortality with a concern for ones state of health. DIF: C REF: 142 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 21. The nurse is caring for an older adult client who has reported symptoms suggestive of depression. Which of the following questions asked by the nurse is most therapeutic in assessing the clients perception of the impact depression has had on her life? 1 What does it mean to be depressed? 2 How does being depressed make you feel? 3 Were you happy before becoming depressed? What makes you think that you are depressed? 4 ANS: 1 Understanding the older persons concept of depression assists nurses in explaining complementary and alternative treatment measures. Asking how depression make the client feel or whether the client was previously happy are best saved until the client defines depression and is open to the possibility of being depressed. Asking what makes the client think they are depressed could be interpreted as being somewhat threatening and may interfere with the clients desire to talk about the situation. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 141 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 22. The nurse is caring for a 6-year-old child who is scheduled for outpatient surgery. Piagets theory of cognitive development suggests that the nurse can help the child cope with the stressors of this hospital experience best by: 1 2 Arranging for the parents to be with the child until the anesthetic takes affect Explaining the entire process with the child using ageappropriate language 3 Using play as a means of familiarizing the child with the events he will experience 4 Providing the child with a coloring book that shows the events he will be experiencing ANS: 3 Play becomes a primary means by which children foster their cognitive development and learn about the world. Nursing interventions during this period will recognize the use of play as the way the child understands the events taking place. You will assist parents in the use of play materials such as thermometers, blood pressure equipment, and play needles that will allow children to communicate feelings about health care procedures they experience. Arranging for the parents to be with the child until the anesthetic takes affect may be an appropriate intervention but it does not reflect effective care suggested by Piagets theory of cognitive development. Explaining the entire process with the child using age-appropriate language would be more appropriate for the older child. Providing the child with a coloring book that shows the events he will be experiencing DIF: C REF: 142 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 23. Which of the following nursing responses is most therapeutic when made in response to a parents concern about her 3-year-old childs tendency to break the rules? 1 Just keep reminding her of the rules. 2 Daycare will help her learn to play fair. 3 She will begin to understand that concept in a year or so. 4 Add an age appropriate punishment for breaking the rules. ANS: 3 The first stage, heteronomous morality, occurs between 4 and 7 years and is characterized by a belief that rules are unchangeable and that when a rule is broken, there is imminent justice. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Before that stage, the child is not able to fully understand rules or other moral issues. While telling the client to keep reminding her of the rules may be useful, it does not help assure the parent that the child is displaying normal, age-appropriate behavior. While socialization will often have a positive effect on a childs sense of fair play, this option does not help assure the parent that the child is displaying normal, age-appropriate behavior. The child is too young to understand the concept that makes punishment effective in acquiring fair play. DIF: C REF: 144 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 24. To help a comatose clients family make a moral decision regarding the termination of life support, the nurse must first: 1 2 3 4 Refrain from expressing his/her personal beliefs concerning the life support issue Provide the family with information regarding the process of terminating life support Determine whether the client had expressed any written or oral wishes regarding the issue Facilitate the familys decision-making process by providing them with a quiet, private space for discussion ANS: 1 Nurses need to know their own moral reasoning level. Recognizing ones own moral developmental level is essential in separating your own beliefs from others when helping clients with their moral decision-making process. Information regarding the process of terminating life support should be provided only after the family makes their decision or has asked for the information. To not influence the family, the nurse must first refrain from interjecting any personal feelings about the termination of life support measures. DIF: C REF: 145 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 25. Which of the following best describes a nurse thinking at stage 5 of Kohlbergs Moral Developmental Theory? 1 The client has a right to decide whether or not to proceed with the treatment plan. 2 The hospitals policies and procedures are excellent tools for making client oriented decisions. It wont be fair to expect to get every weekend and holiday off, so Ill certainly work my share. 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 If you dont keep client information confidential you could be terminated immediately. ANS: 1 The individual also recognizes that different social groups have different values but believes that all rational people would agree on basic rights, such as liberty and life. (Stage 5: Social Contract Orientation). Moral decisions take into account societal perspectives. Right behavior is doing ones duty, showing respect for authority, and maintaining the social order. (Stage 4: SocietyMaintaining Orientation). The principles of justice require the individual to treat everyone in an impartial manner, respecting the basic dignity of all people, and guides the individual to base decisions on an equal respect for all. (Stage 6: Universal Ethical Principle Orientation). Avoidance of punishment or the unquestioning deference to authority is the characteristic motivation to behave. (Stage 1: Punishment and Obedience Orientation) DIF: C REF: 144 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Staff Education 26. Which of the following client statements made by an older adult best reflects an understanding of the decrease in physical strength and stamina in this developmental stage? 1 I know Im not as young as I use to be. 2 3 I just hire help with jobs I cant do myself. You get older you cant do as much, thats life. 4 I have to ask my son for help with the yard work. ANS: 2 A common behavioral task of the older adult client is adjusting to decreasing physical strength. This option reflects the best adjustment because the client has developed a plan for coping. While the other options appear to address the issue, they do not present any proof of the clients healthy acceptance or adjustment to the decrease in physical strength and stamina. Chapter 12. Conception Through Adolescence MULTIPLE CHOICE 1. Which of the following data is the most important for the nurse to assess when caring for a woman in her second trimester of pregnancy? 1 Detection of fetal movement 2 Observation that the uterus is below the pubis 3 Confirmation of the desire to breast- or bottle-feed Determination of the presence of morning sickness 4 ANS: 1 During the second trimester, between 16 and 20 weeks gestation, the mother begins to feel fetal movement. During the second trimester, the uterus should be above the level of the symphysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material pubis. Confirmation of the desire to breast- or bottle-feed is more likely to take place during the third trimester. Morning sickness is most likely to occur during the first trimester. DIF: C REF: 151 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 2. Which one of the following newborn reflexes should the nurse be able to elicit at a 6-month well-baby visit? 1 2 Moro Startle 3 Babinski 4 Extrusion ANS: 3 The Babinski reflex is a normal reflex found in a 6-month-old infant. The Moro reflex is seen in the newborn. The startle reflex is seen in the newborn. Before 6 months of age, the extrusion reflex causes food to be pushed out of the mouth. It is normally present from birth to 4 months. DIF: A OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 3. In evaluating an infants physical status and growth, the nurse expects to find: 1 Birth weight triples by 6 months 2 Anterior fontanel closes 4 to 8 weeks after birth 3 Chest circumference is larger than head circumference at 12 months Birth height increases 1 inch each month for the first 6 months 4 ANS: 4 Height increases an average of 1 inch during each of the first 6 months and inch the next 6 months. Birth weight doubles in approximately 5 months and triples by 12 months. The anterior fontanel closes at about 12 to 18 months. The head and chest circumference are equal at 1 year of age. DIF: A REF: 155 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4. Upon evaluation of a 6-month-old infants developmental status, the nurse expects that the child at this age will be able to: 1 2 3 4 Completely roll over Pull self to a standing position Creep on all four extremities Assume a sitting position independently ANS: 1 A 6-month-old infant is able to roll over. A 9-month-old infant is able to pull self to a standing position, creep on all four extremities, and attain a sitting position independently. DIF: A OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 5. For a 2-year-old child, cognitive development is characterized by: 1 Recognizing right and wrong 2 Initiating play with other children 3 Having a vocabulary of at least 1000 words Using short sentences to express independence 4 ANS: 4 A 2-year-old child uses short sentences to express independence and control, does not understand the concepts of right and wrong, may engage in solitary play and begin to participate in parallel play, may initiate play with other children, and has a vocabulary up to 300 words. DIF: A REF: 159 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 6. In planning nursing care for an 18-month-old child, the nurse should know that the predominant developmental characteristic of children this age is: 1 Parallel play 2 Peer pressure 3 Mutilation anxiety Imaginary playmates 4 ANS: 1 During toddlerhood, the child begins to participate in parallel play, which is playing beside rather than with another child. Peer pressure is seen with the school-age child. A fear of the preschool child is bodily harm. The preschool child may have imaginary playmates. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A REF: 159 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 7. The nurse, in working with children of this age, plans to allow a 5-year-old boy who was admitted to the surgical center to have his tonsils removed to: 1 2 Perform his own preoperative hygienic care Have alone time to relax before the procedure 3 Handle the equipment when taking his blood pressure 4 Have access to age-appropriate magazines and puzzles for diversion ANS: 3 Preschool children may cooperate if they are allowed to manipulate the equipment. A preschooler is unable to take responsibility for his or her own preoperative hygienic care. Leaving the preschooler alone may increase the childs anxiety. Magazines and puzzles would be more appropriate activities for the older child. The preschool child likes to engage in pretend play, using their imagination and imitating adult behavior. DIF: A REF: 160 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 8. A parent of a 3-year-old boy states that she is concerned because he was potty trained long before hospitalization but now refuses to use the toilet. What is the correct response by the nurse? 1 Your son is probably feeling neglected, and you should make an effort to spend more time with him. 2 This is common behavior that is expressed when the hospitalized child is stressed or anxious. 3 You may need to include discipline because children easily lose the ability to be toilet trained during hospitalization. Your son was probably not ready to be potty trained, and you may want to continue the training for the next 6 months. 4 ANS: 2 During times of stress or illness, preschoolers may revert to bed-wetting or thumb-sucking and want the parent to feed, dress, and hold them. Reassuring the parent that this is normal coping behavior may help alleviate their concern. Reverting to a prior level of functioning, such as a WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material child who was potty trained now refusing to use the toilet, does not indicate the child is feeling neglected. The behavior demonstrates that the child is experiencing stress and this is a coping behavior. Disciplining the child would not be a correct response. The child should be provided with experiences he or she can master. Such successes help the child to return to their prior level of independent functioning. Reverting to a prior level of functioning, such as a child who was potty trained now refusing to use the toilet, does not indicate the child was unready to be potty trained. The behavior more likely demonstrates that the child is experiencing stress, and this is a coping behavior. DIF: A REF: 161 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 9. A 4 1/2-year-old child is crying from pain related to her fractured leg. Which of the following is the most appropriate nursing response to her alteration in comfort? 1 Please try to not move your leg and that will make it feel better. 2 Ill give you a shot of medicine that will help take the pain away. 3 Its okay if you need to cry. Would you like to hold your favorite doll? 4 Would you like to tell me now where you want me to give you your shot? ANS: 3 Telling the child its okay to cry and hold a toy informs the child what they can do, and involves an age-appropriate familiar toy to provide comfort. Telling the child not to move when they are in pain is unlikely to be effective. A preschool child may have difficulty in understanding the request. Telling the child they are going to get a shot may increase their anxiety, as they fear bodily harm. If a child is allowed to determine the site for administration of an injection, specific sites should be offered as choices. However, the nurse needs to avoid allowing procrastination by the child. DIF: A REF: 160 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 10. When teaching basic infant safety to the parents of a 3-month-old, the nurse should emphasize: 1 Placing gates at stairways 2 Keeping bathroom doors closed WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Giving large, hard teething biscuits 4 Removing feeding bibs at bedtime ANS: 4 Bibs should be removed at bedtime to avoid suffocation. Placing gates or fences at stairways is an appropriate safety measure to prevent falls of the 8- to 12-month-old infant. Keeping bathroom doors closed is an appropriate safety measure to prevent drowning of the 8- to 12month-old infant. Caution should be exercised when giving teething biscuits to a 4- to 7-monthold infant because large chunks may be broken off and aspirated. Teething biscuits are typically not given to a 3-month-old. DIF: A REF: 156 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 11. The parents of a 3-month-old ask the nurse what behavior they should expect. The nurse informs the parents that the child will be able to: 1 Say Da-da 2 Smile responsively 3 Differentiate strangers 4 Play social peekaboo games ANS: 2 Two- and 3-month-old infants begin to smile responsively rather than reflexively. By 1 year of age, infants have two- or three-word vocabularies such as Da-da. By 8 months, most infants can differentiate a stranger from a familiar person. By 9 months, infants play simple social games such as patty-cake and peekaboo. DIF: A REF: 155 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 12. A client in her first trimester of pregnancy asks the nurse about how the baby is growing. The nurse responds correctly by telling the client that: 1 The sex of the baby can be determined. 2 3 There is a fine hair that covers the body. Fingers and toes are differentiated clearly. 4 The organ systems are beginning to develop. ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material During the first trimester of pregnancy, the organ systems are beginning to develop. During the second trimester of pregnancy, the sex of the fetus can be determined, and fine hair, called lanugo, covers most of the body of the fetus. Also during the second trimester of pregnancy, fingers and toes are differentiated. DIF: A REF: 150 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 13. The nurse assists the family of a 9-year-old with nutritional information. A recommended after-school snack for a child this age is: 1 2 Milk shakes Potato chips 3 Plain popcorn 4 Bite-size candy ANS: 3 Plain popcorn, fresh fruit, raw vegetables, cheese, skim-milk pudding, and hot chocolate are appropriate after-school snacks. Thick milk shakes would be high in fat and calories. There are better food choices for after-school snacks. Potato chips should be discouraged as a snack because they are high in fat and low in nutritional value. Candy bars should be discouraged as a snack because they are high in fat and calories, are low in nutrition, and are cariogenic. DIF: A REF: 168 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 14. The elementary school nurse is responsible for evaluating each childs overall physical development. During the school-age years, the nurse anticipates that: 1 The childs body weight will almost triple 2 There will be few physical differences among children 3 The child will grow an average of 1 to 2 inches per year Body fat will gradually increase, contributing to a heavier appearance 4 ANS: 3 During the school-age years, the child will grow an average of 1 to 2 inches per year and gain an average of 4 to 7 pounds a year. Many children double, not triple, their weight during these middle childhood years. Growth accelerates at different times for different children. There will WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material be many physical differences apparent among children at the end of middle childhood. The school-age child appears slimmer as a result of changes in fat distribution and thickness. DIF: A REF: 164 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 15. A 6-year-old is hospitalized for asthma. Which of the following activities would be appropriate to help this child resolve the crisis of hospitalization? 1 2 3 4 Crayons and a coloring book A 1000-piece puzzle to complete A CD player with soothing CDs A Nerf football to throw around the room ANS: 1 Providing a 6-year-old with crayons and a book to color in would be an age-appropriate activity to help the child with the crisis of hospitalization. Painting, drawing, playing computer games, and making models allow children to practice and improve newly refined skills. A 1000-piece puzzle would be too much for a 6-year-old to complete. A CD player with soothing CDs would not be an age-appropriate activity for a 6-year-old. Throwing a Nerf football around the room may not be appropriate for a hospitalized child with asthma. DIF: A REF: 164 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 16. Which one of the following statements is correct regarding the preadolescence developmental stage? 1 It appears 2 years earlier in boys than in girls. 2 Intimate feelings are confided in the parents. 3 Interest in the opposite sex is not a factor for this group. It signals the development of secondary sex characteristics. 4 ANS: 4 The preadolescence developmental stage (puberty) signals the development of secondary sex characteristics. Physical changes often begin 2 years earlier in girls than in boys. Preadolescents usually develop best friends with whom they share intimate feelings. New interest in the opposite sex develops in the preadolescence developmental stage. DIF: A REF: 167 OBJ: Knowledge TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 17. The nurse is teaching parents about probable warning signs that a teenager is considering suicide and tells parents to be alert to: 1 2 3 4 An increase in appetite A sudden interest in school activities An unexplained increase in sleepiness Talking about death and personal harm ANS: 4 A warning sign that a teenager is considering suicide includes verbalization of suicidal thoughts. Appetite disturbances, usually a decrease in appetite, may be a warning sign that a teenager is considering suicide. A decrease in school performance and loss of initiative are possible warning signs that a teenager is considering suicide. Sleep disturbances, such as the inability to sleep, are a warning sign for suicide. DIF: A REF: 172 OBJ: Knowledge TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 18. In order to obtain the most information, which of the following is the most appropriate question asked of a 14-year-old female who is visiting the county health center for birth control help? 1 Have you told your parents that you are sexually active? 2 Are any of your friends participating in sexual behaviors? 3 What can you tell me about any of your past sexual activities? Have you been physically protecting yourself with safe sex measures? 4 ANS: 3 The nurse can be proactive by using the interview process and open-ended questions such as this one, to identify risk factors in the adolescent. Once identified, the risk factors should lead to strategies for prevention. Inquiring what the client has told parents does not obtain the most information. Asking about friends activities does not address the individual and does not obtain the most information about the health behaviors of the client. Asking whether the client is having safe sex may be answered with a yes or no response and therefore does not obtain the most information. Chapter 13. Young and Middle Adults MULTIPLE CHOICE WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. A client thinks that she might be pregnant. Which first trimester physiological changes would most likely indicate this? 1 2 3 4 Amenorrhea and nausea Braxton Hicks contractions Increased urinary frequency Edematous ankles and dyspnea ANS: 1 Amenorrhea and nausea are physiological changes that may indicate pregnancy in the first trimester. Braxton Hicks contractions are noted during the second trimester of pregnancy. Increased urinary frequency is commonly seen in the third trimester of pregnancy. Edematous ankles and dyspnea may be experienced during the third trimester of pregnancy. DIF: A REF: 183 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/Specific Systems Assessment 2. To determine how the client, who is a single parent of three children, will be able to cope with the current pregnancy, the nurse should ask the client: 1 Have you ever been married? 2 Where do you currently work? 3 Has anyone ever taught you about contraception? 4 Who do you have for support during this pregnancy? ANS: 4 This could be a situational crisis for a single-parent family. The nurse should assess environmental and familial factors, including support systems and coping mechanisms commonly used. Asking the client whether she has ever been married does not assess her ability to cope with the pregnancy. Asking the client where she works may help determine if there are any environmental factors that may place her pregnancy at risk, but it does not assess her ability to cope with the pregnancy. This would not be the most opportune time to discuss contraception with the client and may convey a message of disapproval. Nor does asking the client about contraception assess her ability to cope with the pregnancy. DIF: B REF: 181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Stress Management 3. The nurse is performing a physical examination on a 40-year-old adult client. The nurse will most likely find that the client of this age is experiencing which one of the following physiological changes related to normal aging? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Decreased hearing acuity 2 3 Decreased sense of smell Decreased strength of abdominal muscles 4 Decreased function of the various cranial nerves ANS: 3 A physiological change related to normal aging in the middle adult would be decreased strength of abdominal muscles. The middle adult should have normal auditory structures and acuity. The middle adult should have a normal sense of smell. The middle adult should have normal functioning of the cranial nerves. DIF: A REF: 185 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Reduction of Risk Potential/ Specific Systems Assessment 4. A 49-year-old client is experiencing problems with depression. She has come to the clinic showing signs of malnutrition and fatigue. Which of the following is the best initial statement for the nurse to make in the assessment phase? 1 How much weight have you lost over the past month? 2 Have you recently been experiencing menopausal symptoms? 3 Depression is something to expect at your age, and with assistance you will get better. Your depression is somewhat uncommon. Can you tell me what has happened recently to cause it? 4 ANS: 2 Mood changes and depression are common phenomena during menopause, and this client is in the expected age range to be experiencing menopause. Asking the client about weight loss may be an indication to verify depression; however, it is not the best initial response. Depression is not something to expect, although it can occur. Depression is not uncommon during menopause. DIF: C REF: 186 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Stress Management 5. The nurse, trying to promote positive health habits regarding stress management is aware of the external influences on young and middle adult clients. With this knowledge, the nurse recognizes that an effective strategy for this age-group is: 1 Teaching clients to abstain from all alcohol consumption 2 Demonstrating how to take an accurate blood pressure measurement WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Determining an effective daily exercise schedule for stress reduction 4 Describing the types of medications commonly used for treating depression ANS: 3 Exercise on a routine basis can be an effective strategy to reduce the stress experienced by young and middle adults. Exercise is a positive health habit for this age-group. Clients do not have to abstain from all alcohol consumption. Teaching clients to abstain from excessive alcohol consumption is important, but it is not a proactive positive health habit to help reduce stress. Monitoring ones blood pressure may be important, but it is not a proactive positive health habit to help reduce stress. Teaching clients about types of medication used for treating depression does not help the client develop positive health habits for reducing stress. DIF: A REF: 182 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Lifestyle Choices 6. Individuals at the young adult point in their life are generally expected to, according to developmental patterns: 1 Continue physical growth 2 3 Experience severe illnesses Ignore physical symptoms 4 Seek frequent medical care ANS: 3 Young adults generally are quite active, experience severe illnesses less commonly than older age-groups, tend to ignore physical symptoms, and often postpone seeking health care. Young adults generally do not continue their physical growth. Young adults experience severe illnesses less commonly than older age-groups. Young adults often postpone seeking health care. DIF: A REF: 178 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development 7. A nurse is preparing an education program on safety for a young adult group. Based on the major cause of mortality and morbidity for this age-group, the nurse should focus on: 1 Birth control 2 3 Automobile safety Occupational hazards 4 Prevention of heart disease WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 Violence is the greatest cause of mortality and morbidity in the young adult population. Deaths and injury from motor vehicle accidents are significant among this age-group. Unplanned pregnancies may be a source of stress but is not the major cause of mortality and morbidity in the young adult population. Exposure to work-related hazards or agents may cause diseases and cancer, but it is not the major cause of mortality and morbidity in this age-group. Developing healthy habits to prevent heart disease later in life is important, but heart disease is not the leading cause of mortality and morbidity for the young adult. DIF: A REF: 181 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development/Lifestyle Choices 8. A nurse is working in the health office at a local college where most of the students are young adults. Being aware of the major concerns for this age-group, the nurse includes assessment of these clients: 1 Current marital history status 2 Lifestyle and leisure activities 3 Experience with chronic disease 4 History of childhood accidents ANS: 2 The young adult client may benefit from a personal lifestyle assessment to help identify habits that increase the risk for cardiac, malignant, pulmonary, renal, or other chronic diseases. Assessing a clients marital status does not offer much information about the clients health or risk for future illnesses. Assessing a clients experience with chronic disease is less appropriate for this age-group. Assessing the clients history of childhood accidents does not offer much information about the clients current health or risk for future illnesses. DIF: A REF: 179 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development/Lifestyle Choices 9. As an individual enters middle adulthood health problems generally become more prevalent. The middle adult may be influenced by chronic illness that results in: 1 Decreased health care tasks 2 Reinforcement of family roles 3 Changed sexual behavior habits Improvement of family relationships 4 ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material A few examples of the problems experienced by clients who develop debilitating chronic illness during adulthood include role reversal, changes in sexual behavior, and alterations in self-image. Chronic illness would result in increased health care tasks. Family roles are often changed with chronic illness, not reinforced. Strained family relationships may result from chronic illness. DIF: A REF: 186 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development 10. The nurse is performing a physical examination on a 58-year-old adult client. The nurse will most likely find that the client of this age is experiencing which one of the following physiological changes related to normal aging? 1 2 Palpable thyroid lobes Decreased skin turgor 3 Reduced pupillary reaction 4 Increased range of joint motion ANS: 2 There is a slow, progressive decrease in skin turgor in the middle adult. The thyroid lobes should not be palpable in the middle adult. Pupillary reaction to light and accommodation should not change in the middle adult. A normal change in the middle adult is a decreased range of joint motion. DIF: A REF: 221 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development 11. The nurse is alert to stressors that may have an influence on the young adult client. One example of a common stressor for this age-group is: 1 Occupational pursuits 2 Health-related matters 3 Coping with cognitive changes 4 Caring for the older adult parent ANS: 1 A common stressor for the young adult is job stress. Health-related matters are not common stressors for the young adult. Coping with cognitive changes is not a common stressor for the young adult. Caring for older adult parents is more often seen with the middle adult, not the young adult. DIF: A REF: 182-183 OBJ: Knowledge TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Psychosocial Integrity/Stress Management 12. A client who works in a dry cleaning establishment comes to the clinic for a regular checkup. Based on this information, the nurse assesses the client for: 1 2 3 4 Asbestosis Dermatitis Tendonitis Raynauds phenomenon ANS: 2 Persons who work in dry cleaning establishments are exposed to solvents that may cause dermatitis or liver disease. Asbestosis is more likely to be found as an occupational hazard for automobile workers and insulators. Tendonitis may result from repetitive wrist motion as seen in office computer workers. Raynauds phenomenon may result from vibration as seen with jackhammer operators. DIF: C REF: 182 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Reduction of Risk Potential/ Specific Systems Assessment 13. The nurse is completing a physical exam for a 45-year-old client who has come to the family practice office. In evaluating the observations made during the examination, the nurse recognizes that an expected finding for a client in this age-group is: 1 Hepatomegaly 2 Visual acuity below 20/50 3 An oral temperature of 39 C 4 Increased amount of skin turgor ANS: 2 The visual acuity tested by the Snellen chart should be less than 20/50. Hepatomegaly is not an expected finding and would be considered abnormal. Oral temperature should be 36.1 to 37.6 C. The expected finding would be a slow, progressive decrease in skin turgor. DIF: A REF: 221 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Reduction of Risk Potential/ Specific Systems Assessment 14. When discussing the stressors felt by a single mother in her 30s, the nurse recognizes that the greatest financial impact on this family is caused by: 1 The ever-rising cost of living in the United States WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 3 4 The realization that a female earns 25% less than her male coworker Court-ordered child support is often times inadequate. Daycare expenses are a strain on a single wage earner family ANS: 2 According to the AFL-CIO (2004) workers union, women in the United States are paid 76 cents for every dollar men receive for comparable work. This fact has an all-encompassing effect on the single-parent household. The cost of living is rising; it is not unique to the single mother. While court-ordered support often is inadequate, it does not have the impact that earning power has on the family income. While daycare expenses can be a strain, does not have the impact that earning power has on the family income. DIF: C REF: 178 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Dynamics 15. Because young adults are less likely to experience serious illness, which of the following nursing interventions is most effective in determining risk for illness in this age-group? 1 Health screenings 2 Personal lifestyle assessment 3 Full body systems assessment 4 Cardiopulmonary focal assessment ANS: 2 A personal lifestyle assessment (see Chapter 6) helps nurses and clients identify habits that increase the risk for cardiac, malignant, pulmonary, renal, or other chronic diseases. Health screening helps detect the presence of disease processes. Full body systems assessment would determine deviation from normal but not necessarily identify risk for illness. Cardiopulmonary focal assessment would determine deviation from normal but not necessarily identify risk for illness. DIF: B REF: 178 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk for Injury; Physiological Integrity/Specific System Assessment 16. Research has shown that certain postpartum factors negatively affect a womans general health status after pregnancy. Which of the following women has the greatest risk factor for poor postpartum health? 1 A mother with complaints of fatigue, loss of appetite, and insomnia WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 A practicing attorney who has reluctantly taken a 3-month maternity leave 3 A stay-at-home mom who gave birth 2 months ago and whose husband recently lost his job A mother of a 3-week-old and a 2-year-old whose military husband is currently deployed overseas 4 ANS: 4 Postpartum stress and depression have significant effects on postpartum womens health. In addition, a lack of social support can affect womens health adversely. This woman is the most likely mother to be experiencing depression and economic stressors as well as a lack of support. While fatigue, loss of appetite, and insomnia may be reflective of depression, there are no indications of the other high-risk factors. While this woman may be experiencing anxiety over being away from her career for 3 months, there is no indication of the other risk factors. While this mother may well be at risk for depression and possible financial stressors, there is no indication of a lack of support. DIF: C REF: 180 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems 17. The nurse is preparing to discuss postpartum depression as a part of discharge teaching with the parents of a newborn. Which of the following nursing actions would be most therapeutic regarding early detection of this postpartum condition? 1 Helping the couple understand the importance of social interaction with other adults 2 Providing the couple with a video that tells the story of a new mothers experience with depression 3 Encouraging the couple to attend parenting classes designed to minimize the stressors of parenting an infant 4 Having a discussion with the father in which he identifies the signs and symptoms of postpartum depression ANS: 4 Educating both new mothers and their families regarding the signs and symptoms of postpartum stress and depression will facilitate early detection and treatment of the condition. While preventing social isolation is important to the prevention of generalized depression, it has little impact on detecting the signs and symptoms of the condition. While the video may be informative it is not the most therapeutic option because it lacks interaction between the nurse and the clients. While Option 3 is appropriate in regard to minimizing the risk of developing WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material depression stemming from postpartum stressors, it does not directly impact the identification of the signs and symptoms of the condition. DIF: C REF: 180 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Stress Management/Crisis Intervention 18. Which of the following young adults is at greatest risk for experiencing death or injury? 1 2 An 18-year-old with a father who is an alcoholic A 30-year-old who is a professional rodeo rider 3 A 20-year-old living in an urban housing project 4 A 26-year-old riding a motorcycle across the country ANS: 3 Violence is the greatest cause of mortality and morbidity in the young adult population. Factors that predispose individuals to violence, injury, or death include poverty, family breakdown, child abuse and neglect, repeated exposure to violence, and ready access to guns. This option represents an individual who most likely is both poor and exposed to an environment of repeated violent acts. While Option 1 represents a potential for physical and mental abuse, it does not present the level of potential violence existing in Option 3. While Option 2 represents a potential for physical injury and possible death, it does not present the level of potential violence existing in Option 3. While Option 4 represents a potential for physical injury and possible death, it does not present the level of potential violence existing in Option 3. DIF: C REF: 181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk for Injury 19. The most serious risk for death for a young adult living in rural poverty is: 1 Suicide 2 Homicide 3 Poor health maintenance practices 4 Family history of chronic illnesses ANS: 1 A young adult is more likely to die of self-inflicted injury when living at or below the poverty level when no other risk factors (i.e., a violent environment, drug abuse, etc.) are present. In 2002 the death rate (per 100,000 population) for 25- to 34-year-olds in the United States caused by homicide was 11.2; the death rate caused by accidents was 31.5; and the death rate caused by suicide was 12.6 (U.S. Department of Health and Human Services [USDHHS]). DIF: C REF: 13 OBJ: Analysis TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Psychosocial Integrity/Stress Management/Crisis Intervention 20. During a routine physical assessment a 27-year-old client acknowledges the suspension of his drivers license because of an arrest for driving under the influence of alcohol. This admission should prompt the nurse to discuss which of the following in detail with the client? 1 2 Use of illegal drugs History of depression 3 Unprotected sexual experiences 4 Tendency toward violent behavior ANS: 1 Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for you to investigate the possibility of drug abuse more carefully. A history of depression is not necessarily a risk factor for illegal drug abuse. Unprotected sex is not necessarily a risk factor for illegal drug abuse. A tendency toward violent behavior is not necessarily a risk factor for illegal abuse. DIF: C REF: 181 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors; Psychosocial Integrity/Chemical Dependency 21. In preparing to discuss safe sex practices with a 20-year-old, it is most important that the nurse shares with the client that in addition to physical symptoms of genital pain and discharge, sexually transmitted diseases: 1 Can lead to chronic illness and infertility 2 Are particularly common in young adults 3 Respond well to treatment when detected early May be effectively controlled through the use of condoms 4 ANS: 2 Sexually transmitted diseases (STDs) remain a major public health problem for sexually active persons, with almost half of all new infections occurring in men and women younger than 24 years of age (USDHHS, CDC, 2004). While Option 1 is true, it is vitally important that the nurse first share the high probability of contracting a STD to a sexually active young adult who practices unprotected sex. While some STDs respond well to early treatment, some, such as genital herpes and human immunodeficiency virus (HIV), can only be managed because no cure is currently available. While Option 4 may be true, it is vitally important that the nurse first share the high probability of contracting a STD in a sexually active young adult who practices unprotected sex. DIF: C REF: 181 OBJ: Analysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 22. Which of the following lifestyle choices poses the greatest risk for chronic illness to the young adult? 1 2 3 4 Alcohol and tobacco use Ignoring seat belt and helmet laws Unprotected sex with multiple partners Poor nutrition and a lack of structured exercise ANS: 1 Lifestyle choices of young adults (e.g., use of tobacco or alcohol) put them at risk for chronic illnesses or disabilities during their middle or older adult years. While ignoring seat belt and helmet laws represents a risk factor for injury or death it is not directly related to chronic illness. While unprotected or multiple-partner sex option does represent a risk factor for chronic disease in the form of STDs, the greater risk comes from alcohol and tobacco use. While poor nutrition and lack of exercise do represent risk factors for chronic disease such as heart disease and obesity, the greater risk comes from alcohol and tobacco use. DIF: C REF: 181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 23. Which of the following client responses shows the best understanding regarding the management of risk factors for chronic illness among young adults? 1 Unprotected sex is just plain dangerous. 2 Everyone riding in my car wears a seatbelt. 3 Im a vegetarian, but I eat nonanimal protein. Ive never smoked and I drink only occasionally. 4 ANS: 4 Tobacco use and the abuse of alcohol put young adults at high risk for chronic illnesses in middle and older adult years. While Option 1 shows an understanding of the risk factor for chronic disease in the form of STDs, the greater risk comes from alcohol and tobacco use. While Option 2 shows an understanding of the risk factor for injury and death caused by vehicular accidents, it is not directly related to chronic illness. DIF: C REF: 181 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 24. Which of the following lifestyle choices poses the greatest risk for chronic illness to the young adult? 1 Alcohol and tobacco use WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Ignoring seat belt and helmet laws 3 Unprotected sex with multiple partners Poor nutrition and a lack of structured exercise 4 ANS: 1 Lifestyle choices of young adults (e.g., use of tobacco or alcohol) put them at risk for chronic illnesses or disabilities during their middle or older adult years. DIF: C REF: 180-181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 25. Which of the following client responses shows the best understanding regarding the management of risk factors for chronic illness among young adults? 2 Unprotected sex is just plain dangerous. Everyone riding in my car wears a seat belt. 3 Im a vegetarian, but I eat non-animal protein. 4 Ive never smoked, and I drink only occasionally. 1 ANS: 4 Tobacco use and the abuse of alcohol put young adults at high risk for chronic illnesses in their middle and older adult years. DIF: C REF: 180-181 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 26. Which of the following client responses shows the best understanding regarding the management of risk factors for acquiring a sexually transmitted disease (STD) among young adults? 1 I may want to have children someday, so I need to be careful. 2 Even though there are treatments for STDs, I dont take chances. There is certainly enough literature out there on the use of condoms. 3 4 Having unprotected sex with someone my age is very risky business. ANS: 4 Sexually transmitted diseases (STDs) remain a major public health problem for sexually active persons, with almost half of all new infections occurring in men and women younger than 24 years of age (USDHHS, CDC, 2004). WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material While it is true that some STDs can result in infertility, this option doesnt show the greatest understanding since it focuses on only one outcome. While some STDs respond well to early treatment, some STDs, such as genital herpes and human immunodeficiency virus (HIV), can only be managed since a cure is not currently available. DIF: C REF: 181 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: : Health Promotion and Maintenance/High Risk Behaviors 27. Which of the following statements made by a 27-year-old client shows the greatest need for further nursing assessment regarding the potential use of illegal drugs? 1 Whether you wear a helmet or not should be the choice of the motorcyclist. 2 I fractured my hand 3 years ago when I got so mad I hit a wall in my dorm room. 3 I like to drink a bit too much, and I lost my license once for drinking and driving. 4 My father suffered from depression when he lost his job, and he still takes medication for it. ANS: 3 Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for you to investigate the possibility of drug abuse more carefully. A tendency toward high-risk behavior such as extreme sports or not using safety equipment is not necessarily a risk factor for illegal drug use. A tendency toward violent behavior is not necessarily a risk factor for illegal drug abuse. A family history of depression is not necessarily a risk factor for illegal drug abuse. DIF: C REF: 181 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/High Risk Behaviors 28. Which of the following statements made by the parents of a newborn best reflects an understanding regarding the diagnosis of postpartum depression? 1 I helped my sister when she was depressed after the birth of her second child. 2 I have a wonderfully supportive family who will be there if I start feeling depressed. 3 Weve read over the literature, and Ill be able to recognize any signs of depression in my wife. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Most new moms get a little depressed, but we will be sure to pay attention to any real indications of a problem. ANS: 3 Having someone in close contact with the new mom available to assess her for possible signs of postpartum depression shows both an understanding of the condition as well as a desire to manage it if it occurs. DIF: C REF: 180 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/ Family Systems; Psychosocial Integrity/Stress Management/Crisis Intervention 29. Which of the following questions asked by the nurse best assesses for the signs of pregnancy most likely observed in the second trimester? 1 Have you had any problems climbing steps? 2 Have you noticed any cramping in your abdomen? 3 Have you experienced any nausea in the morning? Have you had any problems with shoes that dont seem to fit? 4 ANS: 2 Braxton-Hicks contractions are noted during the second trimester of pregnancy. Edematous ankles and dyspnea may be experienced during the third trimester of pregnancy. Amenorrhea and nausea are physiological changes that may indicate pregnancy in the first trimester. Edematous ankles and dyspnea may be experienced during the third trimester of pregnancy. DIF: C REF: 183 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/ Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/ Reduction of Risk Potential/Specific Systems Assessment 30. Which of the following client statements would be the best evidence that this young adult has adopted a positive strategy to promote his own personal emotional health? 1 I drink alcohol only on special occasions and then moderately. 2 I run at least three times a week; it seems to help me stay relaxed. 3 I watch for the signs of depression since my mother experienced it. 4 I know stress can affect my blood pressure, so I have it taken regularly. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 Exercise on a routine basis can be an effective strategy to reduce the stress experienced by young and middle adults. Exercise is a positive emotional health habit for this age group. Drinking alcohol in moderation is certainly a positive health habit, but it does not have the strongest impact on emotional health of the available options. DIF: C REF: 181 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Lifestyle Choices; Psychosocial Integrity/Coping Mechanisms 31. Which of the following client statements, made by a young adult regarding health promotion habits, reflects a need for further client education by the nurse? 1 2 I go to the gym and work out 3 times a week with friends. My dad has high cholesterol, so I have mine checked yearly. 3 Diabetes runs in my family, so I watch my carbohydrate intake. 4 I drink alcohol only on weekends, when it doesnt interfere with work. ANS: 4 The correct answer reflects a poor understanding of alcohol abuse. The primary criterion for healthy alcohol consumption is not drinking only when it will not affect work. Further education regarding responsible alcohol consumption and alcoholism is appropriate. The other options reflect a good understanding of health promotion habits. DIF: C REF: 181 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Lifestyle Choices; Psychosocial Integrity/Coping Mechanisms 32. Which of the following nursing assessment questions is best directed toward determining the presence of a normal physiological change experienced by a middle-aged client? 1 Any problems with your teeth or gums? 2 Any family history of thyroid problems? 3 Do you have a skin-moisturizing routine? Are you having a problem with driving at night? 4 ANS: 3 There is a slow, progressive decrease in skin turgor in the middle-aged adult. Dental problems are not a normal physiological change seen in the middle-aged adult. Thyroid problems are not a normal physiological change seen in the middle-aged adult. Night blindness is not a normal physiological change seen in the middle-aged adult. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 185 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development 33. Which of the following nursing assessment questions is best directed toward determining the presence of an occupational hazard-related condition specific for a client working in a dry cleaning establishment? 1 2 Do you have any problems with rashes or itching? How long have you worked in the dry cleaning business? 3 Do you treat the minor burns you experience? 4 Do you drive the company van to make deliveries? ANS: 1 Persons who work in dry cleaning establishments are exposed to solvents that may cause dermatitis or liver disease. While asking about the length of time employed is an appropriate assessment question, it is not directed toward identifying a response to any specific risk factor. While burns may be a risk factor for those working in the dry cleaning industry, the risk is not as specific as assessing for contact dermatitis. While automobile accident-related injuries may be a risk factor in this case, the risk is not as specific as assessing for contact dermatitis. DIF: C REF: 182 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/ Reduction of Risk Potential/ Specific Systems Assessment 34. Which of the following nursing assessment questions is best directed toward determining the presence of career stressors in a young adult? 1 What do you do to relieve stress for yourself? 2 What is the most stressful part of your daily job? 3 Career-wise, where would you like to be in 2 years? Do you miss much work as a result of injuries or illness? 4 ANS: 2 The correct option is an open-ended question that encourages the client to identify and discuss work-related stressors, which are a major source of stress for this age group. DIF: C REF: 182-183 OBJ: Cognitive Level: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and Development; Psychosocial Integrity/Stress Management WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 35. Which of the following statements concerning health promotion habits made by a young adult best reflects an understanding regarding the primary cause of death and injury among that age group? 1 Eating a healthy, low-fat diet is very important to me. 2 AIDS is nothing to mess with, so I always practice safe sex. Regardless of what my friends say, I always wear a seat belt. 3 4 I enjoy mountain biking, but I always wear the right protection gear. ANS: 3 Deaths and injury from motor vehicle accidents are significant among this age group. Developing healthy habits to prevent heart disease later in life is important, but heart disease is not the leading cause of mortality and morbidity for the young adult. Sexually transmitted diseases are a risk factor for this age group, but they do not represent the greatest risk for death and injury. An injury related to occupation and recreation is a risk factor, but it is not the major cause of mortality and morbidity in this age group. Chapter 14. Older Adults MULTIPLE CHOICE 1. A nurse is performing a physical examination on an older-adult client in an assisted living facility. On completion of the examination, the nurse compares the results to findings expected for individuals in this age-group. An expected finding for this client is: 1 Increased tactile responsiveness 2 Increased sensitivity to visual glare 3 Increased hearing acuity for higher tones Increased thoracic expansion during ventilation 4 ANS: 2 A common physiological change in the older-adult client is an increased sensitivity to glare. Increased tactile responsiveness would not be an expected finding in the older-adult client. An expected physiological change in the older adult-client is a loss of hearing acuity for highfrequency tones (presbycusis). The older adult has decreased thoracic expansion during ventilation because of musculoskeletal changes. DIF: A REF: 198 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Integrity/System Specific Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2. A 70-year-old client asks the nurse to explain her hypertension as she is to have her blood pressure checked each shift. An appropriate response by the nurse as to why older clients often experience hypertension is because of: 1 Myocardial muscle damage 2 3 Reduction in physical activity Ingestion of foods high in sodium 4 Accumulation of plaque on arterial walls ANS: 4 Although hypertension is not a normal physiological change of aging, older adults often experience hypertension because of vascular changes and accumulation of plaque on arterial walls, both of which reduce contractility. Vascular changes include thickening of vessel walls, narrowing of vessel lumen, and loss of vessel elasticity. Myocardial damage is not the reason for older adults commonly experiencing hypertension. Hypertension is not caused by a reduction in physical activity. Older adults with hypertension should be counseled on limiting fat and salt in their diet. However, ingestion of processed foods high in salt is not the reason why older clients often experience hypertension. DIF: A REF: 199 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Adaptation/Alteration in Body Systems 3. In reviewing changes in the older adult, the nurse recognizes that which of the following statements related to cognitive functioning in the older client is true? 1 Delirium is usually easily distinguished from irreversible dementia. 2 Therapeutic drug intoxication is a common cause of senile dementia. Reversible systemic disorders are often implicated as a cause of delirium. 3 4 Cognitive deterioration is an inevitable outcome of the human aging process. ANS: 3 Delirium is a potentially reversible cognitive impairment that is often due to a physiological cause such as an electrolyte imbalance, cerebral anoxia, hypoglycemia, medications, tumors, cerebrovascular infection, or hemorrhage. Delirium is not always easily distinguishable from irreversible dementia. Because of the close resemblance between delirium and dementia, the WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material presence of delirium must be ruled out whenever dementia is suspected. The cause of senile dementia (e.g., Alzheimers disease) is not known. Medications and drug effects can cause delirium. Dementia is not an inevitable outcome of aging. DIF: A REF: 202 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 4. A client has been recently diagnosed with Alzheimers disease. When teaching the family about the prognosis, the nurse must explain that: 1 Diet and exercise can slow the process considerably 2 Few clients live more than 3 years after the diagnosis 3 Many individuals can be cured if the diagnosis is made early 4 It usually progresses gradually with a deterioration of function ANS: 4 Alzheimers disease usually progresses gradually with a deterioration in function. Medications, not diet and exercise, can slow the process of Alzheimers disease considerably. Clients may live years after the diagnosis of Alzheimers disease. There is no cure for Alzheimers disease but medications can be given to slow the progression of symptoms. DIF: A REF: 202 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Adaptation/Alteration in Body Systems 5. Which of the following statements accurately reflects data that the nurse should use in planning care to meet the needs of the older adult? 1 50% of older adults have two chronic health problems. 2 Cancer is the most common cause of death among older adults. Nutritional needs for both younger and older adults are essentially the same. 3 4 Adults older than 65 comprise the greatest users of prescription medications. ANS: 4 This is a true statement. Approximately two thirds of older adults use prescription and nonprescription drugs with one third of all prescriptions being written for older adults. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Approximately 90% of adults older than 65 have at least one chronic health condition. Approximately 70% of older adults have multiple chronic conditions with arthritis, hypertension, heart disease, vision impairment, and diabetes mellitus being the most common in noninstitutionalized older adults. Heart disease is the leading cause of death in older adults. Nutritional needs of older adults are affected by their levels of activity and by clinical conditions. DIF: A REF: 209 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 6. The nurse is aware that the majority of older adults: 1 2 Live alone Live in institutional settings 3 Are unable to care for themselves 4 Are actively involved in their community ANS: 4 The majority of adults are indeed active within their community. The majority of older adults live with a spouse or have other living arrangements such as living with a family member. Most older adults live in noninstitutional settings. Most older adults are able to care for themselves. DIF: A REF: 193 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process 7. The nurse works with elderly clients in a wellness screening clinic on a weekly basis. Which of the following statements made by the nurse is the most therapeutic regarding their mobility? 1 Your shoulder pain is normal for your age. 2 Continue to exercise your joints regularly to your tolerance level. 3 Why dont you begin walking 3 to 4 miles a day, and well evaluate how you feel next week. Dont worry about taking that combination of medications since your doctor has prescribed them. 4 ANS: 2 Clients in the older adult age group should be advised to exercise their joints regularly to their level of tolerance. Shoulder pain is not a normal finding in the older adult. It may indicate a WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material condition such as arthritis. Exercise programs should begin conservatively and progress slowly. Periodic and thorough review of all medications being used is important to restrict the number of medications used to the fewest necessary. Concurrent use of medications increases the risk for adverse reactions. DIF: A REF: 207-208 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 8. A long-term care facility sponsors a discussion group on the administration of medications. The participants have a number of questions concerning their medications. The nurse responds most appropriately by saying: 1 2 Dont worry about the medications name if you can identify it by its color and shape. Unless you have severe side affects, dont worry about the minor changes in the way you feel. 3 Feel free to ask your physician why you are receiving the medications that are prescribed for you. 4 Remember that the hepatic system is primarily responsible for the pharmacotherapeutics of your medications. ANS: 3 The nurse should encourage the older adult to question the physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. The older adult should be taught the names of all drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs. The nurse should teach the client how to avoid adverse side effects and to report them to their care provider if they occur. If the client is disturbed by minor side effects, it could be an indication of beginning drug toxicity. Another possibility is that the client may become noncompliant with their medication because they dislike how the side effects make them feel. The hepatic system is not the only system responsible for the pharmacotherapeutics of medication. Older adults are at risk for adverse reactions because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs. Changes in the GI system may affect absorption, distribution may be affected by changes in body composition and by reduced serum albumin levels, and changes in kidney functioning may impair excretion. DIF: A REF: 209 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Pharmacological Therapies WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 9. Which of the following behaviors shows the greatest risk to an older adult as they attempt to minimize the effects of the aging process? 1 2 3 4 Increased cosmetic use Refusing to share their actual ages Spending less time with age-related peers Refusing assistance with certain activities ANS: 4 Some older adults may deny functional declines associated with aging and refuse to ask for assistance with tasks that place their safety at great risk. Some older adults find it difficult to accept themselves as aging and attempt to conceal physical evidence of aging with cosmetics. Older adults who find it difficult to accept themselves as aging may understate their age when asked. Spending more time with other older adults is indicative of the older adults acceptance of personal aging. Those who find it difficult to accept themselves as aging may avoid activities designed to benefit older adults, such as senior citizens centers and senior health promotion activities. DIF: C REF: 195 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process 10. In performing a physical assessment for an older adult, the nurse anticipates finding which of the following normal physiological changes of aging? 1 Increased perspiration 2 Increased airway resistance 3 Increased salivary secretions Increased pitch discrimination 4 ANS: 2 Normal physiological changes of aging include increased airway resistance in the older adult. The older adult would be expected to have decreased perspiration and drier skin as they experience glandular atrophy (oil, moisture, sweat glands) in the integumentary system. The older adult would be expected to have a decrease in saliva. A normal physiological change of the older adult related to hearing is a loss of acuity for high-frequency tones (presbycusis). DIF: A REF: 199 OBJ: Knowledge TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 11. There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age: 1 2 3 4 Men have the greatest incidence of osteoporosis Muscle fibers increase in size and become tighter Weight-bearing exercise reduces the loss of bone mass Muscle strength does not diminish as much as muscle mass ANS: 3 Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as those who are inactive. Postmenopausal women have a greater problem with osteoporosis than older men. Muscle fibers are reduced in size with aging. Muscle strength diminishes in proportion to the decline in muscle mass. DIF: A REF: 207-208 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 12. The nurse, preparing to discharge an 81-year-old client from the hospital, recognizes that the majority of older adults: 1 Require institutional care 2 Have no social or family support 3 Are unable to afford any medical treatment Are capable of taking charge of their own lives 4 ANS: 4 The majority of older adults are interested in their health and are capable of taking charge of their lives. Most older adults do not require institutional care. The majority of older adults have social or family support. Most older adults live with a spouse or have other living arrangements, such as living with a family member. Most older adults receive Social Security benefits and are able to afford medical treatment. DIF: A REF: 93 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 13. To assist older adults to meet their needs for sexuality, the nurse should recognize that the greatest impact on the sexuality of older adults is: 1 2 Therapeutic medications may alter sexual function Sexual interest declines and then fades completely with age 3 Physiological changes do not adversely influence sexual activity 4 Prevention of sexually transmitted diseases is no longer an issue ANS: 1 Many older adults use prescription medications that depress sexual activity, such as antihypertensives, antidepressants, sedatives, or hypnotics. Some drugs increase libido in older adults. For example, phenothiazines increase sexual desire in women, and levodopa has a similar effect in men. It is a common misconception that older adults are not interested in sex. The older adults libido does not decrease, although frequency of sexual activity may decline. Physiological changes may have an adverse influence on sexual activity. The older man may experience decreased firmness in his erection, a decreased need for ejaculation with orgasm, or a longer recovery period between episodes of intercourse. The older woman may experience vaginal dryness. Information about the prevention of sexually transmitted diseases should be included when appropriate. DIF: A REF: 203-204 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 14. The nurse is presenting an information session on nutritional guidelines at a senior living center. Incorporated into the discussion are the recommendations for nutritional intake for individuals of this age-group, which include a reduction in: 1 Fiber 2 Protein 3 Vitamin A Refined sugars 4 ANS: 4 Good nutrition for older adults includes a limited intake of refined sugars. Fiber should not be reduced as it has benefits of aiding bowel elimination and lowering cholesterol. Protein should not be reduced. Protein intake may be lower than recommended if older adults have reduced WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material financial resources or limited access to grocery stores. Difficulty chewing meat may also limit protein intake. Vitamin A does not need to be reduced in the older adult. Vitamin intake may be less than recommended if shopping for fresh fruits and vegetables is difficult. DIF: A REF: 207 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 15. The nurse is presenting an information session on nutritional guidelines at a senior living center. Which of the following foods meets the recommended nutritional guidelines for older adults? 1 Grilled chicken 2 3 Hamburger and french fries Hot dog with dill pickle relish 4 Baked potato with cheese and bacon bits ANS: 1 Grilled chicken would be a good source of protein that is also low in fat. A hamburger and french fries are high in fat content and calories, making them a less desirable food choice. A hot dog with pickle relish is high in fat and sodium. Good nutrition for the older adult includes a limited intake of fat and salt. A baked potato with cheese and bacon bits is higher in calories and fat. A plain baked potato would be a healthier food choice. DIF: A REF: 207 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 16. In the assessment of older-adult clients, it is often difficult to discriminate between delirium and dementia. Delirium is characterized by: 1 A slow progression 2 Lasting months to years 3 A normal state of alertness 4 Occurrences at twilight or darkness ANS: 4 Delirium is characterized by short, diurnal fluctuations in symptoms and is worse at night, in darkness, and on awakening. Delirium has an abrupt onset. Dementia has a slow progression. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Delirium lasts hours to less than 1 month, seldom longer. Dementia may last months to years. Delirium is characterized by fluctuating alertness; the client may be lethargic or hypervigilant. Alertness is generally normal with dementia. DIF: A REF: 202 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 17. Which of the following nursing questions is best directed towards the assessment of a normal finding regarding physiological changes in an older-adult client? 1 Any difficulty driving at night? 2 Are you experiencing any loss of libido? 3 Do you see yourself as becoming forgetful 4 Have you had your cholesterol tested lately? ANS: 1 A common physiological change in the older-adult client is an increased sensitivity to glare, which makes night driving difficult. Decreased sexual drive is not a normal physiological change of aging. Memory loss is not a normal physiological change of aging. Hyperlipidemia is not a normal physiological change of aging, nor should it be monitored only by the older adult. DIF: C REF: 198 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health promotion and Maintenance/Aging Process; Physiological Integrity/System Specific Assessment 18. Which of the following responses by an older-adult client is most reflective of a need for further education by the nurse regarding the physiological changes associated with the older adult? 1 I call a cab if I want to go out after dark. 2 I cant help worrying about becoming forgetful. 3 I have my eyes checked regularly. Cant afford to fall. I really enjoy eating good vanilla ice cream, but I have cut way down. 4 ANS: 2 Although some forgetfulness is accepted, memory loss is not a normal physiological change of aging. This expressed fear requires further education by the nurse so as to help eliminate the WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material clients concerns. A common physiological change in the older-adult client is an increased sensitivity to glare, which makes night driving difficult. A common physiological change in the older-adult client is an alteration in visual acuity, which would require regular vision check-ups. Hyperlipidemia is a concern regarding cardiac health and should be considered by the older adult. DIF: C REF: 201 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health promotion and Maintenance/Aging Process; Physiological Integrity/System Specific Assessment 19. Which of the following statements made by a family member of a client recently diagnosed with Alzheimers disease is most reflective of an understanding of this disease process? 1 Dad has always been a fighter; hell fight this too. He wont give up. 2 We have an appointment with his care provider to see about medication therapy. 3 Good thing we found out about this early so steps can be taken to keep it from getting worse. 4 It usually progresses gradually so we are hoping it will be a while before his memory is gone. ANS: 2 Medications can slow the process of Alzheimers disease considerably when prescribed appropriately. There is no cure for Alzheimers disease. This option suggests that the family member still clings to the hope that there is a cure. Alzheimers disease usually progresses gradually with a deterioration in function, but medications can be given to slow the progression of symptoms, not halt them. Although Alzheimers disease usually progresses gradually with a deterioration in function with some clients living years after the diagnosis of Alzheimers disease, this option does not reflect the best understanding because no mention of management is made. DIF: C REF: 202 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Adaptation/Alteration in Body Systems; Psychosocial Integrity/Sensory Perception Alterations 20. The nurse is planning client education for an older adult being prepared for discharge home after hospitalization for a cardiac problem. Which nursing action addresses the most commonly determined need for this age-group? 1 Suggest that he purchase an emergency in-home alert system. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Arrange for the client to receive meals delivered to his home daily. 3 Encourage the client to use a compartmentalized pill storage container for his daily medications. Provide a written document describing the medications the client is currently prescribed. 4 ANS: 3 Approximately two thirds of older adults use prescription and nonprescription drugs with one third of all prescriptions being written for older adults. A system that allows the client to sort his medication for daily dosage would help minimize the risk of overdosing as well as missing ordered medications. While this option addresses the risk of injury in the home, it does not address the greatest need experienced by this age-groupthe risk of overmedication or undermedication of prescribed drugs. While this option does address the clients nutritional needs, it does not address the greatest need experienced by this age-groupthe risk of over- or undermedication of prescribed drugs. Although this option does address the clients need to monitor the medications he is prescribed, it does not address the greatest need experienced by this agegroupthe risk of overmedication or undermedication of prescribed drugs on a daily basis. DIF: C REF: 209 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Safe, Effective Care Environment/Safety Promotion/Safe Home Environment 21. An assisted living facility has provided its clients with an educational program on safe administration of prescribed medications. Which statement made by an older-adult client reflects the best understanding of safe self-administration of medications? 1 I dont seem to have problems with side effects, but Ill let my doctor know if something happens. 2 Im lucky since my daughter is really good about keeping up with my medications. 3 Ill be sure to read the inserts and ask the pharmacist if I dont understand something. 4 It shouldnt be too hard to keep it straight since I dont have any really serious health issues. ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material This option reflects an understanding of the importance to understand the various aspects of the medication and its effects on the client. The older adult should be encouraged to question the physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. Although this option reflects an understanding of potential risk for side effects, it is not the best option because it focuses on only one aspect of self-medication. This option appears to have the client delegating responsibility to the daughter. This option appears to have the client minimizing the importance of informed self-administration. DIF: C REF: 209 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Pharmacological Therapies 22. Which of the following client statements regarding self-medication administration by an older-adult client requires follow-up teaching by the nurse? 1 I take all the pills ordered once a day at bedtime, so Im less likely to forget them. 2 I have one pill that needs cut in half. I am going to ask the pharmacist to do that for me. 3 The pharmacist said to keep my pills away from the sunlight, so I put them inside the kitchen cabinet. 4 My daughter comes over each morning and puts my pills into a container that sorts them by the time they are due. ANS: 1 There may be a concern regarding drug interactions if all the medications are taken at the same time. The nurse should have a discussion with the client to determine if this practice is appropriate. This option shows the clients willingness to deal with this issue effectively and safely. This option shows an appropriate intervention for keeping the pills out of sunlight. This option shows an appropriate intervention for dealing with multiple medication schedules. DIF: C REF: 209 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Safe and Effective Care Environment/Safety Promotion/Safe Home Environment 23. Which of the following statements made by an older-adult client poses the greatest concern for the nurse conducting an assessment regarding the clients adjustment to the aging process? 1 I use to enjoy dancing and jogging so much, but now I have arthritis in my knees so that its hard to even walk. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Ive given my grandchildren money for college so they can live a better life than I had. 3 Growing old certainly presents all sorts of challenges. I wish I knew then what I know now. As I age Ive found its harder to do the things I love doing, but I guess it will all be over soon enough. 4 ANS: 4 This option should give the nurse concern over the clients possible depression because there are indications of possible suicide. This option does reflect regret over the inability to do the things previously enjoyed and the presence of a painful condition, but it does not present the seriousness of other available options. This option does reflect regret regarding life situations, but it does not present the seriousness of other available options. This option does reflect regret over the perceived changes, but it does not present the seriousness of other available options. DIF: C REF: 209-210 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Psychosocial Integrity/Coping Mechanisms 24. Which of the following statements made by a 75-year-old client shows the best understanding of how the aging process affects the musculoskeletal system? 1 I drink milk and eat cheese to get my calcium. 2 I walk 1 mile everyday to strengthen my bones. 3 I wear sensible shoes so I wont sprain an ankle. 4 At my age I might never fully recover from a hip fracture. ANS: 2 Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as those who are inactive. Walking regularly shows that this client has an understanding of and the disciple to work on health promotion habits for a healthy musculoskeletal system. While this option shows an understanding regarding osteoporosis and the need for calcium, it is not the best option because it focuses on only one aspect of musculoskeletal health. This option focuses only on safety measures, and so it is not the best option. While this option shows an understanding regarding the seriousness of a hip fracture for someone of older age, it is not the best option because it focuses on only one aspect of musculoskeletal health. DIF: C REF: 208 OBJ: Analysis TOP: Nursing Process: Evaluation WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: Process/Health Promotion Programs; Physiological Adaptation/Alteration in Body Systems 25. Which statement made by an older adult would reflect the best understanding of the nutritional requirements of individuals at this developmental stage? 1 2 3 4 An apple a day is my motto; always has been. I eat everything, but just a little a bit of things like sweets. Fiber is more important than ever to my digestive system. I dont need the fat so Ive taken to drinking protein shakes. ANS: 2 Good nutrition for older adults includes a balanced diet with limited intake of refined sugars. This is not the best option because it focuses on only one aspect of nutrition. This option is not the best choice because it focuses on only one aspect of nutrition. This is not the best option because it focuses on only one aspect of nutrition. DIF: C REF: 207 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process/Health Promotion Programs 26. Which statement made by an older adult would reflect the best understanding of the nutritional guidelines for this age-group? 1 I can prepare grilled chicken at least 10 different, delicious ways. 2 When I entertain, I serve healthy foods like veggies and lowfat dip. 3 I know I need to eat nutritiously, and I have certainly been doing better. I take seriously the suggestions my health team gives me on healthy eating. 4 ANS: 2 This option shows an understanding of healthy eating as well as a commitment to incorporating this knowledge into everyday living. While this is a good option, it is not as encompassing regarding knowledge and commitment as other options. This option leaves some doubt as to how committed the client really is to nutritional eating. While this is a good option, it is not as encompassing regarding knowledge and commitment as other options. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 207 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process/Health Promotion Programs 27. Which of the following statements made by an older adult regarding sexuality would be of greatest concern for the nurse? 1 2 3 4 Will this new medication affect my libido? What can I do to help with vaginal dryness? I really miss the intimacy my husband and I shared. Its so nice not to have to worry about an unwanted pregnancy. ANS: 4 This option infers that the client is sexually active and not using protection because there is no longer a possibility of conception. Information about the prevention of sexually transmitted diseases should be included when appropriate because there is a growing number of older adults contracting STDs. Many older adults use prescription medications that depress sexual activity, such as antihypertensives, antidepressants, sedatives, or hypnotics. This question requires further education but the statement does not arouse concern regarding the clients safe sex practices. Physiological changes may have an adverse influence on sexual activity. The older woman may experience vaginal dryness. This question requires further education, but the statement does not arouse concern regarding the clients safe sex practices. It is a common misconception that older adults are not interested in sex. This statement would require further discussion to assess the degree of distress the situation is causing the client, but the statement does not arouse concern regarding the clients safe sex practices. DIF: C REF: 203-204 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 28. Of the following options, which is the greatest barrier to providing quality health care to the older-adult client? 1 Poor client compliance resulting from generalized diminished capacity 2 Inadequate health insurance coverage for the group as a whole 3 Insufficient research to provide a basis for effective geriatric health care WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Preconceived assumptions regarding the lifestyles and attitudes of this group ANS: 4 Despite ongoing research in the field of gerontology, myths and stereotypes about older adults persist. These include false ideas about the physical and psychosocial characteristics and lifestyles of older adults. However, when health care providers hold negative stereotypes about aging, those stereotypes negatively affect the quality of the care. While there may be poor compliance related to diminished physical and cognitive capacity, it is not the primary barrier to effective care of this developmental group. While there are numbers of the older-adult population who are underinsured, it is not the primary barrier to effective care of this developmental group. A lack of research regarding the unique needs of this age-group is not the primary barrier to providing effective care. DIF: C REF: 93 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 29. The nurse is preparing an educational program for members of the local senior center. Which of the following topics would present the greatest learning challenge for this developmental group? 1 Exercising arthritic joints 2 Tips for living with GERD 3 Importance of the human touch Principles of heart-healthy eating 4 ANS: 3 Of the available topics, Importance of the human touch is possibly the most abstract in nature. Older adults are lifelong learners, but concrete rather than abstract material appears to be a better choice for the learning style of most older adults. This option is concrete in nature and so a better choice for the learning style of most older adults. This option is concrete in nature and so a better choice for the learning style of most older adults. This option is concrete in nature and so a better choice for the learning style of most older adults. DIF: C REF: 210 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process/Health Promotion Programs WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 30. When presenting information to the older adult, the client will be most likely to engage with the nurse in the learning process if: 1 2 3 4 Client feedback is encouraged and valued Physical disabilities are accommodated for The topic or information is valued by the learner New knowledge is connected to knowledge already processed ANS: 3 The older adult learner will be more interested and willing to participate actively in the learning if they have been given the opportunity to determine the values of the information to them personally. DIF: C REF: 193 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; 31. Of the following client statements made by an older adult client which best reflects an understanding the educational materials on nutrition presented by the nurse? 1 Ill keep this literature and read it again later. 2 I love rye bread. Its good to know its high in fiber. 3 Nutrition and cooking has always been passions of mine. 4 Now I can see the connection between food and my health. ANS: 2 The correct option shows the client making a connection between a type of food, its nutritional value, and its impact on personal health DIF: C REF: 193 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process; Physiological Adaptation/Alteration in Body Systems 32. The nurse defines ageism most accurately as: 1 The undervaluing of individuals based on their age. 2 Perception of a persons worth based on productivity 3 Biases directed towards individuals considered aged Discrimination based on an individuals increasing age 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 4 The correct option best describes ageism since it identifies discrimination towards a person based solely on the persons age. Devaluing is one aspect of ageism but this option failed to identify discrimination as the goal. While perception of a persons worth is a criteria used to judge, it is not the most complete description of the term. Bias and discrimination are the outcomes of ageism. DIF: C REF: 207 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance/Aging Process 33. Which of the following statements made by a nurse best reflects an understanding of the negative impact of ageism regarding client care? 1 If I dont value the older client, I will never be able to provide the care they are entitled too. 2 Everyone, regardless of age or position, always deserves effective, appropriate nursing care. As a society we lose so much valuable wisdom and knowledge when we devalue our older members. 3 4 If older clients do not feel valued, they are less likely to seek the health care they need and deserve. ANS: 1 According to experts in the field of gerontology, unopposed ageism has the potential to undermine the self-confidence of older adults, limit their access to care, and distort caregivers understanding of the uniqueness of each older adult. Health care providers must be free of such an unethical attitude so that client care will never be compromised. This is a truism that is not specific to ageism Chapter 15. Critical Thinking in Nursing Practice MULTIPLE CHOICE 1. Which of the following best reflects the philosophy of critical thinking as taught by a nurse educator to a nursing student? 1 Think about several interventions that you could use with this client. 2 Dont draw subjective inferences about your clientbe more objective. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Please think harderthere is a single solution for which I am looking. 4 Trust your feelingsdont be concerned about trying to find a rationale to support your decision. ANS: 1 The nurse educator is asking the student to synthesize critical thinking skills by encouraging the student to examine alternatives to meet the clients unique needs within the context of the nursing process. Drawing inferences is a specific critical thinking competency used in diagnostic reasoning. The educator who tells the student not to draw inferences is not allowing the student to practice competencies necessary for specific critical thinking in clinical situations. The critical thinker will look beyond a single solution to a problem. Intuition develops as ones clinical experience increases. The nursing student should examine rationales in order to make good decisions. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The second component of critical thinking in the critical thinking model is: 1 2 Experience Competencies 3 Specific knowledge 4 Diagnostic reasoning ANS: 1 Experience is the second component of critical thinking in the critical thinking model. The third component of the critical thinking model is competencies. Specific knowledge base is the first component of the critical thinking model. Diagnostic reasoning is a specific critical thinking competency in clinical situations. DIF: A REF: 222 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is not right with the client and proceeds to take the vital signs. This is the nurse acting on: 1 Intuition WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Reflection 3 Knowledge Scientific methodology 4 ANS: 1 Intuition is an inner sensing that something is so, as in this example. Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or verifying that a set of facts agrees with reality. DIF: A OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. The nurse manager has developed a staff protocol for peer evaluation. The nurses on her surgical unit are nervous about using her instrument. If the nurse manager continues to implement the new strategy, which of the following critical thinking attitudes is she portraying? 1 Humility 2 Risk-taking 3 Accountability 4 Independent thinking ANS: 2 This is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in trying different approaches to solving problems. Humility is a critical thinking attitude in which a person admits what they do not know and tries to acquire the knowledge needed to make proper decisions. To be accountable means to be answerable for the outcomes of your actions. To think independently, one questions others ways of interpreting knowledge and looks for rational and logical answers to problems. DIF: A REF: 224 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. The nurse is working with a client who has recently had a colostomy and is having difficulty using the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of: 1 Inference WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Management 3 Problem-solving Diagnostic reasoning 4 ANS: 3 This is an example of the critical thinking strategy of problem-solving. The nurse gathers information from the client and combines that information with what the nurse already knows about ostomy care to find a solution. Effective problem-solving involves the examination of alternatives. Inference is the process of drawing conclusions. Management is not a critical thinking strategy. Diagnostic reasoning is a process of determining a clients health status after the nurse assigns meaning to the behaviors, physical signs, and symptoms presented by the client. DIF: A REF: 219 OBJ: Comprehension TOP: Nursing Process: Assessment/Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. Which of the following is an example of a nurses statement that reflects using the scientific method in the nursing process? 1 2 3 4 I believe that this client is getting depressed. The client doesnt look right to me; I think something is wrong. The clients husband told me that she is feeling very uncomfortable. The client reports more pain than yesterday and her blood pressure is elevated. ANS: 4 Reporting more pain than yesterday and elevated blood pressure reflects using the scientific method in the nursing process. The nurse identified a problem of pain, hypothesized that it was greater than the day before, and collected data to evaluate its reality. Believing the client is depressed or thinking something is wrong reflect intuition. Speaking with the husband reflects information gathering, which may be used in diagnostic reasoning. DIF: A REF: 218 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Assessment 2 3 Nursing diagnosis Planning 4 Implementation ANS: 4 Taking appropriate action demonstrates the implementation step of the nursing process. Assessment involves the gathering of data. When formulating a nursing diagnosis, the nurse critically examines and analyzes the data, and identifies the clients response to a problem. The nurse may then determine priorities. Planning involves establishing goals and expected outcomes of care. DIF: A REF: 221 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who: 1 Has a documented blood pressure of 90/50 2 Was medicated for back pain 10 minutes ago 3 Has an order to be out of bed and ambulated Requires instructions for wound care before discharge 4 ANS: 1 The nurse prioritizes actions and determines to see this client first because of a lower than normal blood pressure for a postoperative patient. This nurse is using scientifically and practicebased criteria for making clinical judgment. This is an example of following standards. The nurse uses criteria such as the clinical condition of the client, Maslows hierarchy of needs, and risks involved in treatment delays to determine which clients have the greatest priority for care. In answers 2 through 4, the client is not reported to be having any problems and therefore is not the priority. DIF: C REF: 221 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Coordination/Setting Priorities 9. There are a variety of levels of critical thinking. An example of critical thinking at the complex level is: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Giving medication at the time ordered 2 3 Following a procedure for catheterization step-by-step Reviewing all clients medical records thoroughly 4 Discussing various alternative pain management techniques ANS: 4 Discussing alternative pain management techniques is an example of critical thinking at the complex level. The nurse analyzes and examines alternatives more independently. Giving medication at the time ordered is an example of the basic level of critical thinking. Following a procedure step-by-step is an example of the basic level of critical thinking. Reviewing the clients medical records thoroughly is an example of gathering data and may be used in evaluation of a clients care. DIF: C REF: 218 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. The nurse is deciding on the type of dressing to use for a client. Which step of the decisionmaking process is being used when the nurse observes the absorbency of different dressing brands? 1 Defining the problem 2 Making final decisions 3 Testing possible options 4 Considering consequences ANS: 3 The nurse who observes the absorbency of different brands of dressing is demonstrating testing of possible options. This is not an example of defining the problem. The nurse has not yet made a final decision. The nurse is not examining pros and cons, and therefore is not considering consequences. DIF: A REF: 219 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which one of the following examples demonstrates the critical thinking attitude of responsibility and authority? 1 Reporting client difficulties WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Offering an alternative approach 3 Looking for a different treatment option Sharing ideas about nursing interventions 4 ANS: 1 Reporting client difficulties demonstrates the critical thinking attitude of responsibility and authority. Asking for help if uncertain and following standards of practice also demonstrate the critical thinking attitudes of responsibility and authority. Offering an alternative approach would demonstrate the critical thinking attitude of risk-taking. Looking for a different treatment option demonstrates the critical thinking attitude of creativity. Sharing ideas about nursing interventions demonstrates the critical thinking attitude of thinking independently. DIF: A REF: 223 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. Use of the intellectual standard of critical thinking implies that the nurse: 2 Questions the physicians order Recognizes conflicts of interest 3 Listens to both sides of the story 4 Approaches assessment logically 1 ANS: 4 Use of the intellectual standard of critical thinking implies that the nurse approaches assessment logically and consistently. Questioning the physicians order is an example of the critical thinking attitude of risk-taking. Recognizing conflicts of interest demonstrates the critical thinking attitude of integrity. Listening to both sides of the story demonstrates the critical thinking attitude of fairness. DIF: A REF: 225 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. A client requires urinary catheterization but has difficulty keeping her legs in the usual position needed for this procedure. The nurse has worked for many years and adapts the procedure to allow the client to lie on her side. This action is based on the critical thinking element of: 1 Curiosity 2 Experience WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Perseverance 4 Scientific knowledge ANS: 2 Having worked for many years and being able to adapt a procedure to meet the clients needs is an example of the second component of the critical thinking modelexperience. Curiosity is a critical thinking attitude where the nurse asks why, and continues to learn more about the client to make appropriate clinical judgments. Perseverance is a critical thinking attitude where the nurse does not readily accept the easy answer but does look further to find necessary information and appropriate solutions. Scientific knowledge is knowledge acquired from the study of science. It may be acquired through education, such as coursework, or by reading nursing literature to remain current in nursing science. DIF: A REF: 222 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. Which of the following statements made by a nursing student concerning the use of critical thinking and client care requires follow-up by the nursing instructor? 1 I feel its good practice to always have alternative interventions in mind. 2 I trust my feelings about a clients needs since I work hard at knowing my client. 3 I always try to keep an open mind about what interventions my client will require. 4 I will wait until my assessment is completed before determining the clients needs. ANS: 2 Intuition develops as ones clinical experience increases. The nursing instructor should instruct the student to examine rationales in order to make good decisions regarding client needs. The instructor would encourage the student to examine alternatives to meet the clients unique needs, so this statement would not require follow-up. Basing client care on identified client needs is the appropriate use of critical thinking, and so would not require follow-up. Basing client care on client needs identified by thorough nursing assessments is the appropriate use of critical thinking, and so would not require follow-up. DIF: C OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 15. Which of the following is the best example of a nurses use of reflection? 1 The nurse places a client experiencing respiratory difficulties in a high-Fowlers position. 2 The nurse calls the provider when a client reports feeling chilled and achy while having an oral temperature of 100.2 F. While caring for a client with a history of asthma, the nurse assesses the clients pulse oximetry reading when he doesnt sound right. 3 4 A nurse tells a client; When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time. ANS: 4 Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or verifying that a set of facts agrees with reality. Intuition is an inner sensing that something is so, as in this example. DIF: C REF: 226 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. Which of the following nursing situations best reflects accountability? 1 The nurse takes the oncology nursing certification examination. 2 The nurse files an incident report regarding a medication error. 3 The nurse assesses the client for the possible cause of his pain. The nurse tells the client, I dont know but I will find out for you. 4 ANS: 2 To be accountable means to be answerable for the outcomes of your actions. Answer 2 is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in trying different approaches to solving problems. To think independently, one questions others ways of interpreting knowledge and looks for rational and logical answers to problems. Humility WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material is a critical thinking attitude where a person admits what they do not know and tries to acquire the knowledge needed to make proper decisions. DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which of the following nursing actions is the best example of problem solving? 1 Requesting the IV team to start an antibiotic drip on a client with a history of being a difficult stick 2 Offering to call the kitchen to provide an alternate breakfast for a client who does not like cooked cereal 3 Trying several difficult wound dressings to determine which one the client can apply the most effectively 4 Calling for another pain medication order when the current drug results in the client experiencing nausea ANS: 3 This is an example of the critical thinking strategy of problem solving. The nurse gathers information by using several different products and then uses this information to determine which will work best for the client. Effective problem solving involves the examination of alternatives. While requesting the IV team solves a problem, there is little critical thinking needed because it would be understood that the IV team would be called under these circumstances. Although calling the kitchen solves a problem, there is little critical thinking needed because it would be understood that the kitchen would be called under these circumstances. Calling for another pain medication order solves a problem, but there is little critical thinking needed because it would be understood that the provider would be called for a new drug order under these circumstances. DIF: C REF: 219 OBJ: Analysis TOP: Nursing Process: Assessment/Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. Which of the following clients should be prioritized with the most urgent need for a nursing assessment? 1 A new admission admitted for swelling in the right ankle and knee 2 A second day postoperative client who received pain medication 30 minutes ago WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 A client who the nursing assistant found crying in the bathroom 4 A client ready for discharge who requires a final assessment and documentation ANS: 3 This client has an acute need that requires the nurses attention. The facility has a policy regarding the amount of time available in which to complete such an assessment and this client is in no acute distress, so the assessment does not have priority. While a pain assessment is required to evaluate the effectiveness of pain medication, it does not the have the priority of the other presented options. This client has no acute problems and so the assessment does not have the priority of some of the other options. DIF: C REF: 221 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following nursing interventions is the best example of the implementation step of the nursing process? 1 Determining that the clients ankle edema is worse after he ambulates 2 Asking the client to rate his ankle pain after receiving oral pain medication Arranging for the client to receive pain medication 30 minutes before his ordered ambulation 3 4 Crushing the clients pain medication to facilitate easier swallowing and thus minimize the risk of choking ANS: 4 Taking appropriate action demonstrates the implementation step of the nursing process. Assessment involves the gathering of data. Assessment involves the gathering of data. Planning involves establishing goals and expected outcomes of care. DIF: C REF: 221 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following nursing actions best reflects the consequence stage of the decisionmaking process? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Being physically present when a client is given the results of a tissue biopsy 2 Witnessing the client sign consent for surgery forms before cardiac surgery The client is informed of the various treatments available for his condition. 3 4 The nurse explains to the client the risks of leaving the hospital against medical advice. ANS: 4 The nurse is presenting the possible outcomes, and therefore is presenting consequences. Being physically present is not an example of defining the problem. Witnessing the client sign consent is an example of a final decision. In Answer 3 the client is being given various options. DIF: C REF: 219 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. The concept of nursing responsibility is best reflected in which of the following nursing actions? 1 Providing accurate and timely documentation regarding an incident resulting in a client fall 2 Suggesting that a client might prefer taking a particular medication at bedtime instead of in the morning 3 Posting a note on the unit Kardex how to best apply a dressing to a skin wound on a particular client Referring to the institutions policy manual when unsure of how to handle a clients complaint regarding a social services consult 4 ANS: 4 Asking for help if uncertain and following standards of practice best demonstrate the critical thinking attitudes of responsibility because failure to do so could result in client injury. Reporting client difficulties demonstrates the critical thinking attitude of responsibility but is not the best option of those available because it would not result in client injury/harm. Offering an alternative approach would best demonstrate the critical thinking attitude of risk-taking. Sharing ideas about nursing interventions best demonstrates the critical thinking attitude of thinking independently. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool? 1 2 Performing a head-to-toe assessment on a new admission Placing a client experiencing shortness of breath on oxygen 3 Arbitrating a complaint between roommates over the television 4 Notifying a provider of a clients allergy to an ordered medication ANS: 2 Use of the intellectual standard of critical thinking implies that the nurse approaches nursing care logically, consistently, and appropriately. This option reflects the use of such standards in a situation that addresses client distress. While performing a head-to-toe assessment is an example of intellectual standards, it is not the best example because it does not involve a clients immediate distress. Listening to both sides of the story demonstrates the critical thinking attitude of fairness. Notifying a provider of a clients allergy is an example of nursing responsibility. DIF: C REF: 225 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse is best demonstrating perseverance by: 1 Having a perfect attendance record 2 Completing a lengthy course on current chemotherapies 3 Repeatedly irrigating the nasogastric tube until it is patent Sitting with a client until she is ready to discuss why she is crying 4 ANS: 4 Perseverance is a critical thinking attitude in which the nurse does not readily accept the easy answer but does look further to find necessary information and appropriate solutions. While perfect attendance shows a nurses willingness to complete the work responsibilities regardless of barriers, it is a better representation of responsibility. While completing a course on current chemotherapies shows the nurses willingness to pursue knowledge, it is more representative of WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material the acquiring of scientific knowledge to remain current in nursing science. While repeatedly irrigating the nasogastric tube shows a willingness to repeat a procedure as often as is appropriate, it is a better representation of possessing knowledge of the procedure. DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. With regards to client care, the most likely reason that a veteran nurse tends to be a more skillful critical thinker than a new graduate nurse is because: 1 The veteran nurse has a varied history of client care experiences 2 Critical thinking improves with experience, longevity, and interest 3 Todays short hospital stays minimize the opportunity to develop critical thinking skills 4 New graduates often lack the self-confidence to take the risks often required of critical decision making ANS: 2 Critical thinking is not a simple step-by-step, linear process that you learn overnight. It is a process acquired only through experience, commitment, and an active curiosity toward learning. While experience is a factor in the development of critical thinking skills, it is not the only factor. While having extended periods of time with clients has a positive effect on the development of critical thinking, it is not the primary or sole factor. While lack of self-confidence may have a negative effect on the development of critical thinking skills, it is not the primary or sole factor. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. The primary factor that distinguishes a professional nurses care from care provided by ancillary nursing staff is: 1 Critical thinking 2 Years of education 3 Professional licensure 4 Complexity of the task ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Clinical decision making separates professional nurses from technical personnel. While advanced education is a distinction, the primary factor regarding client care is the professional nurse is responsible for actions that require critical thinking decision making. Although licensure is a distinction, the primary factor regarding client care is the professional nurse is responsible for actions that require critical thinking decision making. 4. While complexity is a distinction, the primary factor regarding client care is that the professional nurse is responsible for actions that require critical thinking decision making. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of the following represents the best response? 1 2 A person with the educational background to solve problems. A person who finds the problem and does what is best to fix it. 3 Its someone who uses the scientific method to solve problems. 4 Someone who uses a system to work through and solve a problem. ANS: 2 A critical thinker considers what is important in a situation, imagines and explores alternatives, considers ethical principles, and then makes informed decisions. Educational background may have an impact on critical thinking but it is not the primary or sole factor to consider. Although the scientific method is often used in critical thinking it is neither the only method nor the sole factor to consider. While an orderly method is used in critical thinking, it is not the only factor to consider. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. Which of the following statements made by a new graduate nurse regarding a clients care needs requires follow-up by the mentor? 1 No one really enjoys being hospitalized. 2 Every client is offered a back rub at bedtime. 3 All post surgery clients are reluctant to ambulate. 4 I always spend extra time with new clients to help them relax. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 3 Because no two clients respond exactly alike to similar health problems, you always have to observe each client closely in order to make critically sound decisions regarding that clients needs. Answer 1 does not require follow-up because even if it is not true, it does not have an impact on the nurses perception of the clients care needs. Answer 2 does not require follow-up because it is a nursing action that should be offered to all clients at bedtime. Answer 4 does not require follow-up because it is a nursing action that should be offered to all clients. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care? 1 Im sure that friction and pressure have caused this problem. 2 Please be sure that her ankles are well padded when you place her in bed. 3 Do you have any suggestions on how we can minimize the pressure to her ankles? 4 It was an ineffective turning schedule that allowed this to happen so now we will reposition every hour. ANS: 3 Nurses who apply critical thinking in their work focus on options for solving problems and making decisions, rather than quickly and carelessly forming quick solutions. Asking for staff input regarding interventions shows critical thinking. While Answer 1 may be true, it is knowledge or experience, not critical thinking, that brought about this conclusion. Although Answer 2 may represent an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion. While Answer 4 may be true and an example of an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this clients care needs? 1 That surgery is painful. Ill get her pain medication ready. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 She was sleeping when I checked 15 minutes ago. Ill go back in right now. 3 Ill be responsible for her PM care so I can spend some uninterrupted time with her. A mastectomy is a blow to a womans self image. Ill notify her provider that she is depressed. 4 ANS: 2 Analysis requires being opened-minded as you look at information about a client. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options? Although pain may be the cause of this clients tears, there are other possible reasons, so making an assumption is not appropriate. Although Answer 3 shows the nurses intention to analyze the clients needs, the delay is not appropriate. While the client may be experiencing some depression, there are other possible reasons for the tears and so the nurse should not assume. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. Which of the following statements made by a nurse regarding personal reflection related to client care requires follow-up by the units nurse manager? 1 Mary and I were comparing foot wound dressing techniques. 2 Ive been caring for orthopedic clients for 10 years and I think Ive seen it all. 3 I cant believe that my client isnt improving after 2 weeks of physical therapy. 4 I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4. ANS: 4 Reflect on your experiences. Identify the ways you can improve your own performance. This option presents a rigid attitude concerning client pain needs. Answer 1 needs follow-up because it shows a willingness to explore others opinions. Answer 2 requires no follow-up because it does not reflect an inflexible attitude toward client care need. Answer 3 requires no follow-up because it does not reflect an inflexible attitude toward client care needs. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. The scope of a clients health problem is a result of which of the following factors? (Select all that apply.) 1 2 3 Religious beliefs Life experiences 4 Lifestyle choices Work environment 5 Family relationships 6 Educational background ANS: 2, 3, 4, 5 Each clients problems are unique and a product of many factors, including the clients physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences. Chapter 16. Nursing Assessment MULTIPLE CHOICE 1. A client interview consists of three phases. The nurse recognizes that those phases are: 1 2 3 4 Orientation, working, termination Introduction, controlling, selection Introduction, assessment, conclusion Orientation, documentation, database ANS: 4 The three phases of an interview are orientation, working, and termination. DIF: A REF: 236 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about: 1 2 The onset and duration of his present breathing problem His personal smoking, alcohol use, and exercise practices WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Any extended family members who have diagnosed heart disease 4 Changes in other body systems that the client perceives as problematic ANS: 1 A clients database originates with the clients perception of a symptom or health problem. If an illness is present, the nurse gathers essential and relevant data about the nature and onset of symptoms. The problem-seeking technique takes the information provided in the clients story to more fully describe and identify the clients specific problems. Habits and lifestyle patterns such as smoking, alcohol use, and exercise may be assessed in an admission history. However, it is not the first question the nurse should ask when obtaining data for a problem-oriented database after the client reports having a health problem. Information regarding family history, such as members who had heart disease, may be obtained in an admission history. However, if a client reports a problem, the nurse should first follow-up with questions relevant to the nature and onset of symptoms. The nurse may inquire about changes in other body systems during an admission history; however, if the client reports a problem, the nurse should first follow-up using a problem-oriented approach. This would include asking specific questions about the clients health problem, such as the nature and onset of symptoms. DIF: A REF: 237 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about: 1 A family history of heart problems 2 3 Medications currently being taken at home Questions or concerns about hospitalization 4 The onset, severity, and duration of the chest pain ANS: 4 If a client comes to the emergency department with chest pain, the nurse should first ask the client about the onset, severity, and duration of the chest pain. In an emergency situation, the clients current health problem becomes the priority assessment. Initially, the nurse should not ask questions regarding family history. Gathering data about the problem currently affecting the client has greater priority. Asking the client about medications taken at home is appropriate, but not at this time. The priority is to assess the symptoms the client is experiencing. Asking the client about concerns regarding hospitalization is not the priority. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A REF: 241 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. A nurse seeks to organize the data obtained from the client in a logical manner. The organizational method that identifies relationships between factors and symptoms in the database is known as: 1 2 Clustering data Validating data 3 Peer reviewing 4 Problem statement ANS: 1 Clustering data means the nurse organizes the information obtained into meaningful clusters. A cluster is a set of signs or symptoms grouped together in a logical order. When clustering data, the nurse identifies relationships between factors and symptoms. Validating data means to compare the data obtained with another source to ensure its accuracy. Peer review is the evaluation of the quality of the work effort of an individual by his or her peers. After validating data and clustering data, the nurse may formulate a problem statement, usually in the form of a nursing diagnosis. DIF: A REF: 234 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. The client recently became febrile and stated he felt hot. The nurse takes the clients temperature and finds it to be 38.2 C. In addition, the pulse rate is 88 beats per minute, and his blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data? 1 Pulse rate of 88 beats per minute 2 Blood pressure of 168/80 mm Hg 3 The statement regarding his feeling hot The supported fact that he became febrile 4 ANS: 3 Subjective data are clients perceptions about their health problems. The statement by the client regarding his feeling hot is an example of subjective data. A pulse rate of 88 beats per minute is an example of objective data. Objective data are observations or measurements made by the data collector. A blood pressure of 168/80 mm Hg is something that can be measured, and therefore is WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material an example of objective data. Becoming febrile can be determined by measurement, and therefore is an example of objective data. DIF: A REF: 234 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning? 1 2 Is your pain worse or better than it was an hour ago? Do you believe that your nausea is from the new antibiotic? 3 What do you think has been causing your current depression? 4 What have you done to alleviate the side effects from your medications? ANS: 3 An open-ended question prompts the client to describe a situation in more than one or two words. This option demonstrates the open-ended question technique. This question limits the clients answers to one or two words. It is an example of a closed-ended question. The question in this option limits the clients answer to one or two words such as yes or no. It is an example of a closed-ended question. This option only requires a few words to form an answer. It does not use the open-ended question technique. DIF: A REF: 239 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job. Job loss best fits into which of the following categories? 1 Family history 2 Psychosocial history 3 Biographical history 4 Environmental history ANS: 2 The psychosocial history reveals the clients support system, if there are any recent losses or stressful events, and how the individual copes with such stressors. The loss of a job would fit the psychosocial history category. Family history is used to obtain data about immediate and blood relatives to determine whether the client is at risk for illnesses of a genetic or familial nature. It WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material also provides information about the family itself. The biographical history provides factual demographic data about the client. The environmental history provides data about the clients home and working environments. DIF: A REF: 241 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. The nurse is going to perform the admission history for a newly admitted client on the medical unit. The optimum time for completion of the history is planned for: 1 Coordination with the physicians visit 2 3 The time when the clients family are visiting Immediately before the clients scheduled MRI testing 4 After the client has become comfortably oriented to the room ANS: 4 Completion of the admission history is scheduled for a time when interruptions by other staff or visiting family members are minimal. The nurse should create an environment where the client feels comfortable. Conducting the admission history after the clients orientation to the room and completion of lunch would be optimum because the client will not be distracted by hunger, and the interview will less likely be interrupted. The admission history should be scheduled for a time when interruptions by other staff are minimal. During the physicians visit would not be an optimum time. The nurse should provide an environment private enough to allow the client to be comfortable when providing personal information. Inclusion of family members should be left up to the client to decide. Information obtained should remain confidential. Immediately before a clients testing would not be an optimum time for obtaining a nursing history. The client may feel more anxious about the upcoming test, impeding communication, and there may not be sufficient time allowed to gather all of the information. DIF: A REF: 236 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. The nurse has completed an assessment and found that the client has an activity and exercise abnormality. This type of wording indicates that which of the following organizing formats has been used? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Review of systems 2 3 Nursing health history Gordons functional health patterns 4 Biographical information database ANS: 3 Utilizing Gordons functional health patterns format, the nurse organizes information and makes an assessment identifying functional patterns (client strengths) and dysfunctional patterns (such as an activity and exercise abnormality). The review of systems is a systematic method for collecting data on all body systems. The nurse asks the client about the normal functioning of each body system and any noted changes. A nursing health history is broader and includes information about the clients current level of wellness, a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness. A biographical information database provides factual demographic data about the client, such as age, address, occupation, marital status, etc. DIF: A REF: 233 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as objective data? 1 Pain in the left leg 2 Elevated blood pressure 3 Fear of impending surgery Discomfort upon breathing 4 ANS: 2 Objective data are observations or measurements made by the data collector, such as a blood pressure reading. Subjective data are clients perceptions about their health problems, such as pain. Fear of surgery would be subjective data because it is the clients perception and not something the data collector can measure. Subjective data are clients perceptions about their health problems, such as discomfort during breathing. A respiratory rate would be an example of objective data. DIF: A REF: 234 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 11. The primary source of information when completing an assessment of a client that is alert and oriented as he is admitted to the medical center for diagnostic testing is the: 1 2 3 4 Client Physician Family member Experienced unit nurse ANS: 1 A client is usually the best source of information. The client who is oriented and answers questions appropriately can provide the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living. The physician may have knowledge of the clients medical problem, but the client is the primary source of information for completing an assessment. Family members can be interviewed as primary sources of information about infants or children or critically ill, mentally handicapped, disoriented, or unconscious clients. Usually, however, they are secondary sources of information and can confirm findings provided by the client. The client in this situation is capable of being the primary source of information. An experienced nurse on the unit may offer insight into a clients health care needs and care, but is not the primary source of information when completing a client assessment. DIF: A REF: 234 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. The process of data collection should begin with the nurse performing a: 1 Physical exam 2 Client interview 3 Review of medical records Discussion with other health team members 4 ANS: 2 The first step in establishing the database is to collect subjective information by interviewing the client. The physical examination follows the client interview so that data can be verified. A review of medical records is not the first step the nurse should take in the process of data collection. The medical record is a valuable tool for checking the consistency and congruency of personal observations made during the client interview. Discussion with other health team members may provide additional information and be used to relay information, but is not the first step in the process of data collection. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A REF: 236 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. During an interview, the nurse needs to obtain specific information about the signs and symptoms of the clients health problem. To obtain these data most efficiently, the nurse should use: 1 2 Channeling Open-ended questions 3 Closed-ended questions 4 Problem-seeking responses ANS: 3 Using closed-ended questions helps the nurse to acquire specific information about health problems such as symptoms, precipitating factors, or relief measures in an efficient manner. Channeling is where the nurse uses active listening techniques, such as all right, go on, or uhhuh, to indicate the nurse has heard what the client said and encourage the client to elaborate further. Using open-ended questions prompts the client to describe a situation in more than one or two words. Because it allows the client the opportunity to tell their story and reveal what is important to them, it is not the most efficient method of obtaining specific information regarding a clients signs and symptoms of a health problem. In problem-seeking technique, the nurse takes the information provided in the clients story to more fully describe and identify the clients specific problems. Using closed-ended questions would be the most efficient method for obtaining specific information about the signs and symptoms of a clients health problem. DIF: A REF: 239 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. The nurse is conducting an interview with the client and wants to clarify information that the client has shared. Which response by the nurse is an example of the clarifying technique of communication? 1 I understand how you must feel. 2 This medication is used to lower your blood pressure. 3 You appear anxious. Youre wringing your hands constantly. Could you give me an example of how you handle stressors? 4 ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material In this option, the nurse is seeking further clarification of information by asking the client to provide an example. Clarification helps the nurse to gain accurate understanding of a clients situation. This is not an example of clarifying information. This response provides information. The nurse is not using the clarifying technique of communication. In this option the nurse describes his or her observations. It does not seek clarification. DIF: A REF: 239 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. When clustering data according to functional health patterns, the nurse determines that the client is only able to ambulate short distances without becoming fatigued and requires rest periods during morning care. The health pattern that requires intervention is identified by the nurse as: 1 2 Respiratory Activity and exercise 3 Sleep and rest pattern 4 Self-care deficit: activities of daily living ANS: 2 Using the functional health pattern format, the nurse clusters data that pertain to a functional health category. Fatigue upon ambulating short distances and requiring frequent periods of rest are examples of data belonging to the category of activity and exercise. Respiratory would be found in a systems approach of health assessment, not a functional health pattern assessment. The functional health pattern category of sleep and rest would focus more on the number of hours of sleep the client obtains, use of sleep aids, and any difficulties associated with sleep. Self-care deficit: activities of daily living would include such aspects as bathing, feeding, and dressing self. The symptoms described would be clustered more accurately under the functional health pattern category of activity and exercise. DIF: A REF: 233 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as subjective data? 1 Client appears sleepy 2 No physical distress noted 3 Abdomen soft and non-tender WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 States feels anxious and tense ANS: 4 Subjective data are clients perceptions about their health problems. Feeling anxious and tense is information that only the client can provide. Objective data are observations or measurements made by the data collector. In this example, the data collector is making the observation that the client appears sleepy. No physical distress noted is an example of objective data because it is an observation made by the data collector. Abdomen soft and non-tender is an example of objective data because it is an observation made by the data collector, not a clients perception. DIF: A REF: 234 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. An ER nurse is interviewing a client who complains of abdominal pain. Which of the following questions asked by the nurse has priority at this time? 1 Can you describe your pain? 2 3 Have you had this problem before? What have you done to ease the pain? 4 When did your abdominal pain begin? ANS: 4 If a client presents to the emergency department with pain, the nurse should first ask the client about the onset, severity, and duration of the pain. In an emergency situation, the clients current health problem becomes the priority assessment. Gathering data about the problem currently affecting the client has greater priority, but a description of the pain does not have priority over onset. Asking the client about medical history is appropriate but not at this time. The priority is to assess the symptoms the client is experiencing. Gathering data about the problem currently affecting the client has greater priority, but attempted self-treatment does not have priority over onset. DIF: C REF: 236-237 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. Which subjective assessment data are most supportive of a clients diagnosis of anxiety? 1 Diaphoretic and cool skin 2 An apical pulse rate of 120 beats per minute 3 Reports needing to leave now WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Claims something is terribly wrong ANS: 4 Subjective data are clients perceptions about their health problems. The statement by the client regarding his sense of impending doom is the best example of subjective data regarding his anxiety because it is his own verbalization of the problem. Cool, damp skin is an example of objective data. Objective data are observations or measurements made by the data collector. A pulse rate is an example of objective data. Objective data are observations or measurements made by the data collector. While a client statement regarding the need to leave the hospital is subjective in nature, it is not as strong an indicator of anxiety as is the verbalization of impending doom. DIF: C REF: 241 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the clients depression? 1 Have you ever felt this depressed before? 2 3 What do you believe is the cause of your depression? What makes you feel that you are experiencing depression? 4 What can we do to make you comfortable while you are here? ANS: 2 This option is an open-ended question that encourages the client to express his insight regarding his condition. This option is a closed-ended question requiring only a yes or no response and so provides minimal information regarding the clients condition. While this is an open-ended question, it is not the best option because it is not directed towards assessment of the clients current complaint. While this is an open-ended question, it is not the best option because it is directed at the clients comfort, not towards assessing his current complaint. DIF: C REF: 234 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following statements best reflects the nurses correct understanding of the importance of selecting the optimum time for interviewing a client newly admitted to the unit? 1 Im going to do the clients history before his family leaves so they can help with the admission history questions. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 You are scheduled for some x-rays, so Id like to complete this admission history interview before you have to leave. 3 I have some questions to ask you regarding your admission history. Ill be back once you are settled in and comfortable. Please let me know when the blood lab is finished with the new client so I can complete his admission history interview. 4 ANS: 3 Completion of the admission history is scheduled for a time when interruptions by other staff or visiting family members are minimal. The nurse should create an environment where the client feels comfortable and the clients orientation to the room is completed. While this may be appropriate if the client requires help with answering the questions, it is not the best option because family and visitors can be distracting and may represent a confidentiality problem. While the history must be taken within a specific time period, rushing to complete it before the client goes to radiology is not appropriate. The interview requires the clients attention and cooperation. Attempting to complete it immediately after a treatment or other intervention would not be the best choice of time. DIF: C REF: 239 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD). Which of the following questions shows the best example of relevant questioning by the nurse? 2 How long have you been dealing with GERD? Are you currently taking any medications for your GERD? 3 Do you follow a particular diet to help manage your GERD? 4 Do you have any other gastrointestinal problems besides GERD? 1 ANS: 4 The nurse should ask relevant questions and collect relevant history and physical assessment data related to the clients presenting health care needs in order to produce the most inclusive, effective nursing care plan. The questions How long have you been dealing with GERD? and Are you currently taking any medications for your GERD? as well as Do you follow a particular diet to help manage your GERD? are directed towards the GERD itself and not towards conditions that might be related to the presence of GERD. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 236 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. A new graduate nurse missed cues regarding the clients emotional state at the time of admission. The most therapeutic response to the nurse by her mentor is: 1 That is why we perform assessments at least daily; so we can catch missed cues. 2 Everyone has missed cues; dont be too hard on yourself and just keep trying. 3 You will be less likely to miss client cues as you acquire more experience with assessments. 4 The positive side to making this mistake is that you wont miss those cues again in another client. ANS: 3 It is possible to miss important cues when you conduct an initial overview. However, always try to interpret cues from the client to know how in-depth to make your assessment. Remember, thinking is human and imperfect. You will acquire appropriate thinking processes in the conduct of assessment, but expect to make mistakes in missing important cues. While this may be true, it is not the most therapeutic option because it does not address the issue personally for the new graduate. While this is true, it is not the most therapeutic option because it does not offer a reason for the omission. While this may be true, it is not the most therapeutic option because it does not address the issue personally for the new graduate. DIF: C REF: 240-241 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse is performing a problem-focused assessment when the client reports pain in his left shoulder. Which of the following nursing questions has priority when determining the nature of the pain? 1 What makes the pain worse? 2 When did you first notice the pain? 3 What do you do to lessen the pain? 4 Can you rate your pain using the pain scale that weve discussed? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 4 Once you complete the assessment, you thoroughly analyze the extent and nature of the clients problem so you are able to later develop a care plan. Identifying the degree of pain the client is experiencing has priority over the other options. While this option is an appropriate pain assessment question, it is more directed towards identifying contributing factors than the characteristics (nature) of the pain. While this option is an appropriate pain assessment question regarding the nature of the pain, it does not have priority over the degree of pain because that represents an issue that requires immediate intervention. While this option is an appropriate pain assessment question, it is more directed towards identifying effective self-treatment rather than the characteristics (nature) of the pain. DIF: C REF: 236 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. When following up on a clients report of hip pain during an admission assessment, the most nursing conclusive observation would be: 1 2 The client tearing when being ambulated to the chair A report from the ancillary staff that the client is reporting pain 3 The client observed grimacing when positioning self in the bed 4 Overhearing the client discuss hip pain with family on the phone ANS: 3 This option where the client was observed grimacing describes nonverbal actions that are associated with pain when the client is unaware of being observed and so represents the most conclusive follow-up evidence of pain. The options where the client is tearing when ambulated to the chair, the ancillary staffs report of the clients pain as well as overhearing the client discuss hip pain may well be an observation of pain, but they are not the most conclusive of the options because the client is aware of being observed. DIF: C REF: 240 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. When obtaining subjective assessment data, the nurse recognizes which of the following client scenarios as being the most likely to produce accurate, credible information? 1 A 50-year-old in the ED reporting chest pain 2 A 70-year-old admitted with fever of unknown origin WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 A 81-year-old receiving follow-up treatment for a hip replacement 4 A 22-year-old being treated at a clinic for a sexually transmitted disease ANS: 3 This option where the 81-year-old is receiving follow-up treatment for a hip replacement presents a client who is not necessarily experiencing pain, embarrassment, guilt, or any other emotion/factor that would inhibit the free communication of subjective symptom data. The 50year-old client is experiencing pain; this is likely to inhibit the communication process. The 70year-old client is febrile; this could interfere with the communication process, especially for an older adult because it may cause confusion and the 22-year-old client may be experiencing guilt and/or embarrassment; both may interfere with the communication process. DIF: C REF: 234 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurses mentor? 1 Conducting the interview with the clients boyfriend present 2 Stopping the interview to answer a page from the nursing station 3 Frequently checking the time while waiting for the client to answer 4 Heard asking the client, Am I correct; youve rated your pain a 9 out of 10? ANS: 3 Clients are less likely to fully reveal the nature of their health care problems when nurses show little interest, appear rushed, or are easily distracted by activities around them. As long as the nurse had the clients permission, this would not require follow-up. While interrupting an assessment is not recommended, a page is an example of an acceptable exception and so this would not require follow-up. If the nurse were confirming the information, it would not require follow-up. If the mentor felt the nurse was questioning the validity of clients pain rating, a follow-up would be appropriate because a clients pain rating should not be questioned. DIF: C dm 234 OBJ: Analysis TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. Which of the following assessment data provided by a clients family will have the greatest impact on the clients care while hospitalized? 1 2 Mom falls asleep fastest with the television on. Dad starts off the day with hot coffee; it regulates his bowels. 3 My wifes sister died 4 months ago, and she is still grieving over her loss. 4 My husband doesnt like to let people know his arthritis is bothering him. ANS: 4 Family and friends can make important observations about the clients health status, changes, and needs that can affect the way care is delivered. Being aware of the clients reluctance to discuss his pain will impact the frequency and way his pain is assessed. While this information will affect the way the staff prepares the client for sleep, it does not have priority over pain assessment. While this information will allow the staff to meet the clients morning coffee need, it does not have priority over pain assessment. While this information will affect the way the staff address the clients emotional needs, it does not have priority over pain assessment. DIF: C dm 237 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. What is the most appropriate method for the nurse to communicate a clients wishes to the nurses on the next shift? 1 Document the request in the nursing notes. 2 Include the clients request in the shift report. 3 Place instructions regarding the clients wishes above the clients bed. 4 Verbally inform the unit clerk of the clients request. ANS: 2 In the acute care setting, the change-of-shift report is the way for nurses from one shift to communicate information to nurses on the next shift Documenting the request in the nursing notes is not appropriate for inclusion in the nursing notes because it does not reflect information regarding the clients condition, response to treatment, or current health status. Placing the instructions regarding the clients wishes above the bed is not appropriate because there is no guarantee that staff will see the posting, but more importantly there are confidentiality issues WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material being ignored. While verbally informing the unit clerk of the clients request may result in the clients wishes being respected, it is not the most effective option. DIF: C dm 234-235 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. While discussing a clients medication history, the client tells the nurse that she thinks she is allergic to a particular type of medication. Which of the following nursing actions has priority in this situation? 1 Note the allergy on the clients Kardex. 2 Inform the provider of the clients possible allergy. 3 Review the clients medical record for confirmation of the allergy. 4 Tell the client to have all medications identified before taking them. ANS: 3 The medical record is a valuable tool for checking the consistency and similarities of personal observations. Information such as a history of allergic reactions would be found in the medical record. Noting the allergy on the clients Kardex would be appropriate only after the allergy is confirmed; although if there was true concern, a notation of a possible allergy should be noted on the medication record. Informing the provider of the clients possible allergy would be appropriate after the medical record was reviewed and no mention of the allergy was confirmed or denied. While telling the client to have all medications identified before taking them is a safety measure appropriate for all clients, it is not the priority in this situation. DIF: C dm 235 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. The nurse realizes that in order to share information from a clients medical record with another facility, the client must provide written consent. The primary reason for this requirement is to: 1 Facilitate the exchange of information between appropriate parties 2 Minimize the opportunity for this information to be assessed inappropriately WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Ensure the clients right to have his medical information regarded as personal and confidential 4 Guarantee that the information will be shared with only those requiring it for client care purposes ANS: 3 Educational, military, and employment records may contain significant health care information. You need written permission from the client or guardian to access or transfer the records. Any information you obtain is confidential, and you treat it as part of the clients legal medical record. This process recognizes the clients right to confidentiality. The other three options, facilitating the exchange of information, ensuring the clients rights to have his medical information regarded as personal and confidential as well as guaranteeing the sharing of information will be only when required for client care purposes are outcomes of the process but not the primary reason for the consent. DIF: C dm 235-236 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. The nurse recognizes that a clients hearing deficits impact the development of the nurseclient relationship. Which of the following has the greatest impact on minimizing this obstacle? 1 2 Speaking slowly, clearly, and in a normal tone Using various forms of nonverbal communication 3 Relying heavily on touch to convey caring and interest 4 Involving family in discussions concerning meeting clients needs ANS: 2 When a client has limited hearing or visual deficits, it becomes more important for a nurse to use nonverbal communication when establishing nurse-client relationships. Speaking slowly, clearly and in a normal tone may make verbal communication more effective, but it will not have the greatest positive impact of the offered options. Relying heavily on touch is only one form of nonverbal communication that can positively impact the development of the relationship. While involving family in discussions may help in the identification of client needs, it does not necessarily have positive impact on developing a healthy nurse-client relationship. DIF: C dm 236 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 32. Which of the following questions will provide the nurse with the best understanding of a terminally ill clients spiritual needs? 1 2 3 4 Do you have a religious preference? Have you given thought to your spiritual needs? Is there a particular clergy you would like to visit with? Are there any spiritual needs you have that I may help with? ANS: 4 In asking if there are any spiritual needs that the client might need help with, you collect information about life goals, values, and religious practices; part of a clients spirituality. This option provides the client with an opportunity to discuss his needs if indeed he has any while reaffirming the nurses wish to meet his needs. Asking simply is a client has a religious preference is a closed-ended question and provides little encouragement to discuss spiritual needs. While asking if the client has given thought to their spiritual needs provides an opportunity to discuss any client needs, it does not allow for the nurse to be of help with attending to these needs. Inquiring about a particular clergy is a closed-ended question and provides little encouragement to discuss spiritual needs. DIF: C dm 237 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following statements made by the nurse should be included in the orientation phase of a nursing interview? (Select all that apply.) 1 Youre answers will be kept confidential. 2 My name is Susan Smith and Im a registered nurse. 3 We are here to make your hospitalization as pleasant as possible. I need to ask you some questions that will help with planning your care. 4 5 6 Only those directly involved in your care will have access to this information. If there is anything you need or help you require simply use your call bell and someone will be right in. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 1, 2, 4, 5 The orientation phase begins with you introducing yourself and your position and explaining the purpose of the interview. Explain to clients why you are collecting data (e.g., for a nursing history or for a focused assessment) and assure them that any information obtained will remain confidential and will be used only by health care professionals. The statements We are here to make your hospitalization as pleasant as possible and I need to ask you some questions that will help with planning your care are more appropriate for the termination phase. DIF: C dm 241 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression? (Select all that apply.) 1 2 My work environment would depress anyone. It seems like almost anything can make me cry. 3 Being here away from my family makes me sad. 4 I just cant seem to get excited about anything anymore. 5 The family always thought that my father was depressed. 6 I like winter because I can just cover up on the couch and sleep. ANS: 4, 5 I just cant seem to get excited about anything anymore and The family always thought that my father was depressed. Remember to always have supporting cues before you make an inference. These options relate a broad lack of interest in life and a family history of depression. While mentioning My work environment would depress anyone as a depressing situation, this option does not infer personal depression. While mentioning It seems like almost anything can make me cry as a potential sign of depression, this option is not a strong inference because crying can be a result of other emotions. While mentioning Being here away from my family makes me sad notes sadness, this option describes a normal reaction to being separated from loved ones. While mentioning I like winter because I can just cover up on the couch and sleep shows withdrawal behaviors, this option is not a strong inference because winter often evokes stay-at-home tendencies in people. DIF: C dm 241 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3. The goal of the orientation phase of a nursing interview is to: (select all that apply) 1 Initiate the nurse-client relationship 2 Begin identifying the clients needs Earn the trust and confidence of the client 3 4 5 Assume the decision role for the client Welcome the client to the nursing unit 6 Gather the clients demographic information ANS: 1, 2, 3 Initiating the nurse-client relationship, beginning to identify the clients needs and earning the clients trust and confidence. During the orientation phase you establish trust and confidence with a client. One important goal for the initial interview is to make the foundation for understanding the clients primary needs. Another is to begin a relationship that allows the client to become an active partner in decisions about care. As the orientation phase proceeds, the client should begin to feel more comfortable speaking with you so the necessary information can be obtained. Assuming the decision role isnt correct as the client should be involved in all care decisions; assuming this role is not appropriate. While welcoming the client to the nursing unit is an expected outcome of the orientation phase of the interview process, it is not a goal. While gathering the clients demographic information is an expected outcome of the orientation phase of the interview process, it is not a goal. Chapter 17. Nursing Diagnosis MULTIPLE CHOICE 1. The nurse uses nursing diagnoses after completion of the client assessment, because they: 1 Are required for accreditation purposes 2 Identify the domain and focus of nursing 3 Assist the nurse to distinguish medical from nursing problems 4 Make all client problems become more quickly and easily resolved ANS: 2 After completing the client assessment, the nurse develops nursing diagnoses based on the data obtained. Nursing diagnoses distinguish the nurses role from that of the physician, and nursing diagnoses help nurses to focus on the role of nursing in client care. Although most state nurse practice acts include nursing diagnosis as part of the domain of nursing practice, nursing diagnoses are not required for accreditation purposes. Medical problems are identified with medical diagnostic statements to treat a disease condition. Nursing diagnoses describe the clients WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material actual or potential response to a health problem that the nurse is licensed and competent to treat. Nursing diagnoses distinguish the nurses role from that of the physician. Nursing diagnoses may facilitate communication among health professionals, but they do not necessarily allow all client problems to become more quickly and easily resolved. DIF: A dm 248 OBJ: Knowledge TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the clients weight, the nurse also considers the age and height. This is an example of: 1 2 3 4 Defining the client problem Recognizing gaps in data assessment Comparing data with normal health patterns Drawing conclusions about the clients response ANS: 3 The nurse uses scientific knowledge and experience to analyze and interpret data collected about the client. This includes comparing the data with norms. The nurse is comparing data to determine if there is a problem. A problem has not yet been identified. The nurse is not recognizing gaps in data assessment. An example of a gap in data assessment would be if the clients weight had not been measured. The nurse has not drawn a conclusion about the clients response. The nurse must first compare the data with normal health problems to be able to arrive at a conclusion. DIF: A dm 249 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1 Acute pain related to left mastectomy 2 Impaired gas exchange related to altered blood gases 3 Deficient knowledge related to need for cardiac catheterization 4 Need for high protein diet related to alteration in client nutrition ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material This nursing diagnosis is written correctly. It defines a problem and its etiology. In this case the problem is the clients response to a diagnostic test. A medical diagnosis should not be recorded as the etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state acute pain related to impaired skin integrity secondary to mastectomy incision. This nursing diagnosis is written incorrectly because it uses supportive data of the problem as the etiology. This nursing diagnosis does not identify the problem and etiology. It identifies the clients goal rather than the problem. It could be reworded as imbalanced nutrition: less than body requirements related to inadequate protein intake. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1 2 Risk for change in body image related to cancer Cardiac output decreased related to motor vehicle accident 3 Ineffective airway clearance related to increased secretions 4 Potential for injury related to improper teaching in the use of crutches ANS: 3 Ineffective airway clearance related to increased secretions is written appropriately. It identifies a problem using a NANDA International diagnostic statement and connects it to its etiology. Risk for change in body image related to cancer is written incorrectly. It uses a medical diagnosis for the etiology. Cardiac output decreased related to motor vehicle accident is written incorrectly. The etiology is not treatable. Potential for injury related to improper teaching in the use of crutches is written incorrectly. It identifies the nurses problem, not the clients. DIF: A dm 250 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 5. The nurse has diagnosed the clients problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except: 1 Poor fiber intake 2 Limited fluid intake 3 Total hip replacement 4 Lower abdominal discomfort WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 3 Total hip replacement because the medical diagnosis requires medical interventions, it is legally inadvisable to use it in the nursing diagnosis. Rather, the nurse should identify the clients response, such as decreased mobility. The nurse should be able to provide nursing interventions that will treat the etiology. Poor fiber intake would be an appropriate etiology for the problem of altered elimination. Limited fluid intake would be an appropriate etiology for the nursing diagnosis of altered elimination. Lower abdominal discomfort is an appropriate etiology for the nursing diagnosis of altered elimination. DIF: A dm 248 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur? 1 2 Impaired gas exchange Decreased cardiac output 3 Ineffective airway clearance 4 Impaired spontaneous ventilation ANS: 1 A potential etiology for impaired gas exchange may be atelectasis. Atelectasis would not support the diagnostic label for decreased cardiac output. Atelectasis would not be an etiology for ineffective airway clearance. Increased tenacious sputum production would be a possible etiology for ineffective airway clearance. Impaired spontaneous ventilation would not be an appropriate diagnostic label for atelectasis. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses? 1 The diagnosis should identify a cause and effect relationship. 2 The diagnosis must remain constant during the clients hospitalization. The etiology of the diagnosis must be within the scope of the health care teams practice. 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 The diagnosis should include the problem and the related contributing conditions. ANS: 4 The diagnosis should include the problem and the related contributing conditions is a true statement. Related factors are causative or other contributing conditions that have influenced the clients actual or potential response to the health problem and can be changed by nursing interventions. The nursing diagnosis does not identify a cause and effect relationship; rather, it indicates that the etiology contributes to or is associated with the clients problem. The nursing diagnosis does not have to remain constant during the clients hospitalization. It should change according to changes in the patient. The etiology or cause of the nursing diagnosis must be within the domain of nursing practice and a condition that responds to nursing interventions, not those of the entire health care team. DIF: A dm 253 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse: 1 Validates the assessment information in the data base 2 Uses the NANDA International list of diagnoses as a primary source 3 Formulates a diagnosis too closely resembling a medical diagnosis Distinguishes the nursing focus instead of other health care disciplines 4 ANS: 3 A nursing diagnosis should identify the clients response, not the medical diagnosis. Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. A nurse should validate assessment data for accuracy and understanding. Using the NANDA International list of diagnoses as a source helps to ensure accuracy. One purpose the nursing diagnosis serves is to distinguish the nurses role from that of the physician. Another purpose is to help nurses focus on the role of nursing in client care. Nursing diagnoses promote understanding between nurses regarding clients health problems. DIF: A dm 248 OBJ: Knowledge TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 9. Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences. 1 2 3 4 Altered speech As evidenced by Recent neurological disturbances Inability to speak in complete sentences ANS: 4 Defining characteristics are assessment findings that support the nursing diagnosis. In this example, the inability to speak in complete sentences supports the nursing diagnosis of altered speech. Altered speech is the diagnostic label identifying the problem. As evidenced by is a connecting statement for the problem and the defining characteristics. Recent neurological disturbances is the etiology. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. The primary purpose of a nursing diagnosis, according to the nurses, is to: 1 Support the medical plan of care 2 Provide a standardized approach for all clients 3 Recognize the clients response to an illness or situation 4 Offer the nurses subjective view of the clients behaviors ANS: 3 The primary purpose of a nursing diagnosis is to recognize the clients response to an illness or situation. The nurse can then use the nursing diagnosis to select appropriate nursing interventions to achieve positive client outcomes. A nursing diagnosis is based on the client, not on the medical plan of care. Although nursing diagnoses may facilitate communication, it does not mean they provide a standardized approach for all clients. Nursing diagnoses are individualized to meet the clients needs. The primary purpose of nursing diagnoses is not to offer the nurses subjective view of the clients behaviors. Nursing diagnoses are based on subjective and objective client data and should not include the nurses personal beliefs and values. DIF: A dm 248 OBJ: Knowledge TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. Which one of the following is an appropriate etiology for a nursing diagnosis? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Myocardial infarction 2 3 Cardiac catheterization Abnormal blood gas levels 4 Increased airway secretions ANS: 4 Increased airway secretions is a condition that responds to nursing interventions and therefore would be an appropriate etiology for a nursing diagnosis. Myocardial infarction would not be an appropriate etiology for a nursing diagnosis because it is a medical diagnosis. Nursing interventions will not alter the medical diagnosis of myocardial infarction. Cardiac catheterization is a diagnostic procedure and would not be an appropriate etiology for a nursing diagnosis. Rather, the clients response to the procedure would be the area of nursing concern. Abnormal blood gas levels would not be an appropriate etiology for a nursing diagnosis because it is not a causative factor, but rather it is a defining characteristic of a problem. DIF: A REF: 253-254 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. Which of the following is an appropriate etiology for a nursing diagnosis? 1 Incisional pain 2 Poor hygienic practices 3 Need to offer bedpan frequently Inadequate prescription of medication 4 ANS: 1 Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies the cause of a clients response to a health problem, and a condition that a nurse can treat or manage. Poor hygiene practices would not be an appropriate etiology for a nursing diagnosis because it insinuates a nurses prejudicial judgment. Need to offer bedpan frequently is not an appropriate etiology because it identifies a nursing intervention, not an etiology. Inadequate prescription of medication by the physician is not an appropriate etiology because it identifies the nurses problem, not the clients problem. The nursing diagnosis should center attention on client needs. DIF: A dm 253-254 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 13. Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1 2 3 4 Diarrhea related to food intolerance Alteration in comfort related to pain Risk for impaired skin integrity related to poor hygiene habits Potential complications related to insufficient vascular access ANS: 1 Diarrhea related to food intolerance is a correctly written nursing diagnosis. It consists of a problem related to an etiology, and it is a condition that nursing interventions can treat or manage. Alteration in comfort related to pain is not written correctly because it is a circular statement. It would be appropriate to state ineffective breathing pattern related to incisional pain. Risk for impaired skin integrity related to poor hygiene habits is not written correctly because it uses a nurses prejudicial judgment. It would be more appropriate and professional to state risk for impaired skin integrity related to knowledge about perineal care. Potential complications related to insufficient vascular access is not written appropriately because it identifies a nursing problem, not a clients problem. It would be appropriate to state risk for infection related to presence of invasive lines. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1 Anxiety related to cardiac monitor 2 Pain related to difficulty ambulating 3 Chronic pain related to insufficient use of medication 4 Bedpan required frequently as a result of altered elimination pattern ANS: 3 Chronic pain related to insufficient use of medication is an example of an appropriately written nursing diagnosis. It consists of a diagnostic label and the associated etiology. Nursing interventions can be directed at treating or managing the behavior of insufficient medication use. Anxiety related to cardiac monitor is written incorrectly because it identifies the equipment rather than the clients response to the equipment. It would be appropriate to state deficient knowledge regarding the need for cardiac monitoring. Pain related to difficulty ambulating is not WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material written correctly. What could be a defining characteristic is used as an etiology. This nursing diagnosis could be rewritten more appropriately as impaired mobility related to pain as evidenced by difficulty ambulating. Or it could be an inaccurate diagnostic label and could be rewritten as anxiety related to difficulty in ambulating. Bedpan required frequently as a result of altered elimination pattern is written incorrectly because it identifies a nursing intervention, not the clients problem. It could be reworded as diarrhea related to food intolerance. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. Based on the following information, what would the nurse identify as the most appropriate nursing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate. 1 Risk for injury 2 3 Excess fluid volume Ineffective airway clearance 4 Impaired spontaneous ventilation ANS: 3 The defining characteristics of abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate cue the nurse to the nursing diagnosis of ineffective airway clearance. Risk for injury does not support the diagnostic label of risk for injury. Excess fluid volume does not support the diagnostic label of excess fluid volume. There would be other defining characteristics such as edema, weight gain, and an elevated blood pressure. Impaired spontaneous ventilation does not most accurately describe impaired spontaneous ventilation. Other characteristics, such as apnea, would better support the diagnostic label of impaired spontaneous ventilation. DIF: A dm 252 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. Which one of the following is a NANDA International nursing diagnosis label? 1 Frequent urination 2 Coughing and dyspnea 3 Risk for impaired parenting Abnormal hygienic care practices 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 3 Frequent urination is a symptom, not a NANDA International nursing diagnosis label. Coughing and dyspnea are symptoms, not a NANDA International nursing diagnosis label. Risk for impaired parenting is a NANDA International nursing diagnosis label. Abnormal hygienic care practices is not a NANDA International nursing diagnosis label. It incorrectly implies a nurses prejudicial judgment. DIF: A dm 251 OBJ: Knowledge TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. When asked to define Nursing Diagnosis the nurses best response is: 1 It is the second step in the Nursing Process. 2 It is the process of defining a clients problems. 3 It correlates a clients problem with a condition a nurse is competent to treat. 4 It focuses care a licensed nurse can provide with the identified needs of a client. ANS: 3 It correlates a clients problem with a condition a nurse is competent to treat is a statement that describes the clients actual or potential response to a health problem that the nurse is licensed and competent to treat. Although It is the second step in the Nursing Process is true, it does not define the term. Although It is the process of defining a clients problems is true, is does not address the nursing aspect of the term. Although It focuses care a licensed nurse can provide with the identified needs of a client is true, the focus is not primarily on care. DIF: C dm 248 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. The nurses initial responsibility in the management of a clients collaborative problem is to: 1 Monitor for changes 2 Advocate for the client 3 Implement interventions 4 Evaluate client outcomes ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Nurses initially monitor to detect the onset of changes in a clients status. Although advocating for the client is a nursing role, it is not reserved exclusively to collaborative problems. Implement interventions is not the initial responsibility. Evaluate client outcomes is not the initial responsibility. DIF: C dm 248 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 19. The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the clients anxiety regarding the procedure? 1 2 Assure the client that preoperative sedation will be administered. Discuss the pre- and postprocedure care that will be provided. 3 Provide a detailed explanation of why the procedure is necessary. 4 Guarantee that family will be regularly updated during the procedure. ANS: 2 A nursing diagnosis focuses on a clients actual or potential response to a health problem rather than on the physiological event, complications, or disease. In the case of the diagnosis deficient knowledge regarding surgery, the nurse will best minimize anxiety by providing information regarding pre- and postoperative routines so as to facilitate the client in formulating realistic expectations. Although the other options are appropriate, they are limited in scope and do not have as much impact on anxiety. DIF: C dm 249 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 20. The nursing diagnosis of acute pain falls under which of the following comfort domain classifications? 1 Social comfort 2 Physical comfort 3 Interpersonal comfort Environmental comfort 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 There are only three classifications for the comfort domain. Acute pain is a physiological response and so is classified as a physical comfort problem. Impaired verbal communication is considered a social comfort issue, while at risk for poisoning would be considered an environmental comfort issue. DIF: A dm 251 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. When asked to define the purpose of diagnostic reasoning, the best nursing response is: 1 Diagnostic reasoning is the foundation of the second step of the nursing process; Nursing Diagnosis. 2 The diagnostic reasoning process flows from the assessment process and includes decision-making steps. 3 Diagnostic reasoning includes data clustering, identifying client needs and formulating the diagnosis or problem. 4 Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis. ANS: 4 Diagnostic reasoning is a process of using the assessment data gathered about a client to logically explain a clinical judgment, in this case a nursing diagnosis. The remaining options do not describe purpose but rather identify outcomes of diagnostic reasoning. DIF: C dm 253 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 22. A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client. Which of the following responses by the clinical instructor is most instructional? 1 After defining the clients symptomatology, eliminate those nursing diagnoses that are not supported by the database. 2 Assess your client and then select the nursing diagnosis that has the greatest number of observable defining characteristics. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable. 4 With experience you will become skilled at identifying the defining characteristics of a nursing diagnosis in your client. Until that time use a nursing diagnosis book to help in the selection process. ANS: 3 After assessing the client, always examine the defining characteristics in your database carefully to support or eliminate a nursing diagnosis. Although the other options are correct, they do not provide as concise an explanation as after assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable. DIF: C dm 252 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 23. A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, what the diagnosis means. Which of the following rationales best supports the nurses determination that the client has knowledge deficit rather than a readiness for enhanced knowledge? 1 2 The client initiated the question. This is a new diagnosis for the client. 3 The client identified a lack of understanding. 4 Type 2 diabetes mellitus is a complicated disease process. ANS: 2 Although all the options are accurate, this is a new diagnosis for the client best reflects the need for knowledge because the client had no previous experience with the condition and so had a true knowledge deficit. DIF: C dm 252 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 24. Which of the following responses best reflects an understanding of the purpose of the related to phrase attached to the diagnostic label deficient knowledge regarding postoperative routines? 1 To focus on the cause of the clients needs WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 To identify the etiology of the clients diagnosis 3 To provide for individualization of the nursing interventions To communicate the clients deficits to the nursing staff 4 ANS: 3 The inclusion of the related to phrase requires you to use critical thinking skills to individualize the nursing diagnosis and then select personalized nursing interventions. Although the other options are not incorrect, they do not reflect the best understanding of the purpose of the phrase, To provide for individualization of the nursing interventions is the correct answer. DIF: C dm 253 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 25. Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process? 2 Paternal family history of osteoarthritis has been reported. Client is observed grimacing when walking to bathroom. 3 Right knee appears edematous when compared to left knee. 4 Client rated the pain felt after walking at a 6 on a scale of 1 to 10. 1 ANS: 2 To collect complete, relevant, and correct assessment data it helps to identify assessment activities that produce specific kinds of data. When possible, the nurse should collect objective data because they are often more supportive than subjective data. Observation of the clients response to the use of the affected joint is the most supportive of the options. DIF: C dm 254 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 26. Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor? 1 I can tell when my Hispanic clients are in pain. 2 Moaning is a classic sign of pain in most cultures. 3 All clients will tell you when they need pain medication. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Chronic pain is difficult to manage especially for the stoic individual. ANS: 3 Nurses who are not familiar with how a particular culture or developmental group expresses pain can often miss the objective signs or assume there is a lack of pain when familiar signs are absent. Being culturally and developmentally aware and sensitive will improve your accuracy in making nursing diagnoses. All clients will tell you when they need pain medication is the correct answer. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 27. Which of the following statements best reflects the nurses understanding of the primary nursing-related purpose of a concept map? 1 To facilitate holistic nursing care 2 To provide visualization of the clients health problems 3 To assist in the identification of client-oriented nursing diagnoses To demonstrate the relationship between the clients various health problems 4 ANS: 4 Concept mapping is one way to graphically represent the connections between concepts and ideas that are related to a central subject (e.g., the clients health problems). Although the other options are correct, they do not provide the best understanding of the purpose of concept mapping in nursing practice as well as to demonstrate the relationship between the clients various health problems. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 28. Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept map to client care? 1 Concept maps help me see the whole client, not just individual health problems. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Concept maps can be easily edited to reflect a clients ever changing health needs. 3 I need help organizing my assessment data and concept mapping is really good for that. I like concept mapping because it helps me focus on how the disease processes affect the client. 4 ANS: 1 The advantage of a concept map is its central focus on the client rather than the clients disease or health alteration, thus concept maps help me see the whole client, not just individual health problems is the correct answer. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 29. A client expresses concern over a scheduled intravenous pyelogram by stating, I dont know what to expect. Which of the following nursing diagnoses is most appropriate for this client need? 2 Anxiety related to scheduled diagnostic testing Knowledge deficit regarding need for diagnostic testing 3 Knowledge deficit related to need for intravenous pyelogram 4 Anxiety related to lack of knowledge concerning intravenous pyelogram 1 ANS: 4 Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself. The client need, identified by the statement, is not related to the necessity for the test but concern over a lack of knowledge about what to expect before, during, and after the test. The remaining options fail to identify a client need. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 30. Which of the following assessment findings best supports the nursing diagnosis of Pain in right knee joint related to degenerative process? 1 Paternal family history of osteoarthritis reported WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Client observed grimacing when walking to bathroom. 3 Right knee appears edematous when compared to left knee Client rated the pain felt after walking at a 6 on a scale of 1-10 4 ANS: 2 To collect complete, relevant, and correct assessment data it helps to identify assessment activities that produce specific kinds of data. When possible, the nurse should collect objective data, because it is often more supportive than subjective data. Observation of the clients response to the use of the affected joint is the most supportive of the options. DIF: C dm 254 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 31. Which of the following statements best reflects the nurses understanding of the primary nursing related purpose of a concept map? 2 To facilitate holistic nursing care To provide visualization of the clients health problems 3 Assist in the identification of client-oriented nursing diagnoses 4 Demonstrate the relationship between the clients various health problems 1 ANS: 4 Concept mapping is one way to graphically represent the connections between concepts and ideas that are related to a central subject (e.g., the clients health problems). While the other options are correct they do not provide the best understanding of the purpose of concept mapping in nursing practice. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance 32. Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept mapping to client care? 1 Concept maps help me see the whole client, not just individual health problems 2 Concept maps can be easily edited to reflect a clients everchanging health needs. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 I need help organizing my assessment data and concept mapping is really good for that. 4 I like concept mapping because it helps me focus on how the disease processes affect the client ANS: 1 The advantage of a concept map is its central focus on the client rather than the clients disease or health alteration. DIF: C dm 255 OBJ: Analysis TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Research has shown that which of the following nursing skills is best strengthened through the use of concept mapping? (Select all that apply.) 1 Client teaching related to health and wellness topics 2 Evaluation of client outcomes in regards to nursing care 3 Identification of patterns in the clients health assessment data 4 Recognition of relationships among the clients various health issues 5 Planning specialized nursing interventions to meet a clients health needs Facilitating assessment data collection through observation and communication 6 ANS: 2, 3, 4, 5 Concept mapping significantly improved students abilities to see patterns and relationships as well as to organize, plan, and evaluate nursing care. Client teaching and assessment collecting are not markedly affected by concept mapping. Chapter 18. Planning Nursing Care MULTIPLE CHOICE 1. The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to prioritizing her request? 1 Low priority WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 An unmet need 3 Intermediate priority A safety and security need 4 ANS: 1 The clients request would be of low priority because it is not directly related to a specific illness or prognosis. An unmet need is not the most appropriate label for the clients request. The clients request is not an intermediate priority. An intermediate priority is one that involves the nonemergent, nonlife-threatening needs of the client. The clients request is not a safety and security need; the outcome does not threaten her well-being. DIF: A dm 262 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 2. Assuming that all of the following are realistic, a long-term goal for a client that is a tailor by trade and has been admitted for eye surgery should include: 1 Returning to sewing 2 Preventing ocular infection 3 Administering eye drops on time in the hospital 4 Performing independent hygienic care in the hospital ANS: 1 Long-term goals focus on prevention, rehabilitation, discharge, and health education. An appropriate long-term goal for this client would be for rehabilitation and the clients return to occupation, in this case sewing. Preventing ocular infection is a short-term goal. A short-term goal is expected to be achieved within a short time, usually in less than 1 week. In 1 weeks time, the clients risk for infection should be greatly reduced. Administering eye drops on time in the hospital is a short-term goal. Long-term goals are usually designed for problem resolution after discharge, especially from an acute care setting. Performing independent hygienic care in the hospital is a short-term goal. Long-term goals are usually made for problem resolution after discharge, especially from an acute care setting. DIF: A dm 265 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 3. The nurse writes the following goal for a client who is hypertensive: Client will maintain a blood pressure within acceptable limits. Which of the following would be the most appropriate outcome criterion? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Client will request pain medication as needed. 2 Client will experience no headache or dizziness. Client will identify at least two things that cause stress. 3 4 Client will have a 7 AM blood pressure reading less than 140/90. ANS: 4 Client will have a 7 AM blood pressure reading less than 140/90 would be the most appropriate outcome criterion. It is client-centered, singular, observable, measurable, time-limited, and realistic. Client will request pain medication as needed does not allow the nurse to be able to determine if change has taken place. It would be more measurable to state the client will rate pain below 4 on a scale of 0 to 10 by 24 hours. Client will experience no headache or dizziness is not time-limited. Client will identify at least two things that cause stress is not time-limited or singular. DIF: A dm 266 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 4. Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated? 1 Teaching a client to administer his or her insulin injection 2 Assisting a new mother with learning the art of breast-feeding 3 Notifying the nutritionist of a clients specific dietary preferences 4 Administering a cleansing enema in preparation for radiological testing ANS: 4 Preparing a client for a diagnostic test is an example of a physician-initiated intervention. Teaching a client to administer his or her insulin injection is an example of a nurse-initiated intervention. Assisting a new mother with breast-feeding is an example of a nurse-initiated intervention. Notifying a nutritionist of a clients dietary preferences is a collaborative intervention. DIF: A dm 268 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 5. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The intervention statement Nurse will apply warm, wet soaks to the patients leg while awake lacks which of the following components? 1 2 3 4 Method Quantity Frequency Performing staff ANS: 3 The intervention statement does not include how frequently the warm soaks should be applied. The method is applying warm, wet soaks to the patients leg while awake. The quantity is warm, wet soaks. The qualification of the person who will perform the action is the designation of the nurse. DIF: A dm 273 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 6. In order that they are clear and easily understood by other members of the health care team, the nurse recognizes that client goals or outcomes should be documented according to specific criterion. Of the following, the outcome statement that best meets the established criteria is: 1 Client will describe activity restrictions. 2 Client will verbalize understanding of treatments. 3 Client will be ambulated in hallway 3 times each day. Clients respiratory rate will remain within 20 to 24 breaths per minute by 9/24. 4 ANS: 4 Clients respiratory rate will remain within 20 to 24 breaths per minute by 9/24 is a correctly written outcome statement. It is client-centered, singular, observable, measurable, time-limited, and realistic. Client will describe activity restrictions is not time-limited. Client will verbalize understanding of treatments is not observable or time-limited. The client will state the purpose of the breathing treatments by 4/10 would be more appropriate. Client will be ambulated in hallway 3 times each day is not client-centered. A correct outcome statement would be Client will ambulate in the hall 3 times a day. DIF: A dm 267 OBJ: Comprehension WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 7. The client is receiving postural drainage from physical therapy and intermittent breathing treatments from respiratory therapy. Which type of care plan would be the ideal method to document interventions for this client? 1 Nursing Kardex 2 3 Computerized care plan Critical pathway 4 Standardized care plan ANS: 3 Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type. The nursing Kardex is a card-filing system that allows quick reference to the particular needs of the client for certain aspects of nursing care. A computerized care plan is a standardized care plan on the computer. A standardized care plan is a prewritten plan created for a specific nursing diagnosis or clinical problem. The nurse individualizes the care plan for the clients needs. DIF: A dm 274 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 8. The nurse is involved in requesting a management consultation for personnel-related issues. Which of the following is true regarding the consultation process in which the nurse is involved? 1 The problem area should be totally delegated to the consultant. 2 Consultation is often used when the exact problem remains unclear. 3 The problem area is identified by any member of the health care team. 4 Feelings about the problem should be described to the consultant by the nurse. ANS: 2 Consultation is appropriate when the nurse has identified a problem that cannot be solved using personal knowledge, skills, and resources, or when the exact problem remains unclear. A consultant objectively entering a situation can more clearly assess and identify the exact nature of the problem. The whole problem is not turned over to the consultant. The consultant is not there to take over the problem but is there to assist the nurse in resolving it. The person WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material requesting the consult usually identifies the problem area. The nurse should not bias the consultant with subjective and emotional conclusions about the client and problem. DIF: A dm 276 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 9. In completing an assessment on an assigned client, the nurse obtains important information for planning nursing care. Which of the following client needs should take priority? 1 2 3 4 Difficulty breathing Financial problems A nutritional deficit An impending divorce ANS: 1 Difficulty breathing would be the highest priority client need. In general, priorities that protect clients basic needs of safety, adequate oxygenation, and comfort are considered high priority. Financial problems are a low-priority client need. Financial problems are not directly related to a specific illness or prognosis but may affect the clients future well-being. A nutritional deficit is an intermediate priority client need. It involves a nonlife-threatening need of the client. An impending divorce is a low-priority client need. It is a need that is not directly related to a specific illness or prognosis but may affect the clients future well-being. DIF: C dm 262 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 10. The nurse recognizes that client goals or outcomes should be documented according to specific criterion in order that they are clear and easily understood by other members of the health care team. Of the following, the outcome statement that best meets the established criteria is the following: 1 Vital signs will return to within normal levels for a middle aged adult. 2 Nursing assistant will ambulate the client in the hallway 3 times each day. 3 Lungs will be clear to auscultation and respiratory rate will be 20/minute. Output will be at least 100 mL/hour of clear yellow urine within 24 hours. 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 4 Output will be at least 100 mL/hour of clear yellow urine within 24 hours. is client-centered, singular, observable, measurable, time-limited, and realistic. Vital signs will return to within normal levels for a middle aged adult. is not measurable (i.e., guidelines for normal are not stated), and it is not time-limited (e.g., by when?). Nursing assistant will ambulate the client in the hallway 3 times each day. is not client-centered. Lungs will be clear to auscultation and respiratory rate will be 20/minute. is not singular and it is not time-limited. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 11. In goal setting, the nurse is aware that the factor that is associated with available client resources and motivation is: 1 Realistic 2 Observable 3 Measurable 4 Client-centered ANS: 1 The nurse sets realistic goals that can be achieved. This increases the clients motivation. The nurse also takes available resources into consideration in order to set realistic goals. Being observable means the nurse must be able to determine through observation if change has taken place. Being measurable means the goal is written so the nurse has a standard against which to measure the clients response to nursing care. Being client-centered means the goal should reflect the clients behavior and responses expected as a result of nursing interventions. DIF: A dm 267 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 12. Nursing interventions may be categorized based upon the degree of nursing autonomy. An example of a nurse-initiated intervention is: 1 Providing client teaching 2 Administering medication 3 Ordering a liver CAT scan 4 Referring a client to physical therapy WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 1 Health teaching is an example of a nurse-initiated intervention. Administering medication is a physician-initiated intervention. Ordering a CAT scan is a physician-initiated intervention. Referring a client to physical therapy is a collaborative intervention. DIF: A dm 267-268 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 13. Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated? 1 Taking vital signs 2 Providing support to a family 3 Changing a dressing 2 times each day 4 Measuring intake and output each shift ANS: 3 Changing a dressing is a physician- or prescriber-initiated intervention. Taking vital signs is a nurse-initiated intervention. Providing support to a family is a nurse-initiated intervention. Measuring intake and output is a nurse-initiated intervention. DIF: A dm 268 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 14. Which one of the following interventions selected by the nurse is classified as Level 2, Domain 2 (Physiological: complex)? 1 Maintaining regular bowel elimination 2 Promoting the health of the entire family 3 Managing severely restricted body movement Restoring tissue integrity to areas damaged by friction 4 ANS: 4 Interventions to maintain or restore tissue integrity are classified as Level 2, Domain 2 (Physiological: Complex). Maintaining regular bowel elimination is classified as Level 2, Domain 1 (Physiological: Basic). Promoting the health of the family is classified as Level 2, Domain 5 (Family). Managing restricted body movement is classified as Level 2, Domain 1 (Physiological: Basic). WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A dm 270 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 15. In documentation of nursing care plans, critical pathways differ from traditional nursing care plans in their: 1 2 Client outcomes Client assessment 3 Nursing interventions 4 Multidisciplinary approach ANS: 4 Critical pathways are multidisciplinary. They allow staff from all disciplines, such as medicine, nursing, pharmacy, and social work, to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type. Client outcomes are included in both critical pathways and traditional nursing care plans. Client assessment is necessary for developing and evaluating critical pathways and traditional nursing care plans. Nursing interventions are included in critical pathways and in the traditional nursing care plan. DIF: A dm 274 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 16. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is: 1 Offer fluids to the client q2h 2 Observe the clients respirations 3 Change the clients dressing daily 4 Irrigate the nasogastric tube q2h with 30 ml normal saline ANS: 4 Irrigate the nasogastric tube q2h with 30 ml normal saline is the most appropriate intervention statement. It includes the action, frequency, quantity, and method. Offer fluids to the client q2h lacks the component of quantity. Observe the clients respirations fails to indicate the frequency or method. Also, what is the reason for observation of the clients respirations? Change the clients dressing daily omits the method. DIF: C dm 267 OBJ: Analysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 17. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is the following: 1 Take vital signs. 2 3 Refer client to a therapist. Turn client as needed while in bed. 4 Apply two 4 4 dry gauze dressing pads tid. ANS: 4 Apply two 4 4 dry gauze dressing pads tid. is the most appropriate. It identifies the action, frequency, quantity, and method. Take vital signs. fails to indicate the frequency and fails to completely indicate nursing actions (e.g., what parameters are used to notify the physician). Refer client to a therapist. fails to completely indicate nursing interventions (e.g., what type of therapist). Turn client as needed while in bed. fails to state an accurate frequency or precisely indicate the nursing actions. DIF: A dm 267 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 18. Care plans created by nursing students usually differ from those that are completed by nurses working on client units. An aspect of the plan that is usually included in the students care plan but not in the clients record is: 1 Client outcomes 2 Nursing diagnoses 3 Scientific rationales Nursing interventions 4 ANS: 3 An aspect of a nursing care plan that is usually included in the students care plan, but not in the clients record, is scientific rationales. Client outcomes are included in both student care plans and the clients record. Nursing diagnoses are included in both student care plans and the clients record. Nursing interventions are a component of both student care plans and a nursing care plan in the clients record. DIF: A dm 271 OBJ: Knowledge WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 19. The purpose and distinction of a concept map, which a nurse may use when implementing a plan of care, are for: 1 2 Multidisciplinary communication Quality assurance in the health care facility 3 Provision of a standardized format for client problems 4 Identification of the relationship of client problems and interventions ANS: 4 A concept map is a diagram of client problems and interventions that shows their relationship to one another. Multidisciplinary communication is enhanced with the use of critical pathways, not concept maps. The use of a concept map promotes critical thinking and helps nurses to organize complex client data, process complex relationships, and achieve a holistic view of the clients situation. The purpose is not quality assurance in the health care facility. Standardized or computerized care plans provide a standardized format for client problems, not the concept map. A concept map is highly individualized. DIF: A dm 274 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 20. A client is newly diagnosed with diabetes mellitus. The nurse identifies a nursing diagnosis of knowledge deficient related to new diagnosis and treatment needs. The most appropriate outcome statement based upon the established criteria is the following: 1 Client will perform glucose measurements often. 2 Client will appear less anxious regarding diagnosis. 3 Urinary output will reach normal young adult levels. Client will independently perform subcutaneous insulin injection by 8/31. 4 ANS: 4 Client will independently perform subcutaneous insulin injection by 8/31. is the most appropriate outcome statement. It addresses the nursing diagnosis by identifying a singular outcome the client can realistically achieve, is observable, and provides a time frame. Client will perform glucose measurements often. does not specify a time frame. Client will appear less anxious regarding diagnosis. is not an appropriate outcome statement. There is no specific behavior WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material observable for will appear. Urinary output will reach normal young adult levels. is not an appropriate outcome statement. It does not provide a standard against which to measure the clients response to nursing care, and therefore is not measurable. It is also not time-limited. DIF: A REF: 267 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 21. Which of the following is the best example of an intermediate prioritized client need for a client diagnosed with risk of injury related to poor skin integrity? 1 Applying adequate clothing to ensure the clients warmth 2 Providing sufficient quantities of an aloe-based skin lotion 3 Helping the client select her favorite foods from the menu form 4 Dressing the clients feet in non-skid soled slippers when ambulating ANS: 2 An intermediate priority is one that involves the non-emergent, nonlife-threatening needs of the client. Having sufficient aloe-based lotion is required for maintaining good skin integrity but is not required for meeting a life-threatening need. Although the other options are an intermediate need, they are not the best option because they are not directly related to the clients stated nursing diagnosis. DIF: C dm 262 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 22. Which of the following would be the best example of a short-term safety goal for a client who recently experienced abdominal surgery? 1 The client will show no systemic or local signs of infection by time of discharge from hospital. 2 The client will demonstrate an understanding of the proper use of patient-controlled analgesia (PCA). The client will demonstrate effective coughing and deepbreathing techniques within 2 hours of surgery. 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 The client will consistently use the call bell to notify the staff of a need for assistance to the bathroom upon return to the nursing unit. ANS: 4 Although all the options represent short-term goals, this option (consistently use the call bell to notify the staff) is directly related to client safety because it deals with fall prevention. Although this is short-term goal (by time of discharge), it is not as directly related to safety as some other options. Although this is short-term goal (time is inferred by nature of pain needs), it is not as directly related to safety as some other options. Although this is short-term goal (2 hours), it is not as directly related to safety as some other options. DIF: C dm 265 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 23. Which of the following would be the most appropriate outcome criterion for the goal, Clients pain will be managed to within an acceptable level within 30 minutes of receiving pain medication. 1 Client will deny presence of any pain or discomfort. 2 Client will rate pain at a level of 3 or less out of a possible 10. 3 Client will demonstrate ability to request pain medication as needed. Client will identify two external factors that decrease presence of pain. 4 ANS: 2 Client will rate pain at a level of 3 or less out of a possible 10 would be the most appropriate outcome criterion because it is directly related to the management of pain levels as reflected by the pain scale. Client will deny presence of any pain or discomfort does not necessarily reflect a reasonable goal. Although client will demonstrate ability to request pain medication as needed is directed towards pain management, it does not have the primary focus that evaluating the pain management intervention has. Client will identify two external factors that decrease presence of pain is not the best option because it does not directly relate to pain management but the identification of contributing factors. DIF: C dm 266 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 24. The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in the morning. Which of the following client needs should take priority? 1 2 3 4 Inventory of clothes and other personal belongings Orientation to the nursing unit and individual room Interview regarding medications currently being taken Assessment of body systems for presurgery checklist ANS: 2 The clients admission has no acute physical needs and so the emotional need of familiarization with the environment has priority. Inventory of clothes and other personal belongings does not reflect a priority because it does not relate directly to a physical need, and there are other emotional needs of higher priority. Interview regarding medications currently being taken does not reflect a priority because it does not relate directly to a physical need, and there are emotional needs of higher priority. Although assessment of body systems for presurgery checklist reflects a needed nursing action, it is not a priority because it does not relate directly to physical need, and there are other emotional needs of higher priority. DIF: C dm 262 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 25. Which of the following outcomes, made by a nurse planning care for a client recently fitted with a hearing aid, best reflects an understanding of short-term client education goals? 1 Client will properly clean the hearing aid ear piece daily with soap and water. 2 Client will state 3 positive effects of wearing his hearing aid at follow-up appointment. 3 Client will wear hearing aid while awake to help improve his ability to understand instructions. Client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today. 4 ANS: 4 Although all the options represent short-term goals, client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today is directly related to patient education because it relates to the proper care of the hearing aid. Client will properly clean the hearing aid ear piece daily with soap and water does not directly relate to client education but more to an expected client action. The goal does not include a time limit for compliance. Although client WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material will state 3 positive effects of wearing his hearing aid at follow-up appointment may be a shortterm goal (depends on time of next appointment), it is not as directly related to client education as it is compliance-oriented. Although client will wear hearing aid while awake to help improve his ability to understand instructions may be a short-term goal, although there is no time limit, it is not as related to client education as some other options. DIF: C dm 262-263 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 26. Which of the following statements made by a new nursing graduate best reflects an understanding of expected outcomes? 1 It gives the client something positive to strive towards. 2 They are statements of how the clients behavior should change. 3 They are measurable criteria by which I can evaluation whether a goal has been achieved. 4 They provide the client with suggestions on how to achieve their long and short term goals. ANS: 3 They are measurable criteria by which I can evaluation whether a goal has been achieved. It is necessary to use expected outcomes or measurable criteria to evaluate goal achievement. Although outcomes are directed at times toward the alteration of client behavior, They are statements of how the clients behavior should change. is not the best option provided to reflect an understanding of the term. It gives the client something positive to strive towards and They provide the client with suggestions on how to achieve their long and short term goals are incorrect as outcomes are nursing-oriented, not client-oriented. DIF: C dm 266 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 27. A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the following statements best reflects an understanding of client-centered goals? 1 The clients A1C levels will be 7 or below at the first testing date. 2 The client will experience no blood sugar readings below 60 mg/dL before first follow up visit. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 The client will be visited weekly by home health nursing staff beginning 1 week after discharge. 4 The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit. ANS: 4 A client-centered goal is a specific and measurable behavior or response that reflects a clients highest possible level of wellness and independence in function, therefore The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit is correct. Although The clients A1C levels will be 7 or below at the first testing date and The client will experience no blood sugar readings below 60 mg/dL before first follow up visit are appropriate, they are not the best options because they do not reflect independence in function. The client will be visited weekly by home health nursing staff beginning 1 week after discharge is not client-centered because it does not reflect a clients highest possible level of wellness and independence in function. DIF: C dm 267 OBJ: Evaluation TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 28. The expected outcome that best evaluates the presurgical goal of, Client will understand purpose of coughing and deep breathing within 4 hours of returning to room is: 1 Client will demonstrate proper technique for coughing and deep breathing 2 Client will cough and deep breathe every 1 hour while awake without staff prompting 3 Client is capable of restating the purpose of coughing and deep breathing in own words 4 Clients lungs will be free of abnormal breath sounds within 1 hour of being returned to room ANS: 2 An expected outcome is a criteria designed to evaluate the achievement of the stated goal. This option best represents evaluation of the clients understanding of the purpose of deep breathing and coughing because it shows appropriate compliance. Although demonstration evaluates the proper technique, it is not the best option to evaluate understanding of purpose. Although restatement evaluates understanding, it is not the best option to evaluate understanding of WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material purpose because it does not include client compliance. The clients lungs being free of abnormal breath sounds within 1 hour is more reflective of a goal than of an expected outcome. DIF: C dm 266 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 29. Which of the following statements made by the nurse best reflects an understanding of the clients role in goal setting? 1 2 He knows what he needs better than anyone else. When he sets the goals he is more likely to follow the plan. 3 He identifies the goals and then together we create the plan of action. 4 He is best suited to determine the level of effort he is capable of providing. ANS: 4 Unless you set goals mutually and make a clear plan for action, clients will not follow the care plan. Clients alone are not always appropriately prepared to set and plan goals without professional help. Although the other answers may be true for many clients, it is not a guarantee that the client possesses all the skills and knowledge necessary to set and plan realistic goals. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 30. A nurse is caring for a client who experienced short-term memory loss as a result of a head injury. Which of the following statements made by the nurse regarding goal setting requires follow-up by the nurse manager? 1 The client will certainly need frequent reorientation to the care plan goals. 2 I will restate the goals Ive created for him regularly so as to win his compliance. 3 Im not sure that his family will be able to support him with these goals but I will discuss it with them. He seems very willing to work towards achieving his goals but his condition will certainly create barriers. 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 If a client or significant other is not able to participate in goal development, you assume responsibility until the client is able to participate. It is vital that to the degree that the client is capable, the client be included in the decision-making process. Frequent reorientation to the care plan goals may be true and so does not require follow-up. The nurse seems pessimistic about the familys ability to play a role in the clients care plan but declares that an attempt will be made to include them; so follow-up is not an immediate priority. The client seems very willing to work towards achieving his goals may be true and so does not require follow-up because there is no indication of the nurses intention to minimize his participation. DIF: C dm 265 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 31. Which of the following goals best shows that the nurse understands the concept of a clientcentered goal? 1 2 Client will consume at least 75% of each meal served. ADLs will be completed before breakfast is served. 3 Pain will be managed so as to be rated at 3 or less out of 10. 4 Client will be transported to physical therapy by 9 AM daily. ANS: 1 Client will consume at least 75% of each meal served is correct. Outcomes and goals reflect the clients behavior and responses expected as a result of nursing interventions. Write a goal to reflect client behavior, not to reflect your goals or interventions. The other options are nursingcentered. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 32. Which of the following client-centered goals best rest reflects singular focus? 1 Client will cough and deep breathe every hour while awake. 2 Client will be free of shoulder and elbow pain by discharge. 3 Client will adhere to a low-fat diet and lose 3 pounds in 30 days. 4 Client will ambulate to the bathroom for the purpose of showering daily. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 4 Each goal and outcome addresses only one behavior or response. In this case the client will walk to the shower daily. Although coughing and deep breathing are usually done as a unit, they are really two separate actions. The client being free of shoulder and elbow pain by discharge relates to two different anatomical locations. Adhering to a diet and losing 3 pounds are two different actions. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 33. The nurse realizes that goals should be singular in focus primarily because: 1 The nurse will find it difficult to modify the plan of care if the goals are not met. 2 The client may not have the strength to accomplish multiply behavioral changes. The client may have difficulty focusing on more than one behavioral modification at a time. 3 4 The nurse will find it difficult to identify appropriate interventions to address multiple behaviors. ANS: 1 The nurse finding it difficult to modify the plan of care if the goals are not met is correct. Singularity allows you to decide if there is a need to modify the plan of care because only one response is considered. Although the other answers may be true, they are not the primary reason for having only one focus per goal. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 34. Which of the following goals concerning client anxiety is the best example of measurability? 1 Client will be less anxious by discharge. 2 Client will appear less anxious by discharge. 3 Client will report anxiety at less than 3 out of 5 by discharge. Client pulse rate and blood pressure will be within normal limits by discharge. 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 3 You need to be able to observe if change takes place in a clients status. Observable changes occur in physiological findings and the clients knowledge, perceptions, and behavior. You observe outcomes by directly asking clients about their condition or by using assessment skills. The client rating his anxiety is one method of observing improvement. The phrase will be less anxious is not observable. The phrase will appear less anxious is not observable. Although pulse rate and blood pressure may be affected by anxiety, there is no assurance that normal readings reflect an improvement. DIF: C dm 267 OBJ: Anxiety TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 35. Which of the following goals best reflects measurability? 1 2 Clients emotional state will be stable by time of discharge. Client will experience normal sensations in feet by discharge. 3 Client will report being free of shoulder pain by discharge. 4 Client will have acceptable range of motion in elbow by discharge. ANS: 3 Terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely. Pain free relates to quantity as well as quality. Do not use vague qualifiers such as normal, acceptable, or stable in an expected outcome statement. Vague terms result in guesswork in determining a clients response to care. DIF: C dm 267 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 36. When developing appropriate nurse-initiated interventions for a client admitted to an acute care facility for abdominal pain, the nurse must first consider: 1 The institutions policies and procedures 2 The states defined scope of nursing practice 3 The clients physiological and psychological needs 4 The scientific rationale for the proposed nursing action ANS: 2 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Each state within the United States has developed a Nurse Practice Act that defines the legal scope of nursing practice (see Chapter 22). According to the Nurse Practice Act in a majority of states, independent nursing interventions pertain to activities of daily living, health education and promotion, and counseling. Although the other answers must be considered, they are not the first consideration. DIF: C dm 268 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 37. The nurse realizes that the primary nursing responsibility regarding a physician-initiated intervention is to: 1 2 Facilitate the intervention in a timely manner Evaluate the clients response to the intervention 3 Possess the technical skills required to implement the intervention 4 Provide client education regarding the implementation of the intervention ANS: 3 Each physician-initiated intervention requires specific nursing responsibilities and technical nursing knowledge. Although the other options are expectations, they are not the primary consideration. DIF: C dm 268 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance 38. The primary function of a care plan is to provide: 1 The client with continuity of care 2 The staff with written client-centered nursing interventions 3 An established criteria for the evaluation of nursing outcomes An organized means of exchanging information between caregivers 4 ANS: 1 The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care. Although the rest are functions, they are not the primary function. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C dm 269 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which of the following characteristics are considered guidelines for the writing of appropriate goals and outcomes? (Select all that apply.) 1 2 Singular Realistic 3 Practical 4 Observable 5 Measurable 6 Meaningful ANS: 1, 2, 4, 5 There are seven guidelines for writing goals and expected outcomes. The guidelines are clientcentered, singular, observable, measurable, time-limited, mutual, and realistic. Practical and meaningful are not recognized characteristics Chapter 19. Implementing Nursing Care MULTIPLE CHOICE 1. The nurse is working with postoperative clients on a surgical unit. One aspect of care is manipulation of the clients environment. This involves the nurse: 1 Repositioning the client q2h 2 Removing clutter from the clients room 3 Delegating ambulation of clients to the nursing assistant 4 Providing pain medication to the client before a dressing change ANS: 2 Making rooms free of clutter is an example of manipulating the environment to create safe surroundings. The remaining options are examples of the organization of care and personnel. DIF: A dm 282 OBJ: Comprehension TOP: Nursing Process: Implementation WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The client is given an injection of an antibiotic. Shortly afterwards the client reports hives and itching. The nurse administers an antihistamine to counteract the effect of the antibiotic. The nurse is using which one of the following intervention methods? 1 Preventive measures 2 Assisting with ADLs 3 Preparing for special procedures 4 Compensation for adverse reactions ANS: 4 Nursing actions that control for adverse reactions reduce or counteract the reaction, such as administering an antihistamine after an allergic reaction to a medication. Preventive measures promote health and prevent illness while assisting with ADLs and preparing for special procedures are direct care measures. DIF: A dm 283-284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning laboratory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the Coumadin. Which step of the implementation process is she using? 1 Reassessing the client 2 Stating an expected outcome 3 Revising the nursing diagnosis 4 Modifying the nursing care plan ANS: 4 The nurse is modifying the nursing care plan. Data have been updated to reflect the clients current status of an elevated PTT; nursing diagnoses and specific interventions are revised. In this case, the revised intervention is withholding the Coumadin. By gathering further assessment data and revising nursing interventions, the nurse is modifying the nursing care plan. DIF: A dm 282 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4. The nurse notes that a narcotic is to be administered per epidural cath. The nurse; however, does not know how to perform this procedure. Which aspect of the implementation process should be followed? 1 Seek assistance 2 3 Reassess the client Use interpersonal skills 4 Critical decision making ANS: 1 If a nurse does not know how to perform a procedure, he or she should seek assistance. Information about the procedure is obtained from the literature and the agencys procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly and safely provides assistance and guidance. Reassessing the client is a partial assessment that may focus on one dimension of the client or on one system. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the client, family, and health care team. Critical decision making is used when the nurse implements the care plan using the knowledge bases necessary for care planning and then completing the planned interventions most effectively. DIF: A dm 284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. The nurse recognizes the discharge needs of a client following a hip replacement. This is an example of which type of nursing skill? 1 Cognitive 2 Interactive 3 Psychomotor 4 Communication ANS: 1 Cognitive skills involve the application of nursing knowledge. Being able to identify a clients discharge needs is a cognitive skill. Interactive skills are interpersonal skills such as developing a trusting relationship and communicating effectively. Psychomotor skills involve the integration of cognitive and motor skills such as with administering an injection. Effective communication is an interpersonal skill. The nurse communicates with the client and family when providing client teaching and emotional support. The nurse communicates with the health care team to achieve client outcomes. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A dm 284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. An example of a cognitive nursing skill is: 1 2 Providing a soothing bed bath Communicating with the client and family 3 Giving an injection to the client per the physicians orders 4 Recognizing the potential complications of a blood transfusion ANS: 4 Cognitive skills involve the application of nursing knowledge. Understanding normal and abnormal physiological and psychological responses is a cognitive skill, as in recognizing the potential complications of a blood transfusion. Providing a soothing bed bath involves both interpersonal skills and psychomotor skills. The nurse who provides a soothing bed bath is expressing a level of caring that is an interpersonal skill. The nurse who provides a soothing bed bath is also using a psychomotor skill in performing the bed bath correctly. Communicating with the client and family is an example of an interpersonal skill. Giving an injection to the client is a psychomotor skill. DIF: A dm 284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. An enterostomal nurse shows a clients significant other how to assist with the supplies for the ostomy and how to manipulate the ostomy equipment. In demonstrating this technique to the clients significant other, the nurse is using what type of nursing skill? 1 Affective 2 Cognitive 3 Interactive Psychomotor 4 ANS: 4 Psychomotor skills involve the integration of cognitive and motor activities, such as in providing ostomy care. Cognitive skills involve the application of nursing knowledge. Knowing the rationale for therapeutic interventions, understanding normal and abnormal physiological and psychological responses, and being able to identify client learning and discharge needs all require cognitive skills. Interpersonal skills are used when the nurse interacts with clients, their WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material families, and other health care team members. Effective communication is an example of an interpersonal skill. Affective means pertaining to an emotion or mental state. DIF: A dm 284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm casts, the nurse should select which of the following methods of nursing intervention? 1 2 3 4 Teaching Counseling Compensating for adverse reactions Assisting with activities of daily living (ADLs) ANS: 4 A client with bilateral arm casts has a temporary need for assistance with ADLs. Counseling is a direct care method that helps the client use a problem-solving process to develop new attitudes and feelings. It does not meet the physical need for assistance with ADLs. Teaching is an implementation method used to present correct principles, procedures, and techniques of health care to clients and to inform clients about their health status. Compensating for adverse reactions means the nurse takes action to reduce or counteract the reaction, such as by administering an antihistamine when a client has an allergic reaction to a medication. Assisting with ADLs would be compensating for the clients impaired mobility. DIF: A dm 285 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The plan of care offers a number of different types of nursing interventions that may be incorporated in. An example of a nurse implemented specific life-saving measure is: 1 Administering analgesics 2 Restraining a violent client 3 Initiating stress-reduction therapy Teaching the client how to take his/her pulse rate 4 ANS: 2 Restraining a violent client is an example of a life-saving measure to protect the client. The purpose of a life-saving measure is to restore physiological or psychological equilibrium. Administering analgesics is an example of physical care techniques. It is not a life-saving WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material measure. Initiating stress-reduction therapy is an example of a counseling technique. Teaching the client how to take his or her pulse rate is an example of the nursing intervention of teaching. The focus is for the client to obtain new knowledge or psychomotor skills. DIF: A dm 285 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. To provide optimum care, a nursing intervention should be based on: 1 2 3 4 An appropriate nursing diagnosis Subjective and objective client data Sound clinical judgment and knowledge Identified physical and psychosocial needs of the client ANS: 3 The assessment data direct the nurse in the formulation of a client-specific care plan grounded within clear, relevant nursing diagnoses and directed towards appropriate, attainable client outcomes. A nursing intervention is any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes. Ideally, the interventions a nurse uses are evidence-based, providing the most current, up-to-date, and effective approaches for client problems. Interventions include both direct and indirect care measures, aimed at individuals, families, and/or the community. DIF: C dm 279 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which of the following interventions is the best example of an indirect intervention directed towards client safety? 1 Checking on a restrained client every 15 minutes 2 Performing hand hygiene between client contacts 3 Including the diagnosis at risk for injury related to falls to a clients care plan Turning on a night light to illuminate the path to the bathroom 4 ANS: 4 Indirect care interventions are treatments performed away from the client but on behalf of the client or group of clients. For example, indirect care measures include actions for managing the clients environment (e.g., safety and infection control), documentation, and interdisciplinary WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material collaboration. Directly impacting the light level in a clients room to minimize the risk for falls is the best example of a safety-oriented indirect care intervention. Including a nursing diagnosis regarding falls would also be an example of an indirect care intervention but it is not as actively affecting the clients safety. Checking a restrained client is a direct care intervention because it involves actual client contact, while performing hand hygiene is directed more towards infection control than safety. DIF: C dm 287 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. Which of the following interventions best reflects the nurses understanding of direct care interventions regarding a cognitively impaired clients need for social interaction? 1 Arranging for the client to attend a sing along in the dayroom 2 Helping the client place a long distance telephone call to his daughter 3 Turning the clients television on when his or her favorite program is playing 4 Talking about the clients favorite sports team while redressing his or her wound ANS: 4 Direct care interventions are treatments performed through interactions with clients. Actively engaging in a conversation with the client is the best direct care intervention and so demonstrates the best understanding of the concept. Facilitating interaction does not have as much impact as being actively involved. Turning on the TV is an example of an indirect care intervention. DIF: C dm 285 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The primary reason for the establishment of standing orders is to: 1 Provide appropriate nursing autonomy in settings where client needs can change rapidly 2 Facilitate adequate care when direct contact with a primary health care provider is not immediately possible 3 Allow nurses to provide certain routine therapies without first notifying the primary health care provider WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Afford the client interventions that reflect the appropriate standard of care in the absence of a primary health care provider ANS: 1 Licensed prescribing physicians or health care providers in charge of care at the time of implementation approve and sign standing orders. These orders are common in critical care settings and other specialized practice settings where clients needs change rapidly and require immediate attention, thus providing for nursing autonomy to assess and implement appropriate care. DIF: C dm 281 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. Which of the following statements best reflects the nurses understanding of the function of client reassessment? 1 The clients blood pressure is lower this morning than it was yesterday morning. 2 30 minutes after receiving his pain medication, the client evaluated his pain at 3 out of 10. 3 Turning the client every 2 hours has helped in the healing of the pressure ulcer on his coccyx. 4 Since the client has been ambulating to the bedroom without difficulty, Ill walk with him to the dayroom after dinner. ANS: 4 When reassessment results in the collection of new data that identify a new client need, the care plan is modified. Modification of a plan also occurs when a clients health care need shows improvement or is resolved. The other options reflect recognition of a change in the clients condition but do not reflect an alteration of the care plan. DIF: C dm 281-282 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. Which of the following statements made by a nurse practitioner best reflects an understanding of the availability of clinical practice guidelines? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Clinical guidelines are so very helpful in providing the most up-to-date nursing care. 2 Im sure we could get a team together and develop a pressure ulcer prevention protocol or search sites for established protocols. I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site. 3 4 Im told that for gerontological issues, the Gerontological Nursing Interventions Research Center (GNIRC) is the primary resource site. ANS: 3 There are clinical practice guidelines already developed by national health groups. These guidelines are readily available to any clinician or health care institution that wishes to adopt evidence-based guidelines in the care of clients with specific health problems. The best option reflects the nurses personal experience with a published protocol. DIF: C dm 281 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. The fundamental goal for the development of a protocol for care of a client who has had a myocardial infarction client is to: 1 Implement care that has its basis in evidence-based practice 2 Produce care plans that are specific to the individual client needs Improve the standard of care provided to the clients cared for on that unit 3 4 Provide the staff on that unit with guidelines to ensure the delivery of quality care ANS: 3 Clinicians within a health care agency sometimes choose to review the scientific literature and their own standard of practice to develop guidelines and protocols in an effort to improve their standard of care. All the other options are potential outcomes of the implementation of a protocol. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C dm 281 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which of the following nursing actions is most likely a result of the nurses clinical experience? 1 Placing an immobile client on a turning schedule 2 Always assessing a clients IV site before hanging a new bag of fluid 3 Requesting that the nursing assistant have vital signs recorded by 0815 4 Administering a pain medication 30 minutes before changing a burn dressing ANS: 2 As a nurse gains clinical experience, he or she will be able to consider which interventions have worked previously, which have not, and why. The decision to check each IV site has become a practice standard for this nurse as a result of previous experiences with IV sites. The remaining options are either standards of care or facility/unit standards. DIF: C dm 280 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. Which of the following statements made by a new nursing graduate requires immediate follow-up by the nurses mentor? 1 Older clients with arthritis require additional time to complete to complete their own AM care. 2 My clients wife says he loves chocolate milk so I will order his dietary supplement in chocolate. 3 My client just received some bad news regarding her tests. Ill see if the chaplain can visit this evening. Teenage diabetics seem to have a more difficult time making good food choices in order to control their blood sugars. 4 ANS: 3 The nurse delivers each intervention within the context of a clients unique situation. It is an assumption that a client who has received bad news would want a visit from a clergy member. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The other options represent statements relating to normal characteristics of a specific development stage, condition, or preference. DIF: C dm 279 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. A client reports to the nurse that the room is too hot. Which of the following nursing actions best reflects the nurses understanding of the therapeutic manipulation of the clients environment? 1 Bringing a portable fan into the room 2 Assisting the client in the removal of excess clothing 3 Offering to ambulate the client into the visiting lounge 4 Closing the blinds to minimize the sunshine through the windows ANS: 1 Although closing the blinds may manipulate the environment, it will always minimize the ambient light in the room. Cooling the room by introducing the fan will not impact any other aspect of the environment. It may not be appropriate for the client to remove clothing and leaving the room is only a temporary solution to the problem. DIF: C dm 282 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following statements made by a new graduate nurse regarding the modification of a clients care plan requires immediate follow-up by the nurses preceptor? 1 I will review the care plan before I do my charting. 2 The client prefers to bathe at night, so thats what Ill do. 3 I gave her a bed bath this morning, but she could really manage showering herself. 4 The order reads clear liquids, but I hear good bowel sounds and shes really hungry. ANS: 4 With the assessment data supporting advancement in diet, the new graduate should initiate a modification of the clients nursing care plan because this directly impacts the clients nutritional status. Although facilitating client independence is appropriate, this option does not have priority WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material over the option impacting nutrition. The other options do not involve modification of the care plan. DIF: C dm 282 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following statements regarding utilization of personnel made by a new graduate nurse requires immediate follow-up by the nurses mentor? 1 My LPN is really good with dressings, so I usually delegate them to her. 2 I always take the time to ambulate a post op client the first time out of bed. 3 I always try to help my nursing assistant with the clients who require a total bed bath. 4 I have my nursing assistant take and document all vital signs and intake and outputs. ANS: 4 The nurse is responsible for determining whether to perform an intervention or to delegate it to another member of the nursing team. Assessment of a client directs the decision about delegation and not the intervention alone. Vital signs are important indicators of a clients health status and the task should be delegated to ancillary personnel only when the client is in a stable condition; otherwise, the nurse should be responsible. The other options reflect responsible assignment of personnel. Chapter 20. Evaluation MULTIPLE CHOICE 1. The client smokes two packs of cigarettes per day. The nurse works with the client, and they agree that he will smoke one cigarette less each week until he is down to one pack per day. In 3 weeks, the client is smoking two and a half packs of cigarettes per day. This is an example of: 1 A realistic goal 2 A compliant client 3 A negative evaluation A nonmeasurable goal 4 ANS: 3 This is an example of a negative evaluation. During evaluation, the nurse is able to determine that the client has not met the expected outcome of decreasing smoking by one cigarette each WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material week but rather has increased his smoking. This is not an example of a realistic goal. It is an example of the evaluation step of the nursing process. The client is noncompliant. The goal is measurable. During evaluation, the nurse determines if expected outcomes are met in order to judge if goals have been met. DIF: A REF: 291 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. The evaluation statement would be: 1 2 3 4 Goal met; client able to state three symptoms Goal not met; client able to list three symptoms Goal not met; client unable to list five symptoms Goal partially met; client able to state three symptoms ANS: 4 The client is showing changes but does not yet meet criteria set; therefore, the goal is partially met. The clients response, being able to state three symptoms, does not meet or exceed the outcome criteria of being able to state five symptoms. The clients response, being able to list three symptoms, demonstrates some change. If the client were showing no progress, then the goal would not be met. If the client were showing no progress, then the goal would not be met. However, this clients response does indicate some change. DIF: A dm 296 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The nurse begins to auscultate the clients lungs. While listening, the nurse notices fresh bloody drainage oozing from the abdominal dressing. The nurse stops auscultating and applies direct pressure to the wound site. This is an example of: 1 Performing a nursing assessment 2 Reorganizing the nursing diagnoses 3 Implementing nursing interventions 4 Critically analyzing client assessment data ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The nurse who stops auscultating lung sounds to take measures to stop noticeable bleeding is analyzing data presented. This is demonstrated by the nurse setting priorities and effectively implementing the safest nursing action. The nurse is doing more than performing a nursing assessment. The nurse is taking action based on new assessment data. The nurse is not reorganizing nursing diagnoses. The nurse is implementing the priority nursing action. This is not an example of setting realistic goals and implementing nursing interventions. Applying direct pressure to a wound site to stop bleeding demonstrates critical analysis of the data and implementation of the safest nursing action. DIF: A dm 298 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. The client is able to ambulate without signs or symptoms of shortness of breath. Which statement by the nurse is the best example of an objective evaluation of the clients goal attainment? 1 Client has no pain after ambulating. 2 Client has no manifestations of nausea while up in hall. Client walked well and did not have any problem when up. 3 4 Client has no evidence of respiratory distress when ambulating. ANS: 4 Client has no evidence of respiratory distress when ambulating is the best example of an objective evaluation of the clients goal attainment. It uses the same evaluative measures gathered during assessment and clearly describes objective data. Client has no pain after ambulating does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not pain. If the clients pain level were going to be used as an evaluative measure, it would be optimal to have the client report the pain using a pain scale to make it more measurable for comparison. Client has no manifestations of nausea while up in hall is not the best example of an objective evaluation of the clients goal attainment. It does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not nausea. Also, nausea is more subjective. Client walked well and did not have any problem when up is not the best example of an objective evaluation. It includes the nurses interpretation rather than documentation of objective data. DIF: A dm 294 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 5. When modifying a care plan to meet a client whose status has changed significantly over the past few days, the nurse should: 1 2 Redevelop the entire client care plan Focus on changing the nursing diagnoses and goals 3 Perform a complete reassessment of all client factors 4 Add more nursing interventions from a standardized plan of care ANS: 3 A complete reassessment of all client factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. After reassessment the nurse will determine what components of the care plan are accurate for the situation. It may not require redoing the entire care plan. The nurse should not only focus on the nursing diagnoses and goals that have changed. Interventions may also need revising to meet new goals. Adding more nursing interventions may or may not be necessary. The nurse adjusts interventions on the basis of the clients response and previous experience with similar clients. Standards of care are used to determine whether the right interventions have been chosen or whether additional ones are required. DIF: A dm 297 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. Based on the following outcome criterion determined by the nurse: Client will independently complete necessary assessments prior to administration of digoxin (cardiotonic) the nurse will evaluate the clients ability to: 1 Assess the respiratory rate 2 Palpate the radial pulse 3 Review dietary habits Inspect color of the skin 4 ANS: 2 The nurse should compare the established outcome criteria with the clients behavior or response. In this case the client is expected to independently complete the necessary assessments before administration of digoxin. The client should be able to palpate the radial pulse as an assessment before administration of digoxin. The outcome criterion does not state anything about exercise. During evaluation, the nurse is to judge the degree of agreement between the outcome criteria and the clients behavior. The outcome criterion does not state anything about diet. Evaluating whether the client reviews dietary habits would not be comparable to necessary assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material before medication administration. The outcome criterion does not state anything about the skin. The nurse, who knows that digoxin is a cardiotonic, understands that the client should be assessing the heart rate. DIF: A dm 291 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. The nurse has determined the following outcome for a client with a skin impairment: Erythema will be reduced in 3 days. Evaluation will specifically focus on: 1 Selection of appropriate wound care 2 3 Notation of the odor and color of drainage Inspection of the color and condition of the area 4 Measurement of the diameter of the ulceration daily ANS: 3 Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspection of the color of the skin, as stated in the outcome criterion. Selection of appropriate wound care is an intervention, not an evaluation of a clients behavior or response. The outcome criterion does not state anything about drainage. Noting the color and amount of drainage may be a part of reassessment of the client, but is not what the nurse is evaluating according to this outcome criterion. The outcome criterion states the erythema will be reduced, not the size of the ulceration. During the evaluation step of the nursing process, the clients behavior or response should be compared to the outcome criterion and judged for degree of agreement between the two. DIF: A dm 294 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. The client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus upon the clients: 1 Respiratory rate 2 Complaint of chest pain 3 Lungs clear bilaterally on auscultation Ability to perform incentive spirometry 4 ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Auscultating lung sounds is the best way to determine if airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement. Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine if airways are free of secretions. A complaint of chest pain would be a negative outcome, and it is not the focus for determining whether airways are free of secretions as written in the outcome statement. Having the ability to perform incentive spirometry does not determine whether the airways are clear or not. It is an intervention that may help achieve clear airways. DIF: A dm 294 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. A client shares with the nurse that they have, almost reached the goal of smoking only one-half pack of cigarettes a day. The best example of a nursing intervention to correct this unmet outcome is: 1 Discuss with the client the desire to comply with the ordered therapy 2 Suggest that the client use another smoking cessation tool to achieve the goal 3 Reevaluate the time frame originally decided upon for achievement of the goal 4 Suggest that the strength of the prescribed nicotine patches be increased to 21 mg ANS: 4 An unmet outcome reveals the client has not responded to interventions as planned. As a result, the nurse changes the plan of care by trying different therapies or changing the frequency or approach of existing therapies. The best option is one that adds to the existing therapy. The remaining options should have been explored as a part of the goal-setting process or exercised if the current therapy proves ineffective. DIF: C dm 296 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. The primary purpose of the nursing evaluation process is to: 1 Determine the effectiveness of the nursing care provided 2 Identify interventions that are ineffective in achieving client goals WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Establish the progress the client is making towards health and wellness 4 Critique the nurses ability to implement appropriate nursing interventions ANS: 1 The evaluation process determines the effectiveness of nursing care. The remaining options are all examples of evaluation but do not reflect the primary purpose of nursing evaluation. DIF: C dm 291 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which of the following statements best reflects a goal based on a clinical standard of practice? 1 2 Client will lose 10 pounds in 90 days. Client will walk 30 feet with minimal assistance. 3 Clients peripheral intravenous site will be free of redness. 4 Clients chronic pain will be managed with oral medication by discharge. ANS: 3 Goals often are also based on standards of care or guidelines established for minimal safe practice. Prevention of acquired infection is a standard of practice; the remaining options reflect client-specific goals. DIF: C dm 293 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. Which of the following outcomes best reflects a nurse-sensitive client outcome? 1 Client will consume 75% of all meals. 2 Client will perform personal hygiene daily. 3 Client will experience no falls during hospitalization. 4 Client will report lessened anxiety regarding surgical procedure. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 3 A nurse-sensitive client outcome is a measurable client or family state, behavior, or perception largely influenced by and sensitive to nursing interventions. The nurse is instrumental in the prevention of falls while the remaining options are dependent on the client. DIF: C dm 293 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The nurse has identified a nursing diagnosis of knowledge deficit regarding the need to monitor blood glucose levels daily. Which of the following statements best reflects the clients understanding of the need for therapy? 1 Client agrees to test blood glucose levels 4 times a day. 2 Client records blood glucose levels for a 3-week period. 3 Client is observed testing his blood glucose level before breakfast. 4 Client is able to demonstrate the proper technique for performing a finger stick. ANS: 2 During the planning phase of the nursing process it is important for you to select an observable client state, behavior, or self-reported perception that will reflect goal achievement. The actual written result of regular blood glucose monitoring is the best indicator of the clients understanding of the importance of regular testing. The remaining options may show initial willingness or ability to perform the test but do not show consistent compliance. DIF: C dm 293 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. Which of the following nursing notes demonstrates the best evaluation of nursing interventions regarding the care provided? 1 Pressure ulcer located on left heel has shown improvement. 2 Pressure ulcer located on left heel has responded to treatment. 3 Pressure ulcer on left heel is no longer producing purulent drainage. 4 Pressure ulcer on left heel has not enlarged in size within the last 24 hours. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 3 In many clinical situations it is important to collect evaluative measures over a period of time to determine if a pattern of improvement or change exists. The absence of purulent drainage indicates successful nursing interventions while the other options either fail to provide measurable data regarding the wound or indicate no improvement. DIF: C REF: 294 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. Which of the following statements made by a clients family is the most reliable for use in the evaluation of a clients outcome? 1 2 3 4 Mom has been eating 90% of all of her meals since shes been home. My daughter is in much less pain now that she is going to physical therapy. My husband has been less depressed since hes been on that antidepressant pill. Mom has been so much better since shes been able to get up and walk by herself. ANS: 1 Input from the family and other caregivers can be used to evaluate client outcomes but it is best to use their observations of measurable actions, such as the amount eaten, than to rely on their subjective opinions of a clients reaction, such as pain, anxiety, or mood. DIF: C dm 294 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. A nurse is providing care for a client receiving normal saline when the IV infiltrates. Which of the following nursing actions represents the evaluation phase of the nursing process? 1 IV is discontinued. 2 Warm compress applied to IV site. 3 Site reinspected for presence of swelling. IV site observed as having significant swelling. 4 ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the nursing process, the clients condition or well-being improves. The remaining options represent the assessment and implementation phases. DIF: A dm 291 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which of the following questions, asked by a nurse, best reflects an understanding of effective evaluation? 1 Do you feel confident in the use of your glucometer? 2 Have you been following your low carbohydrate diet? Any questions regarding the tests you are scheduled for today? 3 4 May we review what we discussed earlier about your medications? ANS: 4 In effective evaluation, the nurse compares client behavior and responses that were assessed before delivering nursing interventions with behavior and responses that occur after administering nursing care. The answer shows direct client knowledge related to the material previously discussed, while the other options reflect close-ended questions that require only a yes or no answer. DIF: C dm 291 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. The nurse caring for an immobile client with a pressure ulcer implements an intervention that requires repositioning the client every 2 hours. Which of the following represents the best evaluation method for this intervention? 1 No additional pressure ulcers are noted over a 1-week period. 2 Client expresses a decrease in pressure ulcer related pain within 1 week. 3 The clients pressure ulcer shows a decrease in size over a 1week period. The turning schedule is initiated to reflect appropriate positioning for a 1-week period. 4 ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material You conduct evaluation measures to determine if you met expected outcomes, not if nursing interventions were completed. The decrease in size of the pressure ulcer best evaluates the effectiveness of this intervention while the remaining options reflect client opinion, further skin breakdown, or implementation of the intervention. DIF: C dm 291 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following statements best defines quality improvement (performance improvement)? 1 The assessment of the delivery system responsible for the implementation of client-oriented interventions 2 Integration of evidence-based practice research into the delivery process used to implement client-oriented interventions 3 High-priority evaluation process directed towards differentiating between good and poor intervention delivery by providers 4 An ongoing evaluation of interventions that is used to improve the delivery of health care for the purpose of managing the clients needs ANS: 4 Quality improvement (QI) and performance improvement (PI) are interchangeable terms that describe an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others. The remaining options reflect individual facets of QI. DIF: C dm 298 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. The primary reason for documenting discontinued portions of the care plan when a client goal has been met is to ensure: 1 Effective use of both nursing time and resources 2 Delivery of both timely and relevant nursing care 3 Concrete evidence of successful outcome achievement WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Minimal ineffective communication among the nursing staff ANS: 2 Documentation of a discontinued plan ensures that other nurses will not unnecessarily continue interventions for that portion of the plan of care. Continuity of care assumes that care provided to clients is relevant and timely. The remaining options refer to the potential nursing outcomes related to poor documentation of care plan editing. DIF: C dm 297 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following nursing actions should be initiated first when dealing with the following unmet client goal: Client will lose 10 pounds in 3 months? 1 Interview the client to identify reasons why the goal was not met. 2 Assess the client for possible physical reasons for failure to lose the weight. 3 Discuss with the client whether they were truly motivated to lose the weight. 4 Re-evaluate whether it was realistic for the client to lose 10 pounds in 3 months. ANS: 1 When goals are not met, the nurse should identify the factors that interfere with goal achievement. The remaining options reflect actions to be taken after the interview to further determine how the care plan will be modified. DIF: C dm 297 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. When a client goal is unmet, which of the following nursing actions is most appropriate? 1 Reevaluation of the original client goal 2 Selection of new but appropriate interventions 3 Evaluation of the clients ability and motivation to be compliant WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Repetition of the entire nursing process regarding the nursing diagnosis ANS: 4 When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to discover changes the plan needs. The remaining options reflect individual elements within the nursing process. DIF: C dm 297 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following is a recognized focus area for quality improvement (performance improvement) evaluations? (Select all that apply.) 1 Effective care 2 Delivery of care 3 4 Client satisfaction Exceeding the standard of care 5 Identification of missed client needs 6 Multidisciplinary approach to client care ANS: 1, 2, 3, 4 Quality improvement is concerned with exceeding the standard of care, examining ways to be more efficient, improving client satisfaction, and focusing on service. Although the remaining options are pertinent, they are not major considerations of QI evaluation. Chapter 21. Managing Patient Care MULTIPLE CHOICE 1. It is necessary for the nurse manager to delegate tasks to the staff. Which of the following is a requirement of the delegation process? 1 Working alongside the staff to evaluate their care 2 Functioning from a laissez-faire style of leadership 3 Obtaining the employees voluntary acceptance of the task 4 Communicating the work assignment in understandable terms ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material When delegating, the nurse should always provide unambiguous and clear directions by describing a task, the desired outcome, and the time period within which the task should be completed. The nurse manager does not necessarily have to work alongside staff to evaluate their care. The nurse manager can often evaluate staff performance in client outcomes. A laissez-faire style of leadership is not a requirement for delegation. Tasks should be delegated to those who are capable, not necessarily to those who are willing. DIF: A dm 309 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. As the nurse starts to perform a procedure, a peer says, Ive done that before. Would you like me to help? The peers leadership style is described as: 1 Directing 2 Coaching 3 Democratic 4 Laissez-faire ANS: 2 This situational leadership style is described as coaching. The peer is willing to explain the procedure and provide the opportunity for clarification. Directing is a highly directive style of leadership where leaders provide specific instructions and close supervision. A laissez-faire style of leadership is where the leader intervenes as little as possible in the direction of others. The laissez-faire style of leadership is described as nondirective, permissive, ultraliberal. A democratic leadership style encourages group discussion and decision making. The democratic leadership style is described as participative and consultative. DIF: A OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. A unit manager on a busy multi-service medical nursing unit decides to take responsibility for the direct client care of one of the many new admissions. Later the manager decides she is too busy to give adequate client care. Which of the following situational leadership styles does the nurse manager need to apply? 1 Coaching 2 Supporting 3 Delegating 4 Directing WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 3 Delegation is transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. To be more efficient in providing adequate client care, the manager needs to use delegation. Coaching would not be the situational leadership style to apply. The manager does not have time to explain decisions and provide the opportunity for clarification. Supporting would not be the situational leadership style of choice. The manager does not need to share ideas and facilitate decision making of other employees at this time. Directing is a highly directive style of leadership. The manager needs to delegate, not provide specific instructions and close supervision. DIF: A dm 309 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. Which of the following statements best reflects the autocratic style of leadership? 1 Lets discuss this case study thoroughly and decide on a plan of action as a group. 2 Ill try to pair you in comparable work teams, and lets evaluate the success of this approach in 2 weeks. Everyone knows their work assignment, so lets not meet together unless we have an unexpected crisis. 3 4 Ill consider each of your requests, and then Ill give you the guidelines for establishing new acuity ratings for our clients. ANS: 4 Ill consider each of your requests, and then Ill give you the guidelines for establishing new acuity ratings for our clients reflects the autocratic style of leadership. The leader is making the decision. Lets discuss this case study thoroughly and decide on a plan of action as a group reflects the democratic style of leadership. The leader encourages group discussion and decision making. Ill try to pair you in comparable work teams, and lets evaluate the success of this approach in 2 weeks reflects the delegating style of leadership. Responsibility and implementation are being turned over to the group, but the leader remains accountable. Everyone knows their work assignment, so lets not meet together unless we have an unexpected crisis reflects the laissez-faire style of leadership. There is much freedom, and the leader assumes a hands off approach. DIF: A OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 5. To meet the needs of assigned clients and the responsibilities associated with the position, nurses need to be aware of time management techniques. The time management skills for the nurse include: 1 Meeting all of the clients needs in the early morning hours 2 Anticipating possible interruptions by therapists and visitors 3 Leaving each day unplanned to allow for adaptations in treatments 4 Completing client assessments and treatments individually at separate times ANS: 2 To manage time, the nurse must anticipate when care will be interrupted for medication administration and any diagnostic testing, and the nurse should also determine the best time for planned therapies such as dressing changes, client education, and client ambulation. Meeting all the needs in the early morning hours would be unrealistic. Some activities have specific time limits in terms of addressing client needs and some activities follow scheduled routines according to hospital policy. The nurse may also have to work around other schedules, such as if the client had a test ordered for the morning. Therefore, the nurse cannot expect to meet all of the clients needs at a specified time of day. Because the nurse has a limited amount of time with clients, it is essential to remain goal-oriented and make a plan for using time wisely. Time management involves using client goals as a way to identify priorities. The nurse in reviewing the care requirements organizes his or her time so the activities of care and client goals can be achieved. A nurse should complete the activities started with one client before moving on to another. DIF: A dm 308 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. In anticipation of a nursing shortage, the nursing management in a facility is investigating a nursing care delivery model that involves the division of tasks, with one nurse assuming the responsibility for particular tasks. This model is called: 1 Total patient care 2 Functional nursing 3 Team nursing Primary nursing 4 ANS: 2 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Functional nursing is task-focused, not client-focused. In this model, tasks are divided, with one nurse assuming responsibility for specific tasks. Total patient care is a model of care where an RN is responsible for all aspects of care for one or more clients. The RN may delegate aspects of care, but retains accountability for care of all assigned clients. In team nursing a registered nurse leads a team that is composed of other RNs, LPNs or LVNs, and nurse assistants or technicians. The team members provide direct client care to groups of clients, under the direction of the RN team leader. Nurse assistants are given client assignments rather than being assigned particular tasks. Primary nursing is a model of care delivery whereby an RN assumes responsibility for a caseload of clients over time. Typically the RN selects the clients for his or her caseload and cares for the same clients during their hospitalization or stay in the health care setting. DIF: A dm 303 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. One advantage of a decentralized management structure for nursing units over a centralized structure is that: 1 Communication pathways are simplified 2 Staff are not responsible for defining their roles 3 Managers handle all of the difficult decision making 4 Each staff member is accountable for evaluating the plan of care ANS: 4 In decentralized management, decision making is moved down to the level of staff. It requires workers to be empowered to accept greater responsibility for the quality of client care provided. This means that each staff member is accountable for evaluating the plan of care. Communication pathways are not simplified. If decentralized decision making is in place, professional staff have a voice in identifying the RN role. Each RN on the work team is responsible for knowing his or her role and how it is to be implemented on the nursing unit. In decentralized management, there is autonomy. In other words, there is freedom to decide and act. The nurse manager does not necessarily handle the difficult decisions. Those staff members who are best informed about a problem or issue make decisions on the basis of knowledge. DIF: A dm 304 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. Indicators in a quality improvement program that evaluates the manner in which care is delivered are: 1 Structure indicators WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Team indicators 3 Process indicators Client indicators 4 ANS: 3 A quality indicator for evaluating the manner in which care is delivered is a process indicator. Structure indicators evaluate the structure or systems for delivering care; an example is adherence to checking if emergency carts are adequately stocked. There is no team indicator. Client indicators would actually be outcome indicators. Outcome indicators evaluate the end result of care delivered. DIF: A dm Chapter 20, 298 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. A threshold of 90% is identified for an outcome indicator in the quality improvement program. Which of the following situations indicates a need for further review of the quality improvement plan? 1 The waiting time for clinic appointments has decreased 96%. 2 Clients with renal dialysis expressed a 95% satisfaction with their care. 3 In 93% of clients, subjective expressions of postoperative pain have decreased. 4 Wound infections are evident in 92% of clients after care of their IV access ports. ANS: 4 Wound infections are exceeding the designated threshold, indicating a need for further review of the quality improvement plan. Waiting time for clinic appointments has decreased, meeting the threshold. Satisfaction with care meets the threshold. Expressions of pain have decreased, meeting the threshold. DIF: A dm Chapter 20, 298 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. In anticipation of a nursing shortage, the nursing management in a facility are investigating a nursing care delivery model that involves staff members working under the direction of a registered nurse leader. This model is called: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Team nursing 2 3 Primary nursing Functional nursing 4 Total patient care nursing ANS: 1 In team nursing a registered nurse leads a team that is composed of other RNs, LPNs or LVNs, and nurse assistants or technicians. The team members provide direct client care to groups of clients, under the direction of the RN team leader. Nurse assistants are given client assignments rather than being assigned particular tasks. Primary nursing is a model of care delivery whereby an RN assumes responsibility for a caseload of clients over time. Typically the RN selects the clients for his or her caseload and cares for the same clients during their hospitalization or stay in the health care setting. Functional nursing is task-focused, not client focused. In this model, tasks are divided, with one nurse assuming responsibility for specific tasks. Total patient care is a model of care where an RN is responsible for all aspects of care for one or more clients. The RN may delegate aspects of care but retains accountability for care of all assigned clients. DIF: A dm 303 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Accountability is a critical aspect of nursing care. An example of a specific decision-making process of accountability is demonstrated by: 1 Selecting the medication schedule for the client 2 Implementing discharge teaching plans that meet individual needs 3 Evaluating the clients outcomes following implementation of care Promoting participation of all staff members in regular unit meetings 4 ANS: 3 Accountability refers to individuals being responsible for their actions. It involves follow-up and a reflective analysis of ones decisions to evaluate their effectiveness. Selecting the medication schedule for the client is an example of taking responsibility. Implementing discharge teaching plans that meet individual needs is an example of autonomy. Promoting participation of all staff members in unit meetings is an example of decentralized management and of promoting authority. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A dm 305 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. The student nurse is seeking to learn skills associated with priority setting. In discussing different priorities of care, an example of a second-order priority is: 1 2 3 4 The need to urinate An obstructed airway The side effects of a medication Activities of daily living in the home environment ANS: 1 Second-order priority needs are actual problems for which the client or family has requested immediate help, such as a full bladder. An obstructed airway is a first-order priority need because it is an immediate threat to a clients survival or safety. Side effects of a medication is an example of a third-order priority need. It is a relatively urgent actual or potential problem that the client or family does not recognize. Activities of daily living in the home environment is a fourth-order priority need. It is an actual or potential problem with which the client or family may need help in the future. DIF: A dm 307 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The nurse on the unit is determining which activities may be delegated to assistive personnel. Assuming that the nurse assistant is competent, which one of the following activities may be safely delegated by the registered nurse? 1 Vital signs on a stable client 2 An admission history on a new client 3 Initial transfer of a postoperative client Administration of medications prepared by the nurse 4 ANS: 1 An institutions policies and procedures and job description for assistive personnel provide specific guidelines in regard to which tasks or activities can be delegated. The nurse should match tasks to the delegates skills, such as delegating vital signs to a nurse assistant. It would not be appropriate to delegate an admission history on a new client to a nurse assistant. The RN should perform this task. Initial transfer of a postoperative client should not be delegated to a WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material nurse assistant, as the client would be considered unstable. The RN should perform this task. The nurse should not delegate medication administration to a nurse assistant, even if the nurse prepared it. The nurse assistant is not licensed to administer medication. DIF: A dm 309 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. The most important responsibility of a nurse manager is to: 1 Foster an environment that enables staff to provide quality nursing care 2 Provide leadership and role modeling for nursing and ancillary staff 3 Evaluate the delivery of nursing care in regard to its effect on client outcomes 4 Create a unit attitude of cooperative engagement directed toward positive client outcomes ANS: 1 Perhaps the most important responsibility of the nurse executive is to establish a vision for nursing that enables managers and staff to provide quality nursing care. The remaining options are means by which the manager can affect the proper environment. DIF: C dm 302 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. The primary benefit of achieving Magnet status is the nursing staff is empowered to make innovative changes that: 1 Promote nursing autonomy 2 Positively affect client care outcomes 3 Enhance the perception of the nursing profession Strengthen the collaborative RN/MD relationship 4 ANS: 2 A Magnet hospital empowers the nursing team to make changes and be innovative. This culture and empowerment combine to produce a strong collaborative relationship among team members and so ultimately improves client quality outcomes. The remaining options are outcomes of the Magnet status but not the primary benefit. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C dm 302 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. Which of the following statements best reflects the nurses understanding of team nursing? 1 The team provides the client care and I provide the leadership and decision making. 2 I will manage the complex care and delegate the remaining care to my LPN and ancillary assistants. 3 Everyone on the team has responsibilities and is accountable to me regarding the effective execution of that care. 4 I delegate the care of the clients to the appropriate team members and I am responsible for coordinating and directing that care. ANS: 4 In team nursing a registered nurse (RN) leads a team that is made up of other RNs, licensed practical nurses (LPNs) or licensed vocational nurses (LVNs), and nurse assistants or technicians. The team members provide direct client care to groups of clients under the direction of the RN team leader. In this model, nurse assistants have client assignments rather than being assigned particular nursing tasks. The remaining options fail to provide an inclusive definition of team nursing. DIF: C dm 303 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which statement best reflects the major limitation of the team nursing model? 1 The team really needed an extra pair of hands today. 2 It complicates things when you have a different team each day. 3 Getting our two new admissions stabilized took up all of my time today. 4 My nursing assistants need to be in-serviced on how to do a bladder scan. ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material One of the limitations to the model is that the team leader does not spend a large amount of time with clients. Depending on the mix of staff members, this sometimes means that clients see an RN infrequently. Risks exist if an RN is unable to make necessary client assessments and be involved in important clinical decision making. The remaining options refer to less frequent problems inherent to the team nursing model. DIF: C dm 303 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. Which of the following clients would most benefit from the case manager model of nursing care? 1 2 A client diagnosed with end-stage renal failure A client who has a chronic wound on the left foot 3 A client newly diagnosed with type 2 diabetes mellitus 4 A postoperative client who had a cholecystectomy (gallbladder removal) ANS: 1 A case manager follows up with the client after discharge home. Case managers do not always provide direct care, but instead they work with and supervise the care delivered by other staff members. Case managers actively coordinate client discharge planning by identifying health care needs, determining the availability of services and resources, and assisting the client in choosing cost-efficient health care options. The client dealing with end-stage renal failure would most benefit from this model of care because the clients case is the most complex and will require extension discharge support. DIF: C dm 304 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following actions is the best example of a nurse exercising nursing authority? 1 Assigning team responsibilities to individual team members 2 Evaluating a team members ability to perform a bladder scan 3 Readjusting a clients turning schedule to provide hourly repositioning Determining that a client will not be ambulated based on assessment findings 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 4 Authority refers to legitimate power to give commands and make final decisions specific to a given position. Canceling a clients ambulation is the best example because it shows critical thinking in determining the appropriateness of an intervention. The remaining options are better examples of nursing responsibility. DIF: C dm 305 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following actions best reflects accountability for the clients care outcomes? 1 Reassessing a clients BP when the reported value is higher than usual 2 Assisting a team member in providing a client with a complete bed bath 3 Reevaluating a clients pain 30 minutes after administering pain medication 4 Asking a clients daughter to bring her fathers non-skid slippers to the hospital ANS: 1 Accountability refers to individuals being responsible for their actions. It means that a nurse accepts the commitment to provide excellent client care and the responsibility for the outcomes of the actions in providing that care. Reassessing an abnormally high BP is the best example of nursing accountability because it shows the nurse being responsible for the accuracy of the assessment. The remaining options better reflect nursing responsibility. DIF: C dm 305 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. When the oncology units interdisciplinary team meets every Monday morning at 0830 to discuss the units individual clients, the group is best displaying: 1 Staff education 2 Collaborative practice 3 Team communication 4 Nursing shared governance ANS: 2 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Collaboration of health care team members is required to help meet the complex needs of clients in health care settings. Such collaborative interaction may strengthen individual members knowledge and communication skills. Nursing shared governance is a process directed towards the standard of nursing care among a particular groups of professional nurses. DIF: C dm 306 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. Clinical nursing decisions are best made using: 1 Clinical pathways 2 3 Accurate assessment data Previous nursing knowledge 4 Interdisciplinary collaboration ANS: 2 When beginning an assignment with a client, the first nursing activity involves a focused but complete assessment of the clients condition. This information enables the nurse to make an accurate clinical decision as to the clients health problems and required nursing therapies. The remaining options support the clinical decision-making process. DIF: C dm 307 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. A client has reported all of the following; which should be given priority by the nurse? 1 Pain 2 Hunger 3 Anxiety 4 Constipation ANS: 1 When a client has diverse priority needs, it helps to focus on the clients basic needs; pain will exacerbate the clients anxiety and interfere with eating and thus should be attended to first. While a concern, constipation is the lowest priority problem. DIF: C dm 307 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 24. A nurse who performs a skin assessment while bathing an immobile client would be displaying: 1 2 3 4 Efficiency Leadership Organization Effectiveness ANS: 1 Effective use of time means doing the right things, whereas efficient use of time means doing things right. The nurse is showing efficiency by combining various nursing activitiesin other words, doing more than one thing at a time. Organization is a general term that may include efficiency, while leadership is the ability to manage people and resources. DIF: A dm 307-308 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. When the nurse gathers all the equipment needed for a particular procedure and arranges the clients room for proficient implementation of the procedure, the nurse is displaying: 1 Multitasking 2 Organization 3 Effectiveness 4 Professionalism ANS: 2 The well-organized nurse approaches any planned procedures by having all of the necessary equipment available and making sure the client is prepared. It always is wise to have the work area organized and preliminary steps completed before asking co-workers for assistance. Multitasking is dealing with more than one task at a time while being effective means doing the right things correctly. Being professional means showing the characteristics of performing the expected tasks of the profession. DIF: A dm 308 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. The primary reason the nurse asks for help when changing a clients complicated dressing is to: 1 Foster efficient client-oriented interventions WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Facilitate a comfortable, safe dressing change 3 Minimize the amount of time spent on a specific task 4 Engage in collaborative learning with other health care professionals ANS: 2 A nurse should never hesitate to have staff assist, especially when there is an opportunity to make a procedure or activity more comfortable and safer for the client. While it is possible that having help with a task can be a learning experience as well as making the task more efficient and less time-consuming, it is not always the case and not the primary reason for asking for assistance. DIF: C dm 308 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. The nurse is prioritizing care for two postoperative abdominal surgery clients; the first is 15 hours postoperative and the second is ready for discharge. Which of the interventions should be accomplished first? 1 Discharge pain control 2 First day dangling and ambulation 3 First day post op coughing and deep breathing 4 Discharge teaching regarding the dressing change ANS: 3 The first clients goals center on restoring physiological function impaired as a result of the stress of surgery. The second clients goals center on adequate preparation to assume self-care at home. Physiological interventions, particularly those affecting breathing, should receive priority. Dangling and ambulation may be addressed after the second client is readied for discharge. DIF: C dm 307 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. Which of the following statements made by a nurse related to the organization of client care requires follow-up by the mentor? 1 I had my LPN bring the Foley catheterization supplies into the room so theyd be there when I got there. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 I delegated all the stable vital signs to my nursing assistant and the treatments to the LPN. 3 I was taking vitals on one client, dangling a second client while I had the third expelling an enema. Organization was never a strength of mine, but I believe Im getting better at completing all my clients care. 4 ANS: 3 Good time management involves completing one task before starting another. If possible, complete the activities started with one client before moving on to the next. Care will then become less fragmented, and the nurse will be better able to focus on what is being done for each client. As a result, it is less likely that errors will be made. The remaining options are not reflective of poor management and so do not need follow-up. DIF: C dm 308 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following are recognized competencies for an entry-level nurse? (Select all that apply.) 1 Views clients holistically 2 Utilizes the nursing process 3 Participates in life-long learning 4 5 Exhibits nursing professionalism Delegates client care appropriately 6 Exhibits expert nursing knowledge ANS: 1, 2, 3, 4, 5 All provided options are recognized competencies for entry-level nurses except the ability to practice with expert nursing knowledge. This will be acquired with time and experience. DIF: C dm 302 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. To achieve Magnet status, the nursing staff of a hospital must exhibit: (Select all that apply.) 1 A client first mentality WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Autonomy of personal practice 3 Strong involvement in life-long learning Ability to use state of the art technology 4 5 6 Strong nurse-health care provider collaboration Clinical competence through earned certifications ANS: 1, 2, 3, 5, 6 All provided options are characteristics required of the nursing staff for recognition as a Magnet hospital except for expertise with state of the art technology. DIF: C dm 302-303 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The advantages of team nursing include: (Select all that apply) 1 Fosters team cooperation 2 Allows for ancillary staff autonomy 3 Strengthens the RN-client relationship 4 Facilitates decision making at the clinical level 5 Encourages collaboration between team members Provides management experience for team leaders 6 ANS: 1, 4, 5, 6 An advantage of team nursing is the collaborative style that encourages each member of the team to help the other members. This model has a high level of autonomy for the team leader and is an example of decision making occurring at a clinical level. Team nursing can limit the actual time the RN spends with the clients; ancillary staff are not afforded autonomy regardless of the nursing care model because their work must be supervised by the RN. Chapter 22. Ethics and Values MULTIPLE CHOICE 1. The client states that she needs to exercise regularly, watch her weight, and reduce her fat intake. This demonstrates that the client: 1 Values health promotion activities 2 Believes she will not become sick 3 Believes she will have a heart attack WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Has unrealistic expectations for herself ANS: 1 A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior. The client is expressing her value of health promotion activities. A belief is a conviction of the truth or reality of a thing. The client does not state she believes these health promotion activities will keep her from becoming sick. A belief is a conviction of the truth of a thing. The clients statement does not indicate she believes she will have a heart attack. These are not unrealistic expectations. DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. A client has actively picketed for gun control. During a robbery of his business, he was shot in the leg. As the nurse assists him with morning care, which statement would the nurse expect him to make that coincides with his values? 1 Firearms may have a place in our society. 2 Individuals should arm themselves for protection. 3 Prosecution should be the maximum for that felon. Protection is a necessary evil for the good guy of the world. 4 ANS: 3 Individual experience influences what we come to value. The client who experienced a gunshot during a robbery of his business may value gun control and verbalize a desire to have his attacker prosecuted for the violent crime. The client who has picketed for gun control and who was gunshot is unlikely to value firearms in our society. The individual who has actively picketed for gun control is unlikely to desire the use of guns. The individual would be more likely to believe that if there were gun control, there would be no need for guns. The individual who has actively picketed for gun control is unlikely to desire the use of guns. The individual would be more likely to believe that if there were gun control, there would be no need for guns. DIF: A dm 316 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. A secondary school teacher with advanced multiple sclerosis insists on teaching from a wheelchair and being treated the same as other colleagues. The teacher is demonstrating which of the following? 1 Prizing her choice WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Choosing from alternatives 3 Considering all consequences Acting with a pattern of consistency 4 ANS: 1 The teacher is demonstrating prizing her choice. She cherishes her choice of being treated like everyone else despite her medical condition and publicly affirms the choice by teaching from a wheelchair and insisting she be treated the same as her colleagues. At this point, the teacher is not choosing from alternatives. She could have chosen to quit teaching, but she did not. She has already made her choice. The teacher is not demonstrating considering all consequences. She has already made her choice. At this point, the teacher is not demonstrating acting with a pattern of consistency. She is not repeating a behavior. DIF: A dm 316 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. The nurse recognizes that values clarification interventions are beneficial for the client when: 1 The client and nurse have different beliefs 2 The client is experiencing a values conflict 3 The nurse is unsure of a clients personal values 4 The client has chosen to reject the normal values ANS: 2 Values clarification can help clients gain an awareness of personal priorities, identify ambiguities in values, and resolve major conflicts between values and behavior. Values clarification for nurses can help nurses strengthen their ability to advocate for a client because nurses are better able to identify personal values and accurately identify the values of the client. Values clarification is not necessarily beneficial for the client when the client and nurse have different beliefs. Values clarification for the client will not necessarily help the nurse who is unsure of the clients values. Values clarification interventions for the client will help the client, not the nurse, gain awareness. The values that an individual holds reflect cultural and social influences, relationships, and personal needs. Values vary among people and develop and change over time. Therefore it may be inappropriate to state a client has rejected normal values when value systems vary among people. What is considered normal to one person may not be to another. DIF: A dm 316 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 5. The nurse is working with the client and trying to clarify the clients values regarding his care. Which of the following statements reflects an example of the type of response a nurse should use in a values clarification situation? 1 Your questions were pretty blunt. 2 3 Tell me what youre thinking right now. Ive felt that way before. Id be upset, too. 4 You seem concerned about your tests. Let me explain them. ANS: 2 Tell me what youre thinking right now is correct. Values clarification is a process of selfdiscovery in which the nurse should assist the client. The goal of values clarification with a client is effective nurse-client communication. As the client becomes more willing to express problems and feelings, the nurse can better establish an individualized plan of care. The character of a nurses response to a client can motivate the client to examine personal thoughts and actions. When the nurse makes a clarifying response, it should be brief and nonjudgmental. Your questions were pretty blunt is incorrect. Values clarification is a process of self-discovery in which the nurse should assist the client. The character of a nurses response to a client can motivate the client to examine personal thoughts and actions. When the nurse makes a clarifying response, it should be brief and nonjudgmental. The client is being judgmental in this response. Ive felt that way before. Id be upset, too is incorrect as well. The nurse should not influence the client with his or her own values, even if they are similar. You seem concerned about your tests. Let me explain them is also incorrect. This statement is therapeutic in that it is reflective of a clients feeling, and offers information. However, it does not encourage the client to examine their values. DIF: A dm 316 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. A nurses use of ethical responsibility can best be seen in which of the following nursing actions? 1 Delivery of competent care 2 Formation of interpersonal relationships 3 Correct application of the nursing process Evaluation of new computerized technologies 4 ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The term responsibility refers to the characteristics of reliability and dependability. In professional nursing, responsibility includes a duty to perform actions well and thoughtfully. When the nurse provides competent care, the nurse is demonstrating ethical responsibility. Formation of interpersonal relationships is not an ethical responsibility. Application of the nursing process is not an ethical responsibility. Evaluation of new computerized technologies is not an ethical responsibility. DIF: A dm 314-315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. A nursing student that immediately informs her clinical instructor after she realizes that she has administered the wrong dose of medication to a patient is best described professionally as: 1 Confident 2 Trustworthy 3 Compliant 4 Accountable ANS: 4 Accountability refers to the ability to answer for ones own actions. The goal is the prevention of injury to the client. The student nurse who informs her instructor of an error is being accountable for her actions and has a goal to prevent injury to the client. The student nurse would not be described professionally as confident (i.e., sure of oneself). The student is not best described as trustworthy. To be trustworthy, one is worthy of trust or confidence and reliable. In this case, the student was not reliable to administer medication correctly. This student nurse is not best described professionally as compliant. The student is not acting in accordance with wishes, commands, or requirements. DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. A client who is recently diagnosed with cancer is encouraged to consider sharing the information with her family so they can support her through the decisions she will need to make regarding her care. The nurse is using the principle of: 1 Confidentiality 2 Fidelity 3 Veracity 4 Justice WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 3 Veracity in general means accuracy or conformity to truth. The nurse is encouraging the client to be truthful with the clients family. Confidentiality means to not impart private matters. Fidelity refers to the agreement to keep promises. Justice refers to fairness. DIF: A OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The correct sequence for attaining the resolution of an ethical problem is: 1 2 3 4 Examine values, evaluate, and identify the problem Evaluate the outcomes, gather data, and consider actions Gather facts, verbalize the problem, and consider actions Recognize the dilemma, evaluate, and gather information ANS: 3 The correct sequence for resolving ethical problems is recognizing the dilemma, gathering facts, examining ones own values, verbalizing the problem, considering actions, negotiating the outcome, and evaluating the action. DIF: A dm 319 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. A nurse is ambivalent as to the need to vigorously suction the secretions of a terminal client in a comatose state. Which of the following is an appropriate statement by the nurse in regard to processing an ethical dilemma? 1 I just feel like I should not suction this client. 2 I need to know the legalities of the living will of this client. 3 I cannot figure out whats right in this situation. I need to collect more data. 4 My spiritual beliefs mandate that I continue to provide all the interventions in my scope of practice. ANS: 3 The first step in processing an ethical dilemma is determining whether the problem is an ethical one. The nurse who cannot figure out what is right, is stating a characteristic of an ethical dilemma, which is that the problem is perplexing. The next step is to gather as much information WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material as possible that is relevant to the case. I just feel like I should not suction this client is the nurse is stating the problem according to her feelings. I need to know the legalities of the living will of this client is the nurse who wants to know the legalities of the living will of a client is collecting some, but not all, data pertaining to the problem. My spiritual beliefs mandate that I continue to provide all the interventions in my scope of practice is the nurse stating her own beliefs. DIF: A dm 316-317 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which of the following statements best illustrates the deontological ethical theory? 1 I believe this disease was allowed by a supreme being. 2 He has become a stronger individual through experiencing the loss of his father. 3 Under no circumstances would it ever be right for a person to stop CPR efforts. 4 The chemotherapy did not cure this person, but it provided a better life for him. ANS: 3 Under no circumstances would it ever be right for a person to stop CPR efforts is correct. Deontology defines actions as right or wrong based on their right-making characteristics, such as fidelity to promises, truthfulness, and justice. Deontology does not look at consequences of actions to determine rightness or wrongness. Fidelity to promises and beneficence may be principles upon which this statement is based on determining wrongness. I believe this disease was allowed by a supreme being does not reflect the deontological ethical theory. Because it reflects a relationship between disease and a supreme being, it follows the feminist ethical theory. He has become a stronger individual through experiencing the loss of his father does not best illustrate the deontological ethical theory because it is citing a consequence. It follows the utilitarian ethical theory. The chemotherapy did not cure this person, but it provided a better life for him does not best illustrate the deontological ethical theory because it is citing a consequence. It follows the utilitarian ethical theory. DIF: A dm 316-317 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. On admission to the hospital, a terminal cancer patient says he has a living will. This document functions to state the clients desire to: 1 Receive all technical assistance to prolong his life WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Have his wife make the decisions regarding his care 3 Be allowed to die without life-prolonging techniques Have a lethal injection administered to relieve his suffering 4 ANS: 3 A living will is an advance directive, prepared when the individual is competent and able to make decisions, regarding that persons specific instructions about end-of-life care. Living wills allow people to specify whether they would want to be intubated, treated with pressor drugs, shocked with electricity, and fed or hydrated intravenously. A living will specifies what interventions the client does not want, so that his or her life will not be prolonged. If his wife has power of attorney she would be able to make decisions regarding the clients care. Assisted suicide, such as a lethal injection, is not a function of a living will. A living will defines a clients wishes for withholding treatment that would prolong his or her life. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. At an accident scene a nurse stopped and began to provide emergency care for the victims. Her actions are best labeled ethically as: 2 Triage Beneficence 3 Nonmaleficence 4 Respect for persons 1 ANS: 2 Beneficence refers to taking positive actions to help others, as in providing emergency care at an accident scene. Triage is the screening and classification of casualties to make optimal use of treatment resources and to maximize the survival and welfare of clients. Nonmaleficence is the avoidance of harm or hurt. Respect for persons has to do with treating people equally despite their social standing, for example. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. The nurse is aware that an ethics committee in a health care facility serves to: 1 Interview all persons involved in a case 2 Illustrate circumstances that demonstrate malpractice WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Serve as a resource for specific situations that may occur 4 Examine similar previous instances for comparison of outcome decisions ANS: 3 Ethics committees serve as a resource to support the processing of ethical dilemmas. Ethics committees serve several purposes: education, policy recommendation, and case consultation or review. Although an ethics committee may gather further information, ethics committees do not interview all persons involved in a case. Rather, they offer consultation or case review. Illustrating circumstances that demonstrate malpractice is not a purpose of an ethics committee. Examining similar previous instances for comparison of outcome decisions may be part of data gathering to help process an ethical dilemma or for policy recommendation, but it is not the purpose of an ethics committee. DIF: A dm 321 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. In the emergency department a client feels that she has been waiting longer than the other individuals due to the fact that she has no insurance. The ethical principle that is involved in this exact situation is: 1 2 Justice Autonomy 3 Beneficence 4 Nonmaleficence ANS: 1 Justice refers to treating people fairly. Allocation of resources and access to health care involves the ethical principle of justice. The client without medical insurance should not have to wait longer to receive health care than those with insurance. Autonomy refers to a persons independence. Autonomy represents an agreement to respect anothers right to determine a course of action. Beneficence refers to taking positive actions to help others. Nonmaleficence refers to the avoidance of harm or hurt. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. Regarding the nurses use of the specific ethical principle of autonomy in a client situation, an example would be: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Learning to do a procedure safely and effectively 2 3 Returning to speak to a client at an agreed upon time Preparing the clients room for comfort and privacy 4 Supporting a clients right to refuse a specific type of therapy ANS: 4 Following the ethical principle of autonomy, the nurse allows a client to make his or her own decisions regarding care and then supports that decision. Learning how to perform a procedure safely and effectively is a nurses use of ethical responsibility. Returning to speak to a client at an agreed upon time demonstrates the ethical principle of fidelity. Preparing the clients room for comfort and privacy is a nurses use of ethical responsibility. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which of the following statements reflects application of the specific ethical principle of confidentiality? 1 Im concerned that funding may affect the outpatient program. 2 Im going to make sure that the client understands the instructions. I cannot share that information with you about the clients condition. 3 4 I need to get more information about the clients personal health history. ANS: 3 I cannot share that information with you about the clients condition reflects the application of the ethical principle of confidentiality. Information is not to be shared with others without specific client consent. Im concerned that funding may affect the outpatient program reflects a concern regarding allocation of resources. It is not a confidentiality issue. The nurse who makes sure a client has gained understanding is being ethically responsible. I need to get more information about the clients personal health history reflects data gathering. Information gathered is to be used for the purpose of providing competent health care. It should not be shared with others without specific consent of the client. DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. The client has been diagnosed with malignant bone cancer and the treatment involves chemotherapy on an outpatient basis. While treating the cancer the client unfortunately becomes very ill, experiences significant side effects from the therapy, and has a severe reduction in the quality of life. The specific ethical principle that is in question in this situation is: 1 2 Veracity Fidelity 3 Justice 4 Nonmaleficence ANS: 4 Nonmaleficence is the avoidance of harm or hurt. Whether the discomforts of treatment are benefiting the client or are worse than the disease itself have to be considered. The health care professional tries to balance the risks and benefits of a plan of care while striving to do the least harm possible. Veracity refers to truthfulness. This situation is not questioning truthfulness. Fidelity refers to the agreement to keep promises. This situation does not question fidelity. Justice refers to fairness. This situation is not a matter of justice. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following statements best reflects the nurses ethical concern for nonmaleficence regarding the clients treatment plan? 1 The radiation therapy has not substantially decreased the clients tumor related pain. 2 The client expressed the idea that this treatment was definitively going to cure her cancer: The clients family requested that she not be informed of the seriousness of her cardiac condition. 3 4 The procedure is quite invasive, and there is little chance that it will improve the clients quality of life. ANS: 4 Nonmaleficence is the avoidance of harm or hurt. Whether the discomforts of treatment are benefiting the client or are worse than the disease itself have to be considered. The health care professional tries to balance the risks and benefits of a plan of care while striving to do the least WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material harm possible. The remaining options are related to veracity (truthfulness), fidelity (keeping a promise), and possibly fairness. DIF: A dm 314 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following statements related to confidentiality made by a nurse requires immediate follow-up by the nurse manager? 1 I believe the client is eligible for both Medicare and Medicaid. 2 The client with pneumonia has tested positive for TB (tuberculosis). 3 Did you know that the client in Room 45 has a daughter who has type 1 diabetes mellitus? 4 I arranged for the clients information to be faxed to the assistive living facility she will be transferred to. ANS: 3 This information is private and the nurse is violating the clients right to confidentiality because the information has no bearing on the care needs of the client. The remaining options are not reflective of an ethical breech because the exchange of that information has a direct bearing on the clients care. DIF: C dm 315 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following nursing actions best reflects a nurses commitment to the ethical principle of fostering autonomy regarding an older client living in an extended care facility? 1 Providing options regarding the furniture arrangement of the clients room 2 Supporting a clients decision to adopt a DNR (do not resuscitate) status Allowing sufficient time for the client to independently accomplish morning hygiene 3 4 Consulting the client regarding personal preferences regarding treatment options WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 Following the ethical principle of autonomy, the nurse facilitates a clients decision-making process in order to make their own decisions regarding all aspects of life, including their care, and then supports those decisions. The most important and possibly controversial decision is that of DNR status and thus shows the greatest commitment on the nurses part. DIF: C dm 314 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. Which of the following statements made by a terminally ill client reflects the best understanding of the purpose of a living will? 1 It will make sure my wishes are respected. 2 My family wont be burdened with making those hard decisions. I dont want strangers making those kinds of decisions for me. 3 4 I can make my wishes known while I still have the ability to express them. ANS: 4 A living will is an advance directive, prepared when the individual is competent and able to make and communicate personal decisions, regarding specific instructions about end-of-life care. The remaining options represent motivation for implementing a living will. DIF: C dm Chapter 23, 328 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse is showing respect for a clients right to autonomy regarding an invasive procedure by: 1 Obtaining consent for the procedure 2 Performing the procedure appropriately 3 Providing client education regarding the procedure 4 Being frank when discussing the pros and cons of the procedure ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The signed consent ensures that the nurse obtained the clients permission before proceeding with the procedure. The remaining options are examples of nonmaleficence, client right to be informed, and veracity. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. The nurse holds a clients hand during a painful procedure. This action shows a positive act towards the client that is referred to as: 1 Veracity 2 3 Fidelity Beneficence 4 Nonmaleficence ANS: 3 Beneficence refers to taking positive actions to help others. The practice of beneficence encourages the urge to do good for others. The agreement to act with beneficence also requires that the best interests of the client remain more important than self-interest. The remaining options reflect truthfulness, keeping true to a promise, and doing no harm. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. When a nurse considers the possible positive effect a treatment will have against the pain it may cause the client, the nurse is displaying: 1 Justice 2 Fidelity 3 Beneficence 4 Nonmaleficence ANS: 4 Nonmaleficence is the avoidance of harm or hurt. In health care, ethical practice involves not only the will to do good but also the equal commitment to do no harm. The remaining options refer to fairness, truthfulness, and kindness. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. When a client who is in need of a lung transplant is placed on the organ donor registry according to his current health needs, this is an example of ethical: 1 2 Justice Fidelity 3 Beneficence 4 Nonmaleficence ANS: 1 Health care providers agree to strive for fairness in health care. Criteria set by a national multidisciplinary committee make every effort to ensure justice by ranking client organ recipients according to need. The remaining options refer to keeping a promise, kindness, and doing no harm. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. Abandoning a client would be an example of a nurses failure to professionally display: 1 Justice 2 Fidelity 3 Beneficence 4 Nonmaleficence ANS: 2 Fidelity refers to the agreement to keep promises. A commitment to fidelity supports the reluctance to abandon clients. The remaining options refer to fairness, kindness, and doing no harm. DIF: A dm 314 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. The nursing professional code of ethics is best defined as: 1 The criteria for judging nursing professionalism 2 A benchmark for professional nursing deeds and actions 3 The nursing professions expectations of its members behavior WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 A document that holds nurses responsible for professional behavior ANS: 3 It is a collective statement about the groups expectations and standards of behavior. The remaining options are not accurate or complete descriptions of the nursing professional code of ethics. DIF: C dm 314 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. The nurse has successfully completed a distance learning class on ECG (electrocardiogram) interpretation. This is an example of the nurse exhibiting the professional principle of: 1 Advocacy 2 3 Responsibility Accountability 4 Confidentiality ANS: 2 The word responsibility refers to a willingness to respect obligations and to follow through on promises. The nurse has a responsibility to remain competent to practice so that he or she is able to reliably follow through on responsibilities. The remaining options are reflective of other professional principles.i DIF: A dm 314-315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. The nurse is explaining the rationale for seeking the familys permission to apply a physical restraint to a combative client. This is an example of the nurse exhibiting the professional principle of: 1 Advocacy 2 Responsibility 3 Accountability 4 Confidentiality ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Accountability refers to the ability to answer for ones own actions. Nurses should ensure that their professional actions are explainable to their clients and to their employer. The remaining options are reflective of other professional principles. DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. The nurse realizes that sharing ones computer password is a violation of which of the professional nursing principles? 1 Advocacy 2 3 Responsibility Accountability 4 Confidentiality ANS: 4 When medical records are computerized, computer security measures include special access codes for all authorized users; sharing private passwords is a breech of client confidentiality because it allows unauthorized individuals to access client information. The remaining options are reflective of other professional principles. DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 32. The belief that all life is sacred and must be preserved regardless of the quality of that life is an example of: 1 Cultural bias 2 Personal value 3 Universal truth 4 Individual preference ANS: 2 A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior. A cultural bias refers to interpreting and judging phenomena in terms particular to ones own culture while a universal truth is so overwhelmingly true that all mankind respects and acknowledges the validity of the statement. An individual preference is a personal choice. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A dm 315 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 33. The nurse realizes that an individual clients value system is most affected by: 1 2 3 4 Life experiences Economic status Spiritual beliefs Formal education ANS: 1 Development of values begins in childhood, shaped by experiences within the family unit, especially dramatic events during the formative years. The other options may influence the value system, but not to the same extent. DIF: C dm 316 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 34. An older client is experiencing the greatest problem with the concept of autonomy when he has difficulty: 1 Expressing his need for pain medication 2 Disagreeing with his health care provider 3 Participating in discussions regarding his treatment 4 Discussing his need for assistive living arrangements ANS: 2 Older people are usually not as familiar with the concept of autonomy as people from younger generations. As a result, older adults are sometimes uncomfortable disagreeing with doctors or nurses. They view assertiveness as a violation of trust. The remaining options reflect autonomy problems but management of personal health issues is the most important issue. DIF: C dm 314 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following elements are essential among a group working towards the successful resolution of a conflict of opinion? (Select all that apply.) 1 Similar value systems WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Presumption of good will 3 Similar cultural background Client-centered decision making 4 5 6 Strict adherence to confidentiality Participation of all involved parties ANS: 2, 4, 5, 6 The resolution of conflicting opinions works best when the following elements are part of the process: the presumption of good will on the part of all participants, strict adherence to confidentiality, client-centered decision making, and the welcome participation of families and primary caregivers. The remaining options represent group characteristics that usually minimize conflict in decision making. DIF: C dm 319 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. Although the American Nurses Associations (ANAs) code of ethics is reviewed and revised regularly to reflect changes in nursing practice, the basic principles that remain constant are: (Select all that apply) 1 Advocacy 2 Reliability 3 Responsibility 4 Accountability 5 Confidentiality Professionalism 6 ANS: 1, 3, 4, 5 The American Nurses Association (ANA) established the first code of nursing ethics decades ago. The ANA reviews and revises the Code regularly to reflect changes in practice. Basic principles remain constant; however, responsibility, accountability, advocacy, and confidentiality. Although admirable, the remaining options are not considered core principles of the code. DIF: C dm 315 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3. The nurse knows that when making choices concerning the adoption of evidence-based practice, the literature must be reviewed regarding its: (Select all that apply) 1 2 3 Content Relevance 4 Reliability Ethical soundness 5 Economic feasibility 6 Transcultural versatility ANS: 1, 2, 3, 4 Nurses make choices regarding evidence-based practice proposals based on content, relevance, reliability, and the ethical implications to their practice. The remaining options are not typically considered when evaluating the global usefulness of research findings. Chapter 23. Legal Implications in Nursing Practice MULTIPLE CHOICE 1. Which source of law best addresses a situation where nurse accidentally administers an incorrect dosage of morphine sulfate to the client? 1 Civil law 2 Criminal law 3 Common law 4 Administrative law ANS: 1 Civil laws protect the rights of individual persons within our society and encourage fair and equitable treatment among people. Generally, violations of civil laws cause harm to an individual or property and damages involve payment of money. Administering an incorrect dosage of morphine sulfate would fall under civil law because it could cause harm to an individual. Criminal laws prevent harm to society and provide punishment for crimes (often imprisonment). Common law is created by judicial decisions made in courts when individual legal cases are decided (i.e., informed consent). Administrative law is created by administrative bodies, such as state boards of nursing when they pass rules and regulations (i.e., the duty to report unethical nursing conduct) DIF: A dm 326 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2. What standard of care applies to the student nurses conduct when providing care normally performed by a registered nurse (RN)? 1 2 The same standard of care as an RN A standard of care of an unlicensed person 3 No special standard of care because her faculty member is responsible for her conduct 4 A standard similar to but not the same as the staff nurse with whom she is assigned to work ANS: 1 Student nurses are expected to perform as professional nurses (i.e., as an RN would in providing safe client care). Students are not working in the same capacity as an unlicensed person, and therefore are not compared to the standard of an unlicensed person. No special standard of care because her faculty member is responsible for her conduct is not a true statement. Staff nurses may serve as preceptors, but that does not excuse the student from performing at the level of an RN. If a client is harmed as a direct result of a nursing students actions or lack of action, the liability for the incorrect action is generally shared by the student, instructor, hospital or health care facility, and university or educational institution. DIF: A dm 333 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. Which of the following is the most important factor in a nurse deciding whether or not to carry malpractice insurance? 1 The nurses knowledge level of Good Samaritan laws 2 The amount of malpractice insurance provided by the nurses employer 3 The time frames and individual liability of the employers malpractice coverage The evaluation of whether the nurse works in a critical area of nursing where clients have higher morbidity and mortality rates 4 ANS: 3 It would be important to know the time frames of the employers malpractice coverage. In other words, is the nurse only covered during the times he or she is working within the institution? It WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material would be important to know the individual liability. For example, if sued, what financial responsibility would the nurse have? The nurse should be aware of Good Samaritan laws, but this would not be sufficient coverage for most nursing practice. Therefore it is not the most importance factor in determining whether to purchase private malpractice insurance. The amount of malpractice insurance provided by the employer is not the most important factor in deciding whether to carry private insurance. Generally, the employers malpractice insurance coverage is much greater than private insurance coverage. The area of nursing in which the nurse is employed is not the most important factor in deciding whether or not to carry malpractice insurance. Lawsuits can occur anywhere. DIF: A dm 334-335 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. An unconscious client with a head injury needs surgery to live. His wife only speaks French, and the health care providers are having a difficult time explaining his condition. Which of the following is the most correct answer regarding this situation? 1 An institutional review board needs to be contacted to give their emergency advice on the situation. 2 The health care team should continue with the surgery after providing information in the best manner possible. 3 A friend of the family could act as an interpreter, but the explanation could not provide details of the clients accident, because of confidentiality laws. 4 Two licensed health care personnel should witness and sign the preoperative consent indicating they heard an explanation of the procedure given in English. ANS: 2 In emergency situations, if it is impossible to obtain consent from the client or an authorized person, the procedure required to benefit the client or save a life may be undertaken without liability for failure to obtain consent. In such cases, the law assumes that the client would wish to be treated. In an emergency, it is not necessary to contact the institutional review board. In doing so, it would take up valuable time. A family member or acquaintance that is able to speak a clients language should not be used to interpret health information. An official interpreter must be available to explain the terms of consent (except in an emergency situation). Telephone consents usually require two witnesses. This is not the case in this situation. DIF: A dm 333 OBJ: Comprehension TOP: Nursing Process: Implementation WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. A physician asks a family nurse practitioner to prescribe a medication that the nurse practitioner knows is incompatible with the current medication regimen. If the nurse practitioner follows the physicians desire, which of the following is the most correct answer? 1 Good Samaritan laws will protect the nurse. 2 The nurse practitioner will be liable for the action. 3 This type of situation is why nurse practitioners should have malpractice insurance. 4 If the nurse practitioner has developed a good relationship with the client, there will probably not be a problem. ANS: 2 A nurse carrying out an inaccurate or inappropriate order may be legally responsible for any harm suffered by the client. Good Samaritan laws will not protect the nurse in this situation. Good Samaritan laws are for providing care at the scene of an accident. The nurse should refuse to administer the medication when he or she knows it is wrong. Having malpractice insurance is not the answer, as it does not protect the client from harm. The nurse practitioner should refuse administering the medication. Developing a good relationship with the client is important, but will not protect the nurse from legal liability for providing incompetent care. DIF: A dm 327 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. A registered nurse interprets a scribbled medication order by the attending physician as 25 mg. The nurse administers 25 mg of the medication to a client, and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who would ultimately be responsible for the error? 1 Attending physician 2 Assisting resident 3 Pharmacist 4 Nurse ANS: 4 A nurse carrying out an inaccurate or inappropriate order may be legally responsible for any harm suffered by the client. The nurse should clarify the order with the physician if unable to read the order. The attending physician could be included in a lawsuit, but it would be the nurse who is ultimately responsible for the error. The assisting resident would not be ultimately WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material responsible for the error. The assisting resident did not carry out an inaccurate order. The pharmacist could be included in a lawsuit, but it would be the nurse who is ultimately responsible for the error because the nurse was the individual who carried out an inaccurate order. DIF: A dm 327 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. A nurse is being asked to move from the eye unit to a general surgery floor where she in inexperienced in this specialty due to an influenza epidemic among the nursing staff. She is aware of her inexperience. The nurses initial recourse is to: 1 2 Fill out a report noting her dissatisfaction Ask to work with another general surgery nurse 3 Notify the State Board of Nursing of the problem 4 Politely refuse to move, take a leave-of-absence day, and go home ANS: 2 Nurses who float should inform the supervisor of any lack of experience in caring for the type of clients on the nursing unit. They should also request and be given orientation to the unit. Asking to work with another general surgery nurse would be an appropriate action. A nurse can make a written protest to nursing administrators, but it should not be the nurses initial recourse. Notifying the state board of nursing should not be the nurses initial recourse. The nurse should first notify the supervisor and request appropriate orientation and training. If problems continue, the nurse should attempt the usual chain of command within the institution before contacting the state board of nursing. A nurse who refuses to accept an assignment may be considered insubordinate, and clients will not benefit from having less staff available. DIF: A dm 335-336 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. There are issues concerning death and dying may influence nursing practice which the nurse recognizes. Concerning the legalities of death and dying issues, which of the following is true? 1 Passive euthanasia is illegal in all states. 2 Assisted suicide is a constitutional right. 3 Organ donation must be attempted if it will save the recipients life. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Feedings may be refused by competent individuals who are unable to self-feed. ANS: 4 Competent clients have the right to refuse treatment. This includes life-saving hydration and nutrition. This is not a true statement. Furthermore, physician-assisted suicide is legal in the state of Oregon. In 1997 the Supreme Court ruled that there is no fundamental constitutional right to assisted suicide. Organ donation does not have to be attempted to save a recipients life. DIF: A dm 330 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The Joint Commission (TJC) sets standards of care, in which an institution is required to have: 1 Limits of professional liability 2 3 Educational standards for nurses A delineated scope of practice for health professionals 4 Written nursing policies and procedures for client care ANS: 4 The TJC requires that accredited hospitals have written nursing policies and procedures. Standards of care help define the limits of professional liability. The TJC does not require an institution to have limits of professional liability. Nurse practice acts establish educational requirements for nurses. Nurse practice acts define the scope of nursing practice. The rules and regulations enacted by the state board of nursing define the practice of nursing more specifically. The American Nurses Association has developed standards for nursing practice that delineate the scope, function, and role of the nurse and establish clinical practice standards. DIF: A dm 326 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. In the event that a nursing license is revoked, which of the following is correct? 1 The hearings are usually held in court. 2 Due process rights are waived by the nurse. 3 Appeals may be made regarding the decisions. 4 The federal government becomes involved in the procedures. ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Because a license is viewed as a property right, due process must be followed before a license can be suspended or revoked. Due process means that nurses must be notified of the charges brought against them, and that the nurses have an opportunity to defend against the charges in a hearing. Hearings for suspension or revocation of a license do not occur in court but are usually conducted by a hearing panel of professionals. Due process must be followed. They do not have to be waived by the nurse. Some states, not the federal government, provide administrative and judicial review of such cases after nurses have exhausted all other forms of appeal. DIF: A dm 330 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which one of the following actions is an example of an unintentional tort? 1 2 3 4 Restraining a client who refuses care Taking photos of a clients surgical wounds Leaving the side rails down and the client falls and is injured Talking about a clients history of sexually transmitted diseases ANS: 3 An unintentional tort is an unintended wrongful act against another person that produces injury or harm. An example of an unintentional tort would be leaving the side rails down and the client falls and is injured. Restraining a client who refuses care would be an example of assault and battery. Taking photos of a clients surgical wounds without the clients permission is an example of invasion of privacy. Talking about a clients history of sexually transmitted diseases would fall under the category of invasion of privacy. Personal information should be kept confidential. DIF: A dm 332 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. Which one of the following individuals may legally give informed consent? 1 A 16-year-old for her newborn child 2 A sedated 42-year-old preoperative client 3 The friend of an 84-year-old married client 4 A 56-year-old who does not understand the proposed treatment plan ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material An emancipated minor, one who is below the age of 18 but who is a parent, can legally give informed consent for the care of her newborn. An emancipated minor can also be someone below the age of 18 who is legally married. A person who has been sedated cannot legally give informed consent. Consent should be obtained before a sedative is administered. If the 84-yearold client were unable to give consent, then the clients wife would be the person legally authorized to do so on the clients behalf. In order for a friend to be legally able to give consent, he or she would have to possess power of attorney or legal guardianship of the client. If a client does not understand the proposed treatment plan, the nurse must notify the physician or nursing supervisor and must make certain that clients are informed before signing the consent. DIF: A dm 332-333 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. When a nurse signs as a witness on an informed consent form, she is indicating that the client: 1 Fully understands the procedure 2 3 Agrees with the procedure to be done Has voluntarily signed the consent form 4 Has authorized the physician to continue with the treatment ANS: 3 The nurses signature witnessing the consent means that the client voluntarily gave consent, that the clients signature is authentic, and that the client appears to be competent to give consent. It is the physicians responsibility to make sure the client fully understands the procedure. If the nurse suspects the client does not understand, the nurse should notify the physician. The nurses signature does not indicate that the client agrees with the procedure, but that the client has voluntarily given consent and is competent to do so. Clients also have the right to refuse treatment, which is also signed and witnessed. The nurses signature does not verify that the client has authorized the physician to continue with treatment. It only verifies that the consent was given voluntarily, the client is competent to give consent, and the signature is authentic. DIF: A dm 332 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. A nurse who is working with clients who have DNR (do not resuscitate) orders knows that these orders: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Are legally required for terminally ill clients 2 May be written by the physician without client consent if resuscitation is futile Are maintained throughout the clients stay in either an acute care or a long-term care facility 3 4 Follow nationally consistent standards for implementation of client interventions ANS: 2 If the client is unable, and there is no surrogate available to give consent, the DNR order can be written but only if the physician is reasonably medically certain that the resuscitation would be futile. A DNR order is not legally required for terminally ill patients.. DNR orders are not necessarily maintained throughout the clients stay because a clients condition may warrant a change in DNR status. The attending physician must review the DNR orders every 3 days for hospitalized clients or every 60 days for clients in residential health facilities. There is no nationally consistent standard for DNR implementation. States have their own statutes regarding DNR orders. DIF: A dm 328-329 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. The nurse understands the implications of the Patient Self-Determination Act. This legislation requires that: 1 Clients designate a power of attorney 2 DNR orders for clients meet standard criteria 3 Organ donation is required upon death, if possible 4 Information be provided to the client regarding rights for refusal of care ANS: 4 The Patient Self-Determination Act requires health care institutions to provide written information to clients concerning the clients rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. The Patient Self-Determination Act does not require clients to designate a power of attorney. The Patient Self-Determination Act does not require that DNR orders meet standard criteria. The Patient Self-Determination Act does not require organ donation upon death. It is the clients decision whether he or she wants to participate in organ donation. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A dm 328 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. The newly enacted Health Insurance Portability and Accountability Act (HIPAA) of 2003 requires: 1 2 Insurance coverage for all clients Policies on how to report communicable diseases 3 Limits on information and damages awarded in court cases 4 Safeguards to protect written and verbal information about clients ANS: 4 The Health Insurance Portability and Accountability Act (HIPAA) requires all hospitals and health agencies to have specific policies and procedures in place to ensure that there are reasonable safeguards to protect written and verbal communications about clients. HIPAA does not require insurance coverage for all clients. It limits the extent to which health plans may impose preexisting condition limitations and prohibits discrimination in health plans against individual participants and beneficiaries based on health status. HIPAA does not require policies on how to report communicable diseases. It does require safeguards to protect written and verbal information about clients. HIPAA does not require limits on information and damages awarded in court cases. DIF: A dm 329 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. A client is told by his nurse that he has to take the medications, including an injection. The client refuses the medications, but continues to have them administered by the nurse. This action is an example of the intentional tort of: 1 Assault 2 Battery 3 Malpractice Invasion of privacy 4 ANS: 2 Battery is any intentional touching without consent. An example of battery is a nurse who gives a medication after the client has refused. Assault is any intentional threat to bring about harmful or WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material offensive contact. No actual contact is necessary. Malpractice is negligence committed by a professional such as a nurse or physician. This case is not an example of malpractice. Invasion of privacy is where the client has unwanted intrusion into his or her private affairs. This case is not an example of invasion of privacy. DIF: A dm 331 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. A nurse who is working with a client who has been diagnosed with AIDS reveals the clients name and diagnosis with a co-worker on the way downstairs in an elevator. Unknowingly, a friend of the client that happens to be sharing the elevator and hears the entire story. The nurse who shared the information may be held liable for: 1 2 3 4 Slander Assault Malpractice Invasion of privacy ANS: 1 A nurse can be held liable for slander if he or she shares private client information that can be overheard by others. Assault is any intentional threat to bring about harmful or offensive contact. No actual contact is necessary. The nurse in this situation has not committed assault. Malpractice is negligence committed by a professional such as a nurse or physician. Nursing malpractice results when care falls below the standard of care. This case is not an example of malpractice. Invasion of privacy occurs when the client has unwanted intrusion into his or her private affairs. This case is not an example of invasion of privacy. This instance falls under the category of defamation of character. DIF: A dm 331 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. A nurse stealing narcotics from an acute care nursing unit is guilty of a: 1 Civil offense 2 Criminal offense 3 Common law offense Administrative law offense 4 ANS: 2 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Criminal laws prevent harm to society and provide punishment for crimes (often imprisonment). A felony is a crime of a serious nature that has a penalty of imprisonment for greater than 1 year or even death. A misdemeanor is a less serious crime that has a penalty of a fine or imprisonment for less than 1 year. An example of criminal conduct for nurses is misuse of a controlled substance. Civil laws protect the rights of individual persons within our society and encourage fair and equitable treatment among people. Common law is created by judicial decisions made in courts when individual legal cases are decided (i.e., informed consent). Administrative law is created by administrative bodies, such as state boards of nursing, when they pass rules and regulations. DIF: A dm 326 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. The case of a nurse accused of unethical nursing conduct will be heard by the state board of nursing. This is an example of: 1 Civil law 2 3 Criminal law Common law 4 Administrative law ANS: 4 Administrative law is created by administrative bodies, such as state boards of nursing when they pass rules and regulations such as unethical nursing conduct. Civil laws protect the rights of individual persons within our society and encourage fair and equitable treatment among people. Criminal laws prevent harm to society and provide punishment for crimes (often imprisonment). Common law is created by judicial decisions made in courts when individual legal cases are decided. DIF: A dm 330 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following statements made by a nursing student regarding responsibility for provided care requires immediate follow-up by the nursing instructor? 1 Im not held to the same standards as a licensed RN. 2 I am required to provide the safest, appropriate care I am capable of. 3 My clinical instructor is ultimately responsible for the care I provide. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 No one expects nursing students to provide care on the level as an experienced RN. ANS: 3 Student nurses are expected to perform as professional nurses, that is, as an RN would in providing safe, appropriate client care. The clinical instructor is responsible for proper instruction, supervision, and guidance but the student is responsible for their own acts. The remaining options do reflect misconceptions, but the issue of responsibility has priority. DIF: C dm 333 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. The nurse is having difficulty reading the prescribed dosage on a handwritten order for a pain medication. The most appropriate action to ensure the clients safety and to minimize legal issues is for the nurse to: 1 Ask another RN to confirm the order 2 Request the pharmacist to interpret the order Call the health care provider to clarify the order 3 4 Consult a current drug book to determine the normal dosage range ANS: 3 A nurse carrying out an inaccurate or inappropriate order may be legally responsible for any harm suffered by the client. The nurse should clarify the order with the prescriber if unable to read the order. Although asking others to interpret the order may appear prudent, it is ultimately the nurses responsibility if a medication error is made. Although the drug book may provide a normal range it does not aid in determining definitively what the order intended. DIF: A dm 336 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The legal basis for a nurse to provide emergency treatment without consent to a client incapable of informed consent is: 1 Such care is clearly a nursing responsibility 2 To fail to provide such care is nursing negligence 3 It is presumed that the client would want the emergency treatment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Health care providers have an obligation to provide emergency treatment ANS: 3 In emergency situations, if it is impossible to obtain consent from the client or an authorized person, the law assumes that the client would wish to be treated. Providing appropriate nursing care is a nursing responsibility, and failure to do so is negligence. DIF: C dm 332 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. An experienced pediatric nurse is reassigned to an adult oncology floor because of staffing issues and immediately recognizes a lack of experience in this specialty. Which of the following nursing actions shows a lack of professionalism? 1 Politely declining the assignment 2 Filling out a report noting her dissatisfaction 3 Asking to work with another oncology nurse Notifying the state board of nursing of the problem 4 ANS: 1 A nurse who refuses to accept an assignment may be considered insubordinate, and clients will not benefit from having less staff available. This is an unprofessional attempt to resolve the problem. Asking to work with another oncology nurse, sending a written protest, and notifying the state nursing board would be appropriates action, and so are not examples of unprofessional behavior. DIF: C dm 335 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. Although a nurse may not agree, the nurse recognizes that a terminally ill client has the legal right to: 1 Seek passive euthanasia in some states 2 Sign an organ donor pledge statement 3 Refuse DNR (do not resuscitate) status 4 Refuse treatment in the form of food and water ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Competent clients have the right to refuse treatment. This includes life-saving hydration and nutrition. Physician-assisted suicide is legal in the state of Oregon, and it is legally a clients decision to declare a DNR status or to sign an organ donor card. DIF: A dm 328 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. Which of the following statements best reflects a nurses understanding of the proper critical thinking process regarding the need for personal malpractice insurance? 1 The states Good Samaritan laws protect me outside of the hospital. 2 I work in a very low risk area of nursing, so I dont really have a need. The hospital carries its own malpractice insurance, so I dont need extra. 3 4 Lawsuits can occur years after the event, so I carry my own liability insurance. ANS: 4 The employing institutions insurance only covers nurses while they are working within the scope of their employment. Because nurses are professionals and it is often difficult to separate their private lives from their professional skills, nurses need to consider purchasing individual professional liability insurance, even if the employing institution has coverage. It would be important to know the time frames of the employers malpractice coverage. The nurse may be only covered during the times he or she is working within the institution. Good Samaritan laws have a narrow scope and would not cover many nursing activities. Although it is true that some areas of nursing have a higher potential for liability claims, all areas have risk. The hospitals insurance may not cover all potential expenses and may not be applicable in all liability situations. DIF: C dm 334-335 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. Which of the following statements made by a nurse puts the nurse at risk for assault of the client? 1 You will be sorry if you dont agree to take this medication. 2 You cant refuse this medication if you really want to feel better. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Ill be so disappointed in you if you dont take your medication. 4 Ill tell your son you arent cooperating if you dont take your medication. ANS: 1 Assault is any intentional threat to bring about harmful or offensive contact. No actual contact is necessary. Threatening to tell a family member may be a breech of confidentiality; the remaining options are examples of unnecessary pressuring of the client. This case is not an example of invasion of privacy. DIF: C dm 331 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. Which of the following statements made by a nurse shows the best understanding regarding the requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 2003? 1 Im always careful to close the door when taping or listening to the units shift report. 2 The nursing assistants know to hand me the vital signs sheet and not just put it on the medication cart. I called the radiology department to tell them I would be faxing the client information they requested. 3 4 The clients niece called to see how she slept last night, but I told her I couldnt share that with her over the phone. ANS: 3 The Health Insurance Portability and Accountability Act (HIPAA) requires all hospitals and health care agencies to have specific policies and procedures in place to ensure that there are reasonable safeguards to protect written and verbal communications about clients. By notifying the receiver of an impending client-oriented fax, the nurse has taken a reasonable measures to ensure it is seen by only the appropriate individuals. Although the remaining options deal with safeguards, the potential for a breech in client confidentiality is not as great in those scenarios. DIF: C dm 331 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. Which of the following statements made by a nurse reflects the best understanding of the legal safeguards of a DNR (do not resuscitate) order? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 All family members need to agree before a DNR order can be written. 2 All terminally ill clients are ultimately required to be declared a DNR status. The DNR order on the terminally ill client in Room 45 needs reviewed today. 3 4 If the clients family cant be located, the physician will write the DNR order. ANS: 3 DNR orders are not necessarily maintained throughout the clients stay because a clients condition may warrant a change in DNR status. To ensure client safety, the attending physician must review the DNR orders every 3 days for hospitalized clients or every 60 days for clients in residential health facilities. If there is no living will or durable power of attorney appointed, members of the family will be consulted regarding a DNR order. Although not all family members need to agree, an order will usually not be written if some family members express strong opposition to the status change. If no family can be located, the attending physician has the legal right to write the order. There is no legal requirement for a terminally ill client to be required to assume DNR status. DIF: C dm 328-329 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. Which of the following statements made by a nurse reflects a lack of understanding regarding a DNR (do not resuscitate) order? 1 All family members need to agree before a DNR order can be written. 2 All terminally ill clients are ultimately required to be declared a DNR status. The DNR order on the terminally ill client in Room 45 needs reviewed today. 3 4 If the clients family cant be located the physician will write the DNR order. ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material If there is no living will or durable power of attorney appointed, members of the family will be consulted regarding a DNR order. Although not all family members need to agree, an order will usually not be written if some family members express strong opposition to the status change. DNR orders are not necessarily maintained throughout the clients stay because a clients condition may warrant a change in DNR status. To ensure client safety, the attending physician must review the DNR orders every 3 days for hospitalized clients or every 60 days for clients in residential health facilities. If no family can be located, the attending physician has the legal right to write the order. There is no legal requirement for a terminally ill client to be required to assume DNR status. DIF: C dm 328-329 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. Which of the following statements made by a nurse shows a lack of understanding regarding the Uniform Anatomical Gift Act? 1 A client must be 21 to give consent to be an organ donor. 2 All clients admitted to the hospital are asked about becoming an organ donor. We have a form here on the unit that must be signed to show a clients informed consent to be an organ donor. 3 4 In our state, you can check the back of a clients drivers license to verify whether they are an organ donor. ANS: 1 An individual who is at least 18 years of age has the right to make an organ donation (defined as a donation of all or part of a human body to take effect upon or after death). Donors need to make the gift in writing with their signature. In many states, adults sign the back of their drivers license, indicating consent to organ donation. In most states, required request laws mandate that at the time of admission to a hospital, a qualified health care provider has to ask each client older than 18 whether he or she is an organ or tissue donor. DIF: C dm 329 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 32. The nurse is heard stating to another staff member that, the client in Room 54 is such a whiner; you would think she was dying. This nurse is liable of: 1 Libel 2 Slander WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Malpractice 4 Invasion of privacy ANS: 2 Defamation of character is the publication of false statements either verbally or in writing that result in damage to a persons reputation. Slander occurs when one verbalizes the false statement. Libel is the written defamation of character, whereas invasion of privacy occurs when the client has unwanted intrusion into his or her private affairs. Malpractice is negligence committed by a professional such as a nurse or physician. Nursing malpractice results when care falls below the standard of care. DIF: A dm 332 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 33. Which of the following nursing statements reflects the best understanding of the importance of appropriate nursing documentation regarding risk management? 1 If the client isnt compliant, Im sure to put that in my notes. 2 Im always careful to document any changes in the clients condition. 3 My notes are the proof that I provided the client with effective, appropriate care. 4 When there is a lawsuit, the nursing notes are the first thing the attorney looks at. ANS: 3 The nurses documentation is often the evidence of care received by a client and serves as proof that the nurse acted reasonably and safely. The remaining options are not incorrect but do not identify the primary importance to the nurse. DIF: C dm 336 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 34. Which of the following statements reflects a nurses need for further instructions regarding an incident report? 1 I hope this incident report will help determine a way to help prevent falls. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Risk management will want to review the incident report on the clients fall. 3 I put the incident report on the clients fall in his chart as soon as I was finished. I need to review the guidelines before I fill out this incident report regarding the clients fall. 4 ANS: 3 The report is confidential and separate from the medical record. The remaining options reflect an understanding about incident reports. DIF: C 336 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 35. Regarding hours worked and frequency of errors, recent research has shown that nurses working more than 12.5 hours per shift and more than a 40-hour week are: 1 Reporting more physical illnesses than those working only 40 hours per week 2 Three times more likely to commit an error in nursing judgment related to client care 3 Experiencing more physical injuries than those working only 40 hours per week 4 Experiencing signs of emotional burn out more frequently than those working only 40 hours per week ANS: 2 Results showed that nurses who worked shifts lasting 12.5 hours or more had a three times greater likelihood of making an error. Overtime increased the odds of making at least one error regardless of length of original shift scheduled. The remaining options are not supported by research data. DIF: C REF: 335 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 36. While working as a nursing assistant, a nursing student is asked to reinsert a Foley catheter by the RN. Which of the following reflects the most appropriate initial student response to the request? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Notify the nursing supervisor of the inappropriate request. 2 3 Tell the RN that she can only perform as a nursing assistant. Agree to perform the task but with the supervision of the RN. 4 Jointly read the nursing assistant job description with the RN. ANS: 2 When students work as nursing assistants or nurses aides, they should not perform tasks that do not appear in a job description for a nurses aide or assistant. The remaining options do not appropriately address the immediate situation. DIF: C REF: 333-334 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following statements is true regarding the implications of the nurses signature as a witness for a clients consent? (Select all that apply.) 1 Client signed voluntarily. 2 The signature is authentic. 3 Client appears to be competent. Client appears knowledgeable about the procedure. 4 5 6 The nurse has discussed the possible risks of the procedure. The nurse has discussed possible post procedure nursing care. ANS: 1, 2, 3, 4 The nurses signature witnessing the consent means that the client voluntarily gave consent, that the clients signature is authentic, and that the client appears to be competent to give consent. When nurses provide consent forms for clients to sign, nurses must ask the clients if they understand the procedure for which they are giving consent. If clients deny understanding or you suspect they do not understand, notify the physician or nursing supervisor. Nursing care post procedure should be discussed but is not inferred by a nurses signature as a witness. Discussing possible risk factors is the physicians responsibility. DIF: C REF: 332-333 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2. When documenting notification of the primary health care provider concerning a client whose condition is deteriorating, the nurse must be sure to include which of the following? (Select all that apply.) 1 Clients wife at bedside. 2 3 Client rating pain at 3 out of 10 at 0920. Client asking to have wife called to come to hospital. 4 Dr. Smith notified of clients pain rating of 8 out of 10 at 0900. 5 Client administered 2 mg morphine sulfate IV every 5 minutes for two doses. Client ordered morphine sulfate 2 mg IV every 5 minutes until pain relief is achieved. 6 ANS: 2, 4, 5, 6 The nurse must be certain to document that the physician was notified and his or her response, nursing action in follow-up of orders, and the clients response. The remaining options are not relevant to the proper documentation of the situation. Chapter 24. Communication MULTIPLE CHOICE 1. The client tells the nurse that he understands most of the information but still has questions concerning the medication after the nurse has provided the client with information regarding the treatment plan for the diagnosis the. This response is an example of: 1 Referent 2 Receiver 3 Channel 4 Feedback ANS: 4 This response is an example of feedback. Feedback is the message returned by the receiver. The referent motivates one person to communicate with another, such as a time schedule. This is not an example of a referent. The receiver is the person who receives and decodes the message. This question is not asking about the receiver, but rather the response. Channels are means of conveying and receiving messages through visual, auditory, and tactile senses. This response is not an example of a channel. DIF: A REF: 343 OBJ: Comprehension TOP: Nursing Process: Implementation/Evaluation WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The nurse is in the process of conducting an admission interview with the client. At one point in the discussion, the client has provided information that the nurse would like to clarify. The nurse employs the technique of clarification as indicated by the response: 1 Im not sure that I understand what you mean by that statement. 2 The ECG records information about your hearts electrical activity. 3 Lets look at the problem you have had with your medication when you were home. 4 Whats your biggest concern related to your hospitalization at the moment? ANS: 1 Im not sure that I understand what you mean by that statement is correct. Clarifying is when the nurse checks whether understanding is accurate by restating an unclear message to clarify the senders meaning, or by asking the other person to restate the message, explain further, or give an example of what the person means. This response indicates the nurse wants to clarify what the client is saying so he or she can have an accurate understanding of what the client means. The ECG records information about your hearts electrical activity is an example of providing information, not clarification. Lets look at the problem you have had with your medication when you were home is an example of focusing, not clarification. Whats your biggest concern related to your hospitalization at the moment is an example of sharing empathy. DIF: A REF: 354 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The faculty member is reviewing a process recording with the student nurse. The student has been working with a client who has had an amputation of the lower left leg and is emotionally fragile. The student receives positive feedback from the faculty member for the following response made to the client: 1 Why are you so upset today? 2 Im sure that everything will be all right. 3 You shouldnt cry. The wound will heal soon. It must be very difficult to have this happen to you. 4 ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material It must be very difficult to have this happen to you is an example of using the therapeutic communication technique of sharing empathy. Why are you so upset today? is an example of a nontherapeutic communication technique of asking for explanations. Im sure that everything will be all right is an example of a nontherapeutic communication technique of giving false reassurance. You shouldnt cry. The wound will heal soon is an example of a nontherapeutic communication technique of giving disapproval. DIF: A REF: 353 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. When reaching over the side rails to take a clients blood pressure, he draws back. To promote effective communication, the nurse should first: 1 Tell the client that the blood pressure can be taken at a later time 2 Rotate the nurses who are assigned to take the clients blood pressure 3 Continue to perform the blood pressure assessment quickly and quietly 4 Apologize for startling the client and explain the need for touching the client ANS: 4 Nurses often have to enter a clients personal space to provide care. The nurse should convey confidence, gentleness, and respect for privacy. This response demonstrates respect and provides information so the client can understand the need for personal contact. Telling the client that the blood pressure can be taken at a later time does not promote effective communication. Rotating the nurses who are assigned to take the clients blood pressure impedes the nurses ability to form a therapeutic, helping relationship. Continuing to perform the procedure quickly and quietly may send a negative nonverbal message. It also does not promote effective communication. DIF: A REF: 343 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. Communication involves both active listening and body language working together. The nurse actively listens to the client and: 1 Sits facing the client 2 Keeps the arms and legs crossed WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Leans back in the chair away from the client 4 Avoids eye contact as much as is physically possible ANS: 1 Active listening means to be attentive to what the client is saying both verbally and nonverbally. A nonverbal skill to facilitate attentive listening is to sit facing the client. This posture gives the message that the nurse is there to listen and is interested in what the client is saying. For active listening, the arms and legs should be uncrossed. This posture suggests that the nurse is open to what the client says. For active listening, the nurse should lean toward the client. This posture conveys that the nurse is involved and interested in the interaction. For active listening, the nurse should establish and maintain intermittent eye contact. This conveys the nurses involvement in and willingness to listen to what the client is saying. DIF: A REF: 344 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. During the assessment phase of the nursing process, the nurse may uncover data that help to identify communication problems. An example of this information is: 1 2 Extreme dyspnea or shortness of breath Urinary frequency and pain 3 Chronic stomach pain 4 Lack of appetite ANS: 1 An extremely breathless person must use oxygen to breathe rather than speak. Urinary frequency may interrupt conversation but is not a communication problem. Chronic stomach pain would not be a communication problem. The patient with chronic pain is, to some degree, used to the pain. A lack of appetite is not a communication problem. DIF: A REF: 349 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. When a nurse tells an advanced nurse practitioner that her client is slipping a little in reference to hemodynamic pressures, The nurse is using: 1 Brevity 2 Relevance Pacing and control. 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Connotative meaning ANS: 4 The connotative meaning is the shade or interpretation of a words meaning influenced by the thoughts, feelings, or ideas people have about the word. Slipping a little in reference to hemodynamic pressures is an example of using connotative meaning. Brevity means that communication is simple, brief, and direct. This is not an example of using brevity. Relevance means the message is relevant or important to the situation at hand. This is not an example of using relevance. Pacing and control mean speaking slowly enough to enunciate clearly and not changing subjects rapidly. This is not an example of using pacing and control. DIF: A REF: 344 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. A client is admitted for a CAT scan (diagnostic test) of the cranium. As the nurse explains this diagnostic test, the client moves away from the nurse. This is an example of what influencing factor in communication? 1 Gender 2 Environment 3 Space and territoriality Sociocultural background 4 ANS: 3 Territoriality is the need to gain, maintain, and defend ones right to space. The client who moves away from the nurse during a conversation is demonstrating the influence of space and territoriality on communication. This not an example of gender influencing communication. This is not an example of environment influencing communication. Noise, temperature extremes, distractions, and lack of privacy are examples of environmental factors that may influence communication. Although people do maintain varying distances between each other depending on their culture, this is not an example of sociocultural background influencing communication, as cultural orientation is not mentioned in this situation. DIF: A REF: 345 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The nurse will often display empathy in communication with clients. Of the following responses by the nurse, which one best conveys empathy? 1 Good morning. How did you sleep last night? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 I can understand your concern about learning to inject yourself. 3 Do you mean you would like to talk to the new family nurse practitioner? Can you describe to me what the pain in your abdomen feels like right now? 4 ANS: 2 I can understand your concern about learning to inject yourself is correct. Empathy is the ability to understand and accept another persons reality, to accurately perceive feelings, and to communicate this understanding to others. Good morning. How did you sleep last night? is asking a question. It does not convey empathy. Do you mean you would like to talk to the new family nurse practitioner? is asking a question to clarify the clients meaning. It does not convey empathy. Can you describe to me what the pain in your abdomen feels like right now? is asking a relevant question that may focus on a particular topic. It is not an example of empathy. DIF: A REF: 353 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. In working with a client who is newly diagnosed with diabetes mellitus, the nurse provides feedback to the client on her progress in learning the treatment regimen. Of the following, the nurse demonstrates the use of therapeutic communication by stating: 1 2 3 4 I believe that you have come a long way in learning how to manage your care. It didnt look like you were ever going to be able to get the injection technique. Check your blood sugar unless you really want to come back to the hospital again. You dont appear to have any real interest in managing your daily dietary intake. ANS: 1 In stating, I believe that you have come a long way in learning how to manage your care the nurse is demonstrating the use of therapeutic communication by sharing hope. The nurse is pointing out that personal growth can come from illness experiences. It didnt look like you were ever going to be able to get the injection technique is a negative statement. The nurse should not state observations that might embarrass or anger the client. Check your blood sugar unless you WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material really want to come back to the hospital again does not demonstrate the use of therapeutic communication. It implies disapproval and is an aggressive, threatening type of response. You dont appear to have any real interest in managing your daily dietary intake is not a therapeutic statement. It is negative and aggressive in nature. If it is a true observation, it is one the nurse should not state as it could anger the client. DIF: A REF: 353 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Ive never told anyone this information about my son, is an example of a parent: 1 Identifying problems 2 Building trust 3 Clarifying roles 4 Revealing ANS: 2 This response is an example of trust. Trusting another person involves risk and vulnerability, but it also fosters open, therapeutic communication and enhances the expression of feelings, thoughts, and needs. This statement is not an example of revealing. Although the parent may have provided information that was never before revealed, in this statement the parent is indicating there is trust between himself or herself and the nurse practitioner. This statement is not clarifying roles of the nurse and client. This statement is not an example of identifying problems and goals. DIF: A REF: 348 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. Discussing the clients follow-up dietary needs immediately after the surgery when the client is experiencing discomfort is an error in: 1 Pacing 2 Intonation 3 Timing and relevance 4 Denotative meaning ANS: 3 Discussing follow-up dietary needs immediately after surgery when the client is experiencing discomfort is an error in timing and relevance. The client is less likely to be able to pay attention WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material and comprehend instruction when in pain, and immediately after surgery, discussing follow-up dietary needs would seem irrelevant. Pacing has to do with the speed of conversation. This is not an example of an error in pacing. Intonation is the tone of voice used. This is not an example of an error in intonation. Denotative meaning is when a single word can have several meanings. This is not an example of an error in denotative meaning. DIF: A REF: 3744 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The nurse is aware of the clients zones of personal space when planning interactions. The zone of personal space and touch that extends the greatest amount from an individual is the: 1 2 Social zone Personal zone 3 Consent zone 4 Vulnerable zone ANS: 1 The social zone extends the greatest amount from an individual in personal space and touch. It is a distance of 4 to 12 feet. Permission is not needed for touch in the social zone. The personal zone is 18 inches to 4 feet. The consent zone of touch requires permission. The vulnerable zone is in the consent zone of touch. Because the vulnerable zone implies special care is needed, permission is required. DIF: A REF: 348 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. Throughout the nursing process communication is used. During the evaluation phase, communication is specifically used by the nurse to: 1 Delegate activities to other staff members 2 Validate the clients health and wellness needs 3 Acquire both verbal and nonverbal client feedback Document expected outcomes and planned interventions 4 ANS: 3 The nurse and client determine whether the plan of care has been successful by evaluating the client communication outcomes established during planning. This process involves acquiring verbal and nonverbal feedback. Delegation is not the purpose of communication in the evaluation WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material phase of the nursing process. Delegation is more likely to be used in the implementation phase of the nursing process. Validation of the clients needs is not why the nurse specifically uses communication in the evaluation phase of the nursing process. Validation of the clients needs is often determined when data are gathered during the assessment phase of the nursing process. Documenting expected outcomes and planned interventions is part of the planning phase of the nursing process, not the evaluation phase. DIF: A REF: 344 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. There are a number of variables that may influence the clients communication with the health care team. Which of the following is an example of an interpersonal variable? 1 Postoperative discomfort 2 An extremely warm room 3 A talkative roommate 4 A loud television ANS: 1 Interpersonal variables are factors within both the sender and receiver that influence communication. An example of an interpersonal variable is postoperative discomfort. An extremely warm room is an example of an environmental variable that may affect communication. A talkative roommate is an example of an environmental variable that may affect communication because of the lack of privacy and distraction. Noise, such as a loud television, is an example of an environmental variable that may affect communication. DIF: A REF: 343-344 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. A helping relationship is being established between nurse and client. In addressing the client, the nurse should: 1 Use the clients first name 2 Touch the client right away to establish contact 3 Sit far enough away from the clients personal space 4 Always knock and pause before entering the clients room ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Common courtesy is part of professional communication. To practice courtesy, the nurse says hello and goodbye, knocks on doors before entering, and uses self-introduction. Knocking on doors is important in addressing the client. Because using last names is respectful in most cultures, nurses usually use the clients last name in the initial interaction, and then use the first name if the client requests it. Touching the client right away would not be an appropriate action in establishing a helping relationship. It would more likely be interpreted as invading the clients personal space. Sitting far enough away from the client is important in that the nurse should not enter the clients personal space when establishing a helping relationship. However, leaning toward the client conveys that the nurse is involved and interested in the client. Knocking on the door before entering the clients room would be the first step in addressing the client properly. DIF: A REF: 348 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. In using communication skills with clients, the nurse evaluates which response as being the most therapeutic? 1 Why dont you stick to the special diet? 2 I noticed that you didnt eat lunch. Is something wrong? 3 I think you need to find another physician thats better than this one. 4 We cant continue talking about your problems; its time for your bath. ANS: 2 The nurse who is sharing an observation, I noticed that you didnt eat lunch. Is something wrong? is using the most therapeutic response. Sharing observations often helps the client communicate without the need for extensive questioning, focusing, or clarification. Why dont you stick to the special diet? is an example of a nontherapeutic response. It is asking for an explanation. Why questions can cause resentment, insecurity, and mistrust. I think you need to find another physician thats better than this one. is not a therapeutic response. It is giving a personal opinion. Changing the subject, We cant continue talking about your problems; its time for your bath, is not therapeutic. DIF: A REF: 352 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. When dealing with toddlers or preschoolers what communication technique may be used most effectively? 1 Using analogies to explain health-related ideas WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Allowing manipulation of equipment to be used 3 Moving quickly and minimizing contact to avoid distress 4 Focusing on what other children on the unit may have been doing ANS: 2 Allowing toddlers and preschoolers to touch and examine objects that will come in contact with them is an effective communication technique. Toddlers and preschoolers are unable to understand analogies. Sudden movements can be frightening. Children often prefer to make the first move in interpersonal contacts. Focusing on what other children have done is not an effective communication technique for toddlers or preschoolers. Communication should be focused on the child. DIF: A REF: 350 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. When working with a client with aphasia, the nurse may attempt to enhance communication by: 1 Using visual cues 2 Speaking loudly 3 Using open-ended questions 4 Communicating through a speech therapist ANS: 1 The nurse may enhance communication for a client with aphasia by using visual cues (e.g., words, pictures, and objects) when possible. The nurse should not shout or speak too loudly to enhance communication with a person who has aphasia. The nurse should ask simple questions that require yes or no answers to enhance communication with the client who has aphasia. Using a speech therapist is not the primary way to enhance communication with a client who has aphasia. The nurse can use communication techniques to facilitate communication and to develop a helping relationship with the client. The speech therapist may help the client to learn new ways or to relearn how to communicate. DIF: A REF: 357 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following statements best reflects the clients positive feedback to the nurses question, Do you understand how to check your blood sugar? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Nodding affirmatively 2 3 I test it 4 times a day. Yes, I understand how to do it. 4 Demonstrating a fingerstick to the nurse ANS: 4 Feedback is the message the receiver returns. It indicates whether the receiver understood the meaning of the senders message. Demonstrating the technique is the best way to show the nurse an understanding of the process. The other options either nonverbally or verbally indicate understanding; they are not as conclusive as showing understanding. DIF: C REF: 343 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following nursing statements is the best example of the communication tool of clarification? 1 Please say that again. 2 I dont think I understand. 3 What did you mean by that? 4 Can you give me an example? ANS: 4 To check whether understanding is accurate, ask the other person to rephrase it, explain further, or give an example of what the person means. By asking for an example, the nurse is best able to determine the meaning of the clients statement. The other options either simply ask the client to repeat the statement or state that the nurse needs further information. DIF: C REF: 354 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. Which of the following is the single most negative factor affecting a nurses credibility? 1 Deficient technical skills 2 Unethical or illegal behavior 3 Lack of caring and empathy Poor nurse-client communication 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 4 Breakdown in communication is a top contributor to errors in the workplace and threatens professional credibility. The remaining options affect credibility but not to the extent that poor communication does. DIF: C REF: 340 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The best communicator is the nurse who: 1 Thinks critically 2 Is a good listener 3 Is comfortable talking 4 Empathizes with the client ANS: 1 Nurses who develop good critical thinking skills make the best communicators. The remaining options identify components of good communication. DIF: C REF: 340-341 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. Which of the following statements shows the best attempt by a nurse to overcome personal biases? 1 So how does that make you feel? 2 Most people really like Dr. Jones. 3 I know how that must frighten you. How much did the medication help your pain? 4 ANS: 1 People often assume that others think, feel, act, react, and behave as they would in similar circumstances. They tend to distort or ignore information that goes against their expectations, preconceptions, or stereotypes. This statement clearly shows the nurse attempting to assist the client in expressing his or her personal feelings. The remaining options all make a presumption about the clients feelings or attitudes. DIF: C REF: 341 OBJ: Analysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. A close, effective nurse-client relationship impacts interpersonal communication most by facilitating: 1 2 3 4 Client education regarding health-related issues The accurate interpretation of shared information A free exchange of information between client and nurse The clients expression of physical and emotional needs ANS: 2 The more the sender and receiver have in common and the closer the relationship, the more likely they will accurately perceive one anothers meaning and respond accordingly. The remaining options are outcomes of an effective nurse-client relationship but they do not impact communication as directly. DIF: C REF: 340 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. Mentally reviewing the steps of a complicated nursing procedure before entering the clients room is an example of: 1 Nonverbal communication 2 Interpersonal communication 3 Intrapersonal communication Transpersonal communication 4 ANS: 2 A type of intrapersonal communication, self-instructions, provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more effectively. Interpersonal communication is one-to-one interaction between the nurse and another person that often occurs face to face while transpersonal communication is interaction that occurs within a persons spiritual domain. Nonverbal communication includes all five senses and everything that does not involve the spoken or written word. DIF: A REF: 342 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 27. The nurse can best detect that a client needs clarification of the information provided on a special diet by: 1 2 Asking the client frequently if they have any questions Assessing the clients nonverbal cues that suggest confusion 3 Providing the client with written supportive materials on the diet 4 Requesting that the client rephrase the information in his or her own words ANS: 2 You determine the need for clarification by watching the listener for nonverbal cues that suggest confusion or misunderstanding. The remaining options are means of reinforcing or evaluating the listeners understanding of the information. DIF: C REF: 354 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. The nurse observes a client with head bowed and hands folded seemingly in prayer. The nurse recognizes this as an example of: 1 Nonverbal communication 2 Interpersonal communication 3 Intrapersonal communication 4 Transpersonal communication ANS: 4 Transpersonal communication is interaction that occurs within a persons spiritual domain. Many persons use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their higher power. Intrapersonal communication, self-talk or self-instruction provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more effectively. Interpersonal communication is one-to-one interaction between the nurse and another person that often occurs face to face while nonverbal communication includes all five senses and everything that does not involve the spoken or written word. DIF: A REF: 342 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 29. The nurse is discussing discharge instructions with a client who was recently diagnosed with type 1 diabetes mellitus and is now taking insulin. The nurse recognizes this as an example of: 1 2 3 4 Nonverbal communication Interpersonal communication Intrapersonal communication Transpersonal communication ANS: 2 Interpersonal communication is one-to-one interaction between the nurse and another person that often occurs face to face. Transpersonal communication is interaction that occurs within a persons spiritual domain whileintrapersonal communication, self-talk or self-instruction provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more effectively. Nonverbal communication includes all five senses and everything that does not involve the spoken or written word. DIF: A REF: 342 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. A nurse provides a brief but concise orientation to the use of the rooms telephone and television to a newly admitted older client experiencing abdominal pain. The clients daughter later reports that her father attempted to call her but was never shown how to use the telephone. The most likely cause for the clients apparent lack of knowledge retention is: 1 Admission to the hospital has caused mild confusion that is not atypical in older clients 2 The pain was distracting him from focusing on the information when it was provided 3 He is experiencing forgetfulness regarding newly introduced nonessential information The nurse did not take adequate time to explain the use of either the telephone or the television 4 ANS: 2 Timing is critical in communication. Even though a message is clear, poor timing prevents it from being effective. Do not begin routine teaching when a client is in severe pain or emotional distress. Although the other options may affect client retention of information, the scenario did not provide reason to believe that any of the options rather than poor timing was the primary factor. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 344 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. An older client who appears confused after discussing his new diagnosis of Parkinsons disease shares with the nurse that, I didnt understand much of what you said. The nurse determines that the most likely cause of the clients failure to understand is that: 1 The conversation included unfamiliar medical terminology 2 The client is in denial concerning the diagnosis of Parkinsons disease The nurses choice of timing for the client education was poor 3 4 The etiology of the condition is too complicated for this client to understand ANS: 1 Medical jargon (technical terminology used by health care providers) sounds like a foreign language to clients unfamiliar with the health care setting. Limiting use of medical jargon to conversations with other health team members will improve communication. The remaining options may have contributed to the problem, but the more common problem deals with inappropriate use of jargon. DIF: C REF: 344 OBJ: Analysis TOP: Nursing Process: Planning/Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 32. The nurse shares with a client diagnosed with bipolar disorder who is in the manic phase that, The CNA will be in 20 minutes to complete your ADLs. This nurse-initiated communication will likely result in client confusion or noncompliance because: 1 The timing of the conversation was poorly chosen 2 The client was not actively involved in the decision-making process The conversation relied on terms familiar only to health care providers 3 4 The nurse assumed that the client would accept the nursing assistants help ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Medical jargon (technical terminology used by health care providers) sounds like a foreign language to clients unfamiliar with the health care setting. Limiting use of medical jargon to conversations with other health team members will improve communication. The remaining options may contribute to client confusion and/or noncompliance, but the heavy reliance on unfamiliar terms is the most likely primary cause in this situation. DIF: C REF: 344 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 33. The nurse sits on a chair alongside a clients bed to discuss the postoperative nursing care the client will receive. The therapeutic outcome of sitting beside the client is that: 1 The nurse-client relationship will be strengthened 2 The client will feel less threatened by the nurses presence The nurse can appear more relaxed during the conversation 3 4 The nurse and client will be equal participants in the conversation ANS: 1 Looking down on a person establishes authority, whereas interacting at the same eye level indicates equality in the relationship. While the remaining options may be correct in some situations, the primary benefit of the nurse sitting is to convey to the client that both are equal contributors to the conversation. DIF: C REF: 345 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 34. The nurse enters a clients room and finds her crying softly. The most therapeutic statement the nurse can make at this time is to ask: 1 Are you alright? 2 Why are you crying? 3 What can I do to help you? Is being hospitalized upsetting you? 4 ANS: 2 Sounds have several interpretations: crying may communicate happiness, sadness, or anger. The nurse needs to validate such nonverbal messages with the client to interpret them accurately. Although the other options may elicit information regarding the clients tears, they make WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material assumptions or attempt to provide generalized comfort without first establishing the cause of the tears. DIF: C REF: 345 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 35. Supporting a client by holding onto her elbow while accompanying her as she ambulates around the nursing unit is considered social touching and so would typically: 1 Be considered nonthreatening by the client 2 Not require the clients permission 3 Be viewed as therapeutic by the nurse 4 Not be needed unless the client was ataxic ANS: 2 A persons hands, arms, shoulders, and back are considered social zones and typically do not cause a client emotional discomfort if touched, and so permission to do so is not generally required. Nurses frequently move into clients personal space because of the nature of caregiving. You need to convey confidence, gentleness, and respect for privacy, especially when your actions require intimate contact or involve a clients vulnerable zone. The remaining options do not necessarily deal with a clients social touching zone. DIF: C REF: 353-354 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 36. When meeting for the first time, the home health nurse smiles warmly and shakes the clients hand. The nurse-client relationship is in the: 1 Working phase 2 Orientation phase 3 Termination phase Preinteraction phase 4 ANS: 2 When the nurse and client meet and get to know one another, they are engaged in the orientation phase of the nurse-client relationship. The remaining options are phases that occur either before or after the orientation phase. DIF: C REF: 346 OBJ: Analysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 37. The nurse recognizes that a clients sense of personal control is most therapeutically impacted when: 1 2 The client attends a self-help/support group The nurse encourages the client to make menu selections 3 The client views a video on the use of a personal glucose monitor 4 The nurse provides instructions on a patient-controlled analgesic (PCA) pump ANS: 4 Personal control over the situation contributes to emotional comfort. Pain control is a very basic need, and by providing the client with the power to control that pain, the need has been therapeutic. The remaining options contribute to personal control but not on the same elemental level as pain control. DIF: C REF: 348 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 38. Which of the following statements made by a nurse best reflects an understanding of the therapeutic value of perceived client control? 1 The client was very interested in the information about support groups. 2 The client fell right to sleep when I told her the procedure was canceled. 3 Research has shown that clients are less stressed when told what to expect. I always include the client in on any decisions regarding their nursing care. 4 ANS: 3 Research has shown that personal control over a situation contributes to emotional comfort. By informing the client of expectations, the clients personal sense of control is increased and emotional stress should then be decreased. The remaining options show an understanding of emotional comfort but do not express an understanding of the origin of that comfort. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 348 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 39. Which of the following statements made by a nurse most reflects a poor understanding of trustworthiness regarding nurse-client communication in response to a clients report that, I dont like the night shift nurse? 1 2 How can I meet your needs and expectations on dayshift? Tell me more about why you dislike the night shift nurse. 3 Can you give me an example of why you are dissatisfied? 4 The nurse on night shift has your well being in mind always. ANS: 2 To foster trust, the nurse communicates warmth and demonstrates consistency, reliability, honesty, competence, and respect. Sharing personal information or gossiping about others sends the message you cannot be trusted and damages interpersonal relationships. The nurse appears to be gossiping by the way the client is encouraged to discuss what the night shift nurse is doing. The remaining options show varying degrees of addressing the clients statement. DIF: C REF: 348 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 40. Which of the following statements made by a nurse most reflects the best understanding of the effect assertiveness has on interpersonal communication? 1 Can anyone help; Im feeling overwhelmed today? 2 I think we need to tell the doctors to write more legibly. 3 I will need some help with that complicated dressing change. 4 You will need to do the admission assessments today because Im so busy. ANS: 3 Assertiveness conveys a sense of self-assurance while also communicating respect for the other person. Assertive responses often contain I messages, such as I want, I need, I think, or I feel, but in a fashion that is not demeaning or demanding. The remaining options are not the best examples because some lack an explanation of the nurses actual needs while others are not respectfully stated. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 348 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 41. The nurse identifies the nursing diagnosis risk for injury for a client who is unable to verbally communicate effectively. The primary risk for injury occurs because the client: 1 2 Lacks the ability to tell the staff what he or she needs Cannot notify the staff when he or she has fallen 3 Is not able to effectively use the call bell to communicate 4 Displays impatience when needs are not met effectively ANS: 1 The client who cannot communicate effectively will often have difficulty expressing needs and responding appropriately to the environment. A client who is unable to speak is at risk for injury unless the nurse identifies an alternate communication method. The remaining options relate to potential outcomes of ineffective verbal communication but not to the risk for injury. DIF: C REF: 351 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 42. Which of the following statements made by a nurse reflects a need for further instruction regarding communicating with the older adult client? 1 Children and the elderly have the same communication barriers. 2 If I tell him why he needs to know something, hell usually listen. 3 Hearing deficits can certainly make communication a challenge. I always try to have family around when I talk with an elderly client. 4 ANS: 1 Even though some older adults have communication barriers, you need to communicate with them on an adult level and avoid patronizing or speaking in a condescending manner. Older adults do not necessarily have the same barriers as children. The remaining options reflect interventions and/or statements that are not inappropriate and so do not require further instructions. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 356-357 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Which of the following critical thinking attitudes contributes to an effective nurse-client relationship? (Select all that apply.) 1 2 3 Fairness Guarded 4 Curiosity Creativity 5 Perseverance 6 Self-confidence ANS: 1, 3, 4, 5, 6 Curiosity motivates the nurse to communicate and know more about a person. Perseverance and creativity are also attitudes conducive to communication because they motivate the nurse to communicate and identify innovative solutions. A self-confident attitude is important because the nurse who conveys confidence and comfort while communicating more readily establishes an interpersonal, helping-trust relationship. Risk-taking rather than a guarded attitude is important because colleagues sometimes question the suggested nursing interventions. At the same time, an attitude of fairness goes a long way in the ability to listen to both sides of any discussion. DIF: C REF: 340-341 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The nurse realizes that the cancer support group for breast cancer clients will be most effective if the group: (Select all that apply.) 1 2 3 Is not too large Is similar in age 4 Members feel valued Communicates freely 5 Shares a common culture 6 Meets in a comfortable place ANS: 1, 3, 4, 6 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Small groups are more effective when they are a workable size and have an appropriate meeting place, suitable seating arrangements, and cohesiveness and commitment among group members. Group participants need to feel accepted, feel able to communicate openly and honestly, and actively listen to others in the group. Similarity in age and similarity in culture are not necessary criteria for a successful group interaction. DIF: C REF: 342 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The nurse is preparing a community outreach program on stress management. The nurse realizes that speaking in public requires some specific adaptations regarding: (Select all that apply.) 1 Makeup 2 Clothing attire 3 Vocal inflection 4 5 Voice projection Physical gesturing 6 Making eye contact ANS: 3, 4, 5, 6 Public communication requires special adaptations in eye contact, gestures, voice inflection, and use of media materials to communicate messages effectively. Makeup and clothing need to be appropriate but do not require specific adaptations. DIF: C REF: 342 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. Which of the following are reasons for communication during the assessment phase of the nursing process? (Select all that apply.) 1 2 3 Providing information to the client Obtaining information from the client 4 Establishment of the nurse-client relationship Identification of the clients physical health needs 5 Mutual goal setting regarding client health needs 6 Identification of clients emotional health WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 1, 2, 4, 5, 6 The reasons for communication include information exchange, goal achievement, problem resolution, and expression of feelings. The initiation of the nurse-client relationship is not considered a facet of assessment communication. Chapter 25. Patient Education MULTIPLE CHOICE 1. The client has been informed that he can be discharged once he can irrigate his colostomy independently. The client requests the nurse to observe his irrigation technique. Which of the following learning motives is the client displaying? 1 2 3 4 Physical need Social activity Task mastery Evaluation stance ANS: 3 Task mastery motives are based on needs such as achievement and competence. The client who must demonstrate irrigating his colostomy independently in order to be discharged is displaying the learning motive of task mastery. A physical motive may be seen in the client who desires to return to a level of physical normalcy. A social motive is the need for connection, social approval, or self-esteem. An evaluation stance would be determining whether the outcomes of the teaching-leaning process met the clients goal. Evaluation is not a learning motive. DIF: A REF: 366-367 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. An industrial nurse is planning to give an informative talk on hypertension to employees in honor of heart month. He plans to teach individuals how to take their blood pressure measurements. Which information is important for him to ask the planning committee before this presentation? 1 Ages of all employees involved 2 Names of employees who are married 3 Number of employees with high blood pressure 4 Type of room available and number of participants ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The number of persons being taught, the need for privacy, the room temperature, the room lighting, noise, the room ventilation, and the room furniture are important factors when choosing the setting. The ideal setting helps the client focus on the learning task. Knowing the specific ages of all the people involved is not as important as providing an environment conducive to learning. It is not necessary to know the names of employees who are married to teach individuals how to take their blood pressure. Whether an employee has high blood pressure should not be as important to the teacher as providing an environment conducive to learning. Having high blood pressure may be a motivating factor for employees to learn how to take their blood pressure, because of its personal relevance. DIF: A REF: 369 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. The nurse established the following objective for the client who was unable to void: The clients intake will be at least 1000 mL between 7 AM and 3:30 PM. Feedback showing success is indicated by the client: 1 2 3 4 Voiding at least 1000 mL during the shift Verbalizing abdominal comfort without pressure Having adequate fluid intake and urinary output Drinking 240 mL of fluid five or six times during the shift ANS: 4 The nurse evaluates success by observing the clients performance of each expected behavior. Feedback indicating success in this situation is the client drinking 240 mL of fluid five or six times during the shift. This would be a fluid intake of 1200-1440 mL, meeting the objective of at least 1000 mL during the designated time period. Voiding at least 1000 mL is not the objective. The objective is to have the client drink at least 1000 mL. Verbalizing abdominal comfort without pressure is not an evaluation of the objective regarding specific fluid intake. Having adequate intake and output is not accurate feedback indicating success. The term adequate is not quantified. DIF: A REF: 381 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. There are a variety of teaching methodologies fro a nurse to choose from to use with clients. For a toddler, the nurse should use: 1 Role-playing 2 Problem-solving WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Independent learning 4 Simple explanations and pictures ANS: 4 Effective teaching methodologies for the toddler include simple explanations and picture books that describe a story of children in a hospital or clinic. Role-playing is an appropriate teaching methodology for the preschooler. Problem-solving is an appropriate teaching methodology for the adolescent. Independent learning is best used as a teaching methodology for the young or middle adult. DIF: A REF: 368 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 5. The nurse has important information to share with a parent who has brought his child to the emergency department. The nurse discovers that the parent, who appears very anxious, has just learned his son will require surgery. The most effective teaching approach in this situation is: 1 2 Telling Trusting 3 Participating 4 Group teaching ANS: 1 The telling approach is useful when limited information must be taught. If a client is highly anxious but it is vital for information to be given, telling can be effective. The entrusting approach provides the client the opportunity to manage self-care. The nurse observes the clients progress and remains available to assist without introducing more new information. This would not be the most effective teaching approach in this situation. Participating involves the nurse and client setting objectives and becoming involved in the learning process together. This would not be the most effective teaching approach in this emergency situation. Group teaching would not be the most effective teaching approach in this situation. A person who is anxious would benefit more from individual instruction. DIF: A REF: 376 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. A client, after being taught of the clinical manifestations of inflammation to enable early detection of a complication of a surgical wound states, I will look at the wound four times a day and tell my surgeon if it looks red or swollen. Her statement is an example of: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Attitudes 2 3 Application Analysis 4 Evaluation ANS: 2 Application involves using abstract, newly learned ideas in a concrete situation. The client who is taught the clinical manifestations of inflammation and who will assess for signs such as redness or edema is using newly learned information in a concrete manner. Attitude has to do with affective learning. The client is not expressing an attitude, but is applying new knowledge in a concrete way. Analysis involves breaking down information into organized parts. The client is not demonstrating analysis. Evaluation is a judgment of the worth of a body of information for a given purpose. The client is not expressing judgment. DIF: A REF: 365 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. The client continues to ask questions about a surgical wound. The client states, I think I would like help the first time I look at my wound. This is an example of: 1 Adaptation 2 Perception 3 Organizing 4 Guided response ANS: 4 A guided response is the performance of an act under the guidance of an instructor. The client who is seeking help is demonstrating a guided response. Adaptation occurs when a person is able to change a motor response when unexpected problems arise. The client is not exhibiting adaptation. Perception is being aware of objects or qualities through the use of sense organs. This situation is not an example of perception. Organizing is developing a value system by identifying and organizing values and resolving conflicts. This situation is not an example of organizing. DIF: C REF: 449 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. There are many factors are assessed before teaching the client to learn insulin injection sites, but the most important factor for the nurse to assess first is the: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Previous knowledge level of the client 2 3 Willingness of the client to want to learn the injection sites Financial resources available to the client for the equipment 4 Intelligence and developmental level of the individual client ANS: 2 If a person does not want to learn, it is unlikely that learning will occur. Motivation is the first factor the nurse should assess before teaching. To determine learning needs, the nurse should assess the clients previous knowledge level. However, this would not be the most important factor for the nurse to assess first. Assessing the financial resources available to the client for obtaining equipment is important; however, it is not the most important factor for the nurse to assess first. Assessing the clients physical and cognitive ability to learn is important. However, it is not the most important factor for the nurse to assess first. DIF: A REF: 364 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. The nurse is demonstrating to the client how to put on anti-embolitic stockings. In the middle of the lesson the client asks, Why have my feet been swelling? The nurse stops and responds to the client. Which of the following is the teaching principle that the nurse should follow? 1 Timing 2 Setting priorities 3 Building on existing knowledge 4 Organizing the teaching materials ANS: 1 The nurse who stops a demonstration of applying anti-embolitic stockings to answer a clients question is following the teaching principle of timing. If the client has a question, it is important to answer the question immediately, so the client may return his or her focus to the task being taught. Setting priorities is important to conserve the time and energy of the client and nurse. The nurse who stops to answer a question is not setting priorities. A client learns best on the basis of preexisting cognitive abilities and knowledge. This situation is not an example of building on existing knowledge. Organizing teaching materials means the nurse considers the order of information to present. This is not an example of organizing teaching materials. DIF: A REF: 375 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 10. Clients give various responses to teaching sessions. For the nurse, an example of an evaluation of a psychomotor skill is: 1 2 3 4 Client states side effects of a medication Client responds appropriately to eye contact Client independently plans an exercise program Client demonstrates the proper use of a walking cane ANS: 4 Determining whether the client is able to demonstrate a newly learned skill is an example of an evaluation of a psychomotor skill. Psychomotor learning involves acquiring skills that require the integration of mental and muscular activity, such as walking with a cane. Having the client state side effects of a medication is an example of an evaluation of cognitive learning. Determining whether a client responds appropriately to eye contact is an example of evaluation of affective learning. The client who planned an exercise program is demonstrating cognitive learning. DIF: A REF: 366 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Different topics are presented in the information sessions that are held in the outpatient clinic. In planning for a session on health maintenance/illness prevention, the nurse should select a topic on: 1 Use of assistive devices, such as canes 2 Self-help devices for post-CVA clients 3 Stress management techniques for working parents Environmental alterations for clients in wheelchairs 4 ANS: 3 Stress management techniques for working parents is an appropriate topic for health maintenance/illness prevention. Use of assistive devices, such as canes, is not a health maintenance/illness prevention topic. It is a coping with impaired function topic. Self-help devices for post-CVA clients is not a health maintenance/illness prevention topic. It is a coping with impaired function topic. Environmental alterations for clients in wheelchairs is not a health maintenance/illness prevention topic. It is a coping with impaired function topic. DIF: A REF: 362 OBJ: Comprehension TOP: Nursing Process: Planning WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. The nurse is evaluating the responses of clients to teaching sessions. An example of an evaluation of a clients attainment of a cognitive skill is: 1 Client explains that the medication should be taken with meals 2 Client looks at the surgical incision without requiring prompting 3 Client uses crutches appropriately to move both up and down stairs 4 Client independently capable of dressing self after eating breakfast ANS: 1 The client who is able to explain that the medication should be taken with meals is demonstrating attainment of a cognitive skill. The client who is able to look at the surgical incision without prompting is demonstrating attainment of affective learning. The client who uses crutches appropriately is demonstrating attainment of a psychomotor skill. The client who dresses self after breakfast is most likely demonstrating attainment of psychomotor learning. DIF: A REF: 365 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. The nurse evaluates which of the following statements as an indication that the client is not ready to learn at this time? 1 I need to understand more about the reason for the colostomy. 2 I will find out more about that when the support group meets. 3 Theres no sense in showing me that now. Im too sick right now. Please be sure to tell me if I am completing all the steps correctly. 4 ANS: 3 Readiness to learn is related to the stage of grieving. This response by the client is demonstrating anger. The client is unwilling to learn at this time. The client has not yet reached the acceptance state of grieving in which learning can occur. This statement indicates the client is ready to learn and desires to find out more to gain understanding. This statement indicates the client is willing to learn. The client who requests feedback is expressing readiness to learn. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A REF: 362 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. In planning to teach an older adult client, the nurse should incorporate which teaching method or principle into the plan? 1 2 3 4 Keep teaching sessions short. Teach in the early morning or late evening. Put as much as possible into each teaching session. Focus on teaching a family member or caregiver instead. ANS: 1 Keeping teaching sessions short is an appropriate method when teaching an older adult client. The older adult should be taught when the client is alert and rested, not early morning or late evening. The teaching session should not be filled with numerous topics. The older adult client is capable of learning and should be the focus. A family member or caregiver may be included in teaching, but the older adult client should not be excluded. DIF: A REF: 376 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. The nurse has completed an assessment on the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned? 1 Activity intolerance related to pain 2 Ineffective management of treatment regimen 3 Noncompliance with prescribed exercise plan Knowledge deficit regarding impending surgery 4 ANS: 1 Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate. The nursing diagnosis of activity intolerance related to pain indicates a need to postpone teaching. Teaching may be delayed until the nursing diagnosis is resolved or the health problem is controlled. Ineffective management of treatment regimen does not indicate a need to postpone teaching. Ineffective management of treatment regimen reinforces the need for teaching. Noncompliance with prescribed exercise plan does not indicate a need to postpone teaching. The client who is noncompliant may require further teaching. Knowledge deficit regarding WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material impending surgery does not indicate a need to postpone teaching. A knowledge deficit reinforces the need for teaching. DIF: A REF: 366 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. There are a variety of teaching methodologies that may be utilized to meet the clients needs. Which teaching method is best applied to a cognitive learning need? 1 2 3 4 Modeling of behavior Discussion of feelings Computer-assisted instruction Demonstration of a procedure ANS: 3 An independent project such as computer-assisted instruction is an appropriate teaching method for cognitive learning. Modeling of behavior is an appropriate teaching method for psychomotor learning. Discussion of feelings is an appropriate teaching method for affective learning. Demonstration is an appropriate teaching method for psychomotor learning. DIF: A REF: 365 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. For a functionally illiterate client, the nurse particularly focuses on: 1 Using intricate analogies and examples 2 Avoiding lengthy return demonstrations 3 Incorporating familiar nonmedical terminology Providing longer learning sessions with the client 4 ANS: 3 When teaching a functionally illiterate client, the nurse should use simple terminology, avoiding medical jargon. The nurse should incorporate familiar terminology to enhance the clients understanding. The nurse should use simple analogies and real life examples. The nurse should ask for return demonstrations as this provides the opportunity to clarify instructions and time to review procedures. Although teaching sessions may be kept short, they should be scheduled at more frequent intervals. DIF: A REF: 378-379 OBJ: Comprehension WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. In preparing a teaching plan for adult clients in a cancer support group, the nurse incorporates evidence-based information. The nurse recognizes that evidence obtained about adult learners has identified that this group prefers: 1 Computer-assisted instruction 2 3 Traditional classroom settings Long sessions with plenty of technical information 4 Interesting personal communication techniques ANS: 4 Adults have a wide variety of personal and life experiences to employ. Therefore adult learning is enhanced when they are encouraged to use these experiences to solve problems. Evidencebased information indicates that adult clients prefer interactive, personal communication with nurses or physicians. Evidence-based information indicates computer-assisted learning is not a preferred method of instruction by many adult learners. As clients become more comfortable with computers, this preference may change. Evidence-based information indicates that not all clients are comfortable in class settings or in support groups. Other educational opportunities should be available. Adult learners prefer short teaching sessions without a great deal of technical information. DIF: A REF: 369 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. While teaching the client about management of his heart disease, a nurse might use a strategy that is implemented to promote learning in the affective domain such as: 1 Asking the client what he believes he needs to know about the diagnosis 2 Providing brochures both on current exercises and on nutrition guidelines Encouraging the client to personally discuss his feelings about his health status 3 4 Having the client return-demonstrate self-measurement of his own blood pressure ANS: 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material An intervention to promote learning in the affective domain would be encouraging the client to discuss his feelings about his health status. Asking the client what he believes he needs to know about the diagnosis would be an intervention to promote learning in the cognitive domain. Providing brochures on current exercises and nutrition guidelines would be an intervention to promote learning in the cognitive domain. Having the client return-demonstrate selfmeasurement of his blood pressure would be an intervention to promote learning in the psychomotor domain. DIF: A REF: 365 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. The nurse is preparing to present a teaching session on skin protection for a group of older adults at a senior center. A principle that has been found to be most effective in teaching older adults is: 1 2 3 4 Moving the group along at a predetermined pace Providing information in longer teaching sessions Speaking very slowly and in a louder tone of voice Beginning and ending each session with important information ANS: 4 The nurse should begin and end each teaching session with important information because clients are more likely to remember information that is taught early in the teaching session, and key points can be summarized at the end. Repetition also reinforces learning. The group should not be moved along at a predetermined pace. Clients may have questions that would go unanswered if there were a predetermined pace. Or, sometimes teaching sessions have to be stopped after the nurse observes a clients loss of concentration such as nonverbal cues of poor eye contact or slumped posture. Shorter (approximately 20 minutes), frequent sessions are more easily tolerated and retain the clients interest in the material. The nurse should face the client and speak in a low tone of voice for the older adult with a hearing problem. DIF: A REF: 380-381 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. The nurse is preparing the discharge teaching materials on newly prescribed drugs to a client diagnosed to be in the early stage of Alzheimers disease. The nurse best deals with the clients cognitive deficits by: 1 Providing written material to supplement the discussion 2 Arranging for family to be present during the discussion WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Presenting the material in two short but focused sessions 4 Requiring the client to restate the information in her own words ANS: 2 The clients family needs to understand and accept many changes in the patients physical and/or cognitive capabilities. The familys ability to provide support results in part from education, which begins as soon as the nurse identifies the clients needs and the family displays a willingness to help. The remaining options may support retention of material but not as effectively as including family in the educational sharing. DIF: C REF: 381 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. The nurse recognizes that the clients teaching plan is most directly driven by: 1 The clients identified learning needs 2 3 The complexity of the clients health needs The clients readiness and motivation to learn 4 The presence of cultural or physical barriers ANS: 1 Teaching is most effective when it responds to the learners needs. While assessing and diagnosing a clients health care problems, the nurse identifies the need for education that in turn generates the teaching plan. The remaining options reflect factors that will affect both the teaching plan and the clients learning. DIF: C REF: 363 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse recognizes that the primary goal of a clients teaching plan is to: 1 Facilitate a knowledge-based client decision-making process 2 Provide information that brings about informed client consent 3 Enhance the clients sense of personal control regarding his or her health care Therapeutically affect the clients health, wellness, and independence 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 4 Creating a well-designed, comprehensive teaching plan that fits a clients unique learning needs ultimately helps clients make informed decisions about their care and results in clients becoming healthier and more independent. The remaining options affect the primary goal by enhancing decision making, providing for informed consent, and bringing about a sense of personal control. DIF: C REF: 363 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. Which of the following teaching topics is an example of health maintenance and promotion and illness prevention? 1 2 3 4 Glucose monitoring at home Living with rheumatoid arthritis Stress managements impact on depression What to expect after hip replacement surgery ANS: 1 Promoting healthy behavior through education allows clients to assume more responsibility for their health. Greater knowledge results in better health maintenance habits. When clients become more health conscious, they are more likely to seek early diagnosis of health problems. The remaining options address restoration of health and coping with impaired functioning, whereas stress management is a topic that relates to the promotion of health and the prevention of illness. DIF: A REF: 362-363 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. Which of the following teaching topics is an example of restoration of health? 1 Glucose monitoring at home 2 Living with rheumatoid arthritis 3 Stress managements impact on depression What to expect after hip replacement surgery 4 ANS: 4 Injured or ill clients need information and skills to help them regain or maintain their levels of health. The remaining options address health maintenance and promotion and illness prevention WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material and coping with impaired functioning while what to expect after hip replacement surgery is a topic that relates to the restoration of health and function. DIF: A REF: 363 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. Which of the following actions is the primary nursing responsibility regarding client education? 1 2 Providing accurate, current, relevant information Answering the clients questions regarding health-related issues 3 Assessing the individual clients readiness and motivation to learn 4 Identifying areas where clients are in need of educational information ANS: 1 Nurses have an ethical responsibility to teach their clients (Redman, 2005, 2007). The information needs to be accurate, complete, and relevant to the clients needs. The remaining options are factors that affect learning and so require the nurses attention but are not as primary as providing information that is accurate, current, and relevant to the clients needs. DIF: C REF: 363 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 27. When a client newly diagnosed with type 2 diabetes mellitus assumes responsibility for checking her blood glucose level four times a day, this is an example of: 1 Cognitive learning 2 Affective learning 3 Impaired learning Psychomotor learning 4 ANS: 4 Psychomotor learning involves acquiring skills that require the integration of mental and muscular activity. The remaining options are involved with expression of feelings and acceptance of attitudes, opinions, or values or the acquisition of knowledge. Impaired learning involves alteration to the normal learning process that requires alterations in methods and techniques. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A REF: 366 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. When a client newly diagnosed with type 2 diabetes mellitus selects a lunch menu that correlates with the number of carbohydrates he is allowed for that meal, this is an example of: 1 2 Cognitive learning Affective learning 3 Impaired learning 4 Psychomotor learning ANS: 1 Cognitive learning includes all intellectual behaviors and requires thinking. The remaining options are involved with expression of feelings and acceptance of attitudes, opinions, or values or acquiring skills that require the integration of mental and muscular activity. Impairing learning involves alteration to the normal learning process that requires alterations in methods and techniques. DIF: A REF: 365 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 29. Which of the following statement best reflects the nurses appropriate attention to a clients need for self-efficacy? 1 What can I do to help you lose the weight? 2 Are you really ready to start a regular exercise regimen? 3 After you watch me demonstrate this inhaler, you will have no problems using it at all. 4 Come on; with all the self-help products out there, you will be able to stop smoking. ANS: 3 Self-efficacy refers to a persons perceived ability to successfully complete a task. When people believe that they are able to execute a particular behavior, they are more likely to actually perform the behavior consistently and correctly. Although the other options are related to behavioral change to achieve a goal, they do not support the client by both encouragement and providing the skills necessary to be successful. DIF: C REF: 367 OBJ: Analysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 30. A client has been recently told that the primary cancer has metastasized, and the cancer is considered terminal. When the nurse offers to discuss palliative care options, the client replies, Im going to have the reports reevaluated by another doctor; I feel fine and I think a mistake has been made. The nurse recognizes this response as: 1 2 3 4 Anger Disbelief Bargaining Acceptance ANS: 2 In this example, the client avoids discussion of the illness, choosing to believe a mistake has been made. The remaining options are other stages of the grieving process. DIF: A REF: 368 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 31. A client has been recently told that the primary cancer has metastasized and the cancer is considered terminal. When the nurse offers to discuss palliative care options the client replies, I cant understand why you all want to upset me by bringing the topic up. Now please just leave me alone. The nurse recognizes this response as: 1 Anger 2 Disbelief 3 Bargaining Acceptance 4 ANS: 1 In this example, the client blames others and complains. The client often directs anger toward the nurse or others. The remaining options are other stages of the grieving process. Chapter 26. Informatics and Documentation MULTIPLE CHOICE 1. The nurse is preparing the information that will be provided to the staff on the next shift. Which of the following should the nurse include in the inter-shift report to nursing colleagues? 1 Audit of client care procedures 2 The clients diagnostic-related group WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 All routine care procedures required by the client 4 Instructions given to the client in a teaching plan ANS: 4 A change-of-shift report should include instructions given in a teaching plan and the clients response. This should not include detailed content unless staff members ask for clarification. The nurse should relay to staff significant changes in the way therapies are given, but should not describe basic steps of a procedure. The clients diagnosis-related group is not essential background information to be shared in an inter-shift report. The nurse should not review all routine care procedures or tasks. DIF: A REF: 399 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. An incident report is to be completed because the client climbed over the side rails and fell to the floor. The correct reporting of an incident involves which of the following? 1 2 The witnessing nurse completes the report. Details of the incident are subjectively described. 3 An explanation of the possible cause for the incident is entered. 4 A notation is included in the medical record that an incident report was prepared. ANS: 1 The nurse who witnessed the incident is the one who completes the report. Details of the incident should be objectively described. An explanation of the possible cause is not included. The sequence of events is described objectively. A notation is not included in the medical record that an incident report was written. DIF: A REF: 403 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care? 1 1230Clients vital signs taken. 2 0700Client drank adequate amount of fluids. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 0900Demerol given for lower abdominal pain. 4 0830Increased IV fluid rate to 100 mL/hr according to protocol. ANS: 4 Information within a recorded entry needs to be complete, containing appropriate and essential information. This notation (0830) provides the time and action taken by the nurse including the reason for doing so. This entry (1230) does not indicate what the vital signs were. This entry (0700) does not provide the specific amount the client drank. Stating adequate is subjective, not objective. This notation (0900) does not have the client describe his or her pain or rate it according to a pain scale for comparison later. It also does not indicate whether the clients pain was in the lower left or lower right quadrant, or both. DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 4. The nurse makes a late entry in a clients record. Which of the following is the best example of how to document this type of situation? 1 2:45 PMASA gr X given for temperature of 38.1 C. 2 8:30 AMClient received Percodan (1 tablet) PO an hour before going to radiology. 12:15 PMI gave the client morphine 10 mg IM at 11:10 AM but did not document it then. 3 4 8:30 PMAbdominal dressing change at 7:30 PM. No s/s of infection, and wound edges approximating well. ANS: 1 This is the best example of a late entry. The time (2:45 PM) is indicated along with the action and an objective observation. This notation (8:30 AM) is not complete. It does not indicate why the Percodan was given. What was the clients level of pain? Where was the pain located? The nurse does not need to document about herself; only the client. In this option (12:15 PM), the nurse does not indicate why the morphine was given (clients level of pain? location of pain?). This entry (8:30 PM) is not complete. It does not state the size of the wound, type of dressing used, or the clients tolerance of the procedure. DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 5. The following statement: Upon exertion, the client is wheezing and experiencing some dyspnea, is an example of: 1 2 3 4 The P of PIE FOCUS documentation The R in DAR documentation The S in SOAP documentation ANS: 1 These data are examples of the P of PIE because they describe the problem. FOCUS charting does not concentrate on only problems. It is structured according to a clients concerns. The R in DAR documentation is the response of the client. This situation describes the clients problem, not the clients response. The S in SOAP documentation represents subjective data (verbalizations of the client). DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 6. To locate the recording of a nurses description of the teaching provided to the client on performance of self-medication administration, one would look in a(n): 1 Kardex 2 Incident report 3 Nursing history form Discharge summary form 4 ANS: 4 A nurses description of the teaching provided to the client on performance of self-medication administration is recorded in the discharge summary form. A Kardex is a written form that contains basic client information. A Kardex contains an activity and treatment section and a nursing care plan section that organizes information for quick reference as nurses give changeof-shift report. It does not include a description of teaching that was provided to the client. An incident report is any event that is not consistent with the routine operation of a health care unit or routine care of a client (e.g., a client falls). A nursing history form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems. It provides baseline data about the client. DIF: A REF: 397-398 OBJ: Comprehension TOP: Nursing Process: Evaluation WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safe, Effective Care Environment 7. The nurse has made an error and is documenting such on the clients record and notes. The action that the nurse should take is to: 1 2 Draw a straight line through the error and initial it. Erase the error and write over the material in the same spot. 3 Use a dark color marker to cover the error and continue immediately after that point. 4 Footnote the error at the bottom of the page. ANS: 1 If a nurse has made an error in documentation, the nurse should draw a single line through the error, write the word error above it, and sign his or her name or initials. Then record the note correctly. The nurse should not erase, apply correction fluid, or scratch out errors made while recording because charting becomes illegible. Also, entries should only be made in ink so they cannot be erased. Using a dark color marker to cover the error is not correct. It may appear as if the nurse was attempting to hide something or deface the record. Footnotes are not used in nursing documentation. DIF: A REF: 388-389 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 8. The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse: 1 Uses a pencil to make the entries 2 Uses correction fluid to correct written errors 3 Identifies an error made by the attending physician Dates and signs all of the entries made in the record 4 ANS: 4 Each entry should begin with the time and end with the signature and title of the person recording the entry. All entries should be recorded legibly and in black ink because pencil can be erased. The nurse should never erase entries, never use correction fluid, or never use a pencil. The use of correction fluid could make the charting become illegible and it may appear as if the nurse were attempting to hide something or to deface the record. If the physician made an error, the nurse should not document it in the clients chart. It should be documented in an incident report. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 9. What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients. 1 Let me get the Registered Nurse on the phone. 2 I am unable to take the order at this time. Please call in the morning. 3 Please repeat the order for me so I can make sure it is written correctly. 4 Let me have your phone number and I will have the supervisor call you back. ANS: 1 A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse. Saying that an order is unable to be taken and to call back in the morning is not an appropriate response and not in the clients best interest. It is best to repeat any prescribed orders back to the physician, who can then verify if it is correct or clarify the order. This is not the appropriate response. A registered nurse needs to take the verbal order, but it does not have to be the nursing supervisor. DIF: A REF: 402 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 10. The client developed a slight hematoma on his left forearm. The nurse labels the problem as an infiltrated intravenous (IV) line. The nurse elevates the forearm. The client states, My arm feels better. What is documented as the R in FOCUS charting? 1 Infiltrated IV line 2 My arm feels better 3 Elevation of left forearm Slight hematoma on left forearm 4 ANS: 2 The R in FOCUS charting is the clients response. In this case, the nurse would document, My arm feels better. Infiltrated IV line would be documented as D referring to data in FOCUS WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material charting. Elevation of left forearm is the A in FOCUS charting. It describes the action or nursing intervention. Slight hematoma on left forearm is the D referring to data in FOCUS charting. DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 11. Which of the following is evaluated as a legally appropriate notation? 1 2 Dr. Green made an error in the amount of medication to administer. Verbalized sharp, stabbing pain along the left side of chest. 3 Nurse Williams spoke with the client about the surgery. 4 Client upset about the physical therapy. ANS: 2 Entries should be concise, factual, and accurate. Verbalized sharp, stabbing pain along the left side of chest is an example of an objective description of a clients behavior. The nurse should not document physician made error. Instead, the nurse could chart that Dr. Green was called to clarify order for medication administration. The nurse should chart only for himself or herself. In this case, nurse Williams should write the charting entry. Only objective descriptions of the clients behavior should be recorded. For example: Client states, I dont want physical therapy! I want to go home! DIF: A REF: 388-389 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 12. To avoid legal risks and possible lack of confidentiality associated with computerized documentation, many programs currently have: 1 Periodic changes in staff passwords 2 Thumbprint identification restrictions 3 All nursing staff uses the same access code 4 Only centralized medical records use the client data ANS: 1 A good system of computerized documentation requires periodic changes in personal passwords to prevent unauthorized persons form tampering with records. Many programs do not have thumbprint identification restrictions. All nurses do not use the same access code. Each nurse should have his or her own password. Only centralized medical records using the client data is WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material not a true statement. Authorized health care providers from any department can access and use the data. DIF: A REF: 406 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment 13. Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy? 1 2 Medicare reviews client charts to determine care given. Good charting results in good Medicare reimbursement. 3 Our nursing salaries are paid for by the Medicare reimbursement funds. 4 The hospital is reimbursed for the nursing care documented in the client chart. ANS: 4 Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for each diagnosis-related group (DRG). Everything that is done for a client must be documented in the medical record for the health care institution to recover its costs. DIF: C REF: 387 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 14. The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, conversation, or treatment: 1 Secured 2 Accessible 3 Confidential 4 Documented ANS: 3 Nurses are legally and ethically obligated to keep information about clients confidential. Nurses may not discuss a clients examination, observation, conversation, or treatment with other clients or staff not involved in the clients care. The other options are primarily directed towards written records and are not ethically oriented. DIF: A REF: 385 OBJ: Comprehension WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 15. Which of the following nursing statements regarding the release of a clients medical record to another institution requires immediate follow-up by the nurses manager? 1 Im pretty sure this will require the clients permission. 2 Are you sure of the exact policy? Do you know what I should do? 3 The client agreed to the consultation, so Ill have the chart sent over. 4 I think the client will need to give a verbal consent before it can be sent. ANS: 3 Each institution has policies to control the manner for sharing records. In most situations, clients are required to give written permission for release of medical information. The other options have the nurse asking for help or expressing doubt about the proper protocol for the release of the records; these would be appropriate statements and the manager should provide the correct information. DIF: C REF: 385 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 16. Regarding access to client records, the nursing faculty informs the nursing students to be prepared to: 1 Show the unit staff proper student identification 2 Sign a confidentiality agreement when on the unit to preplan 3 Review the medical record only in the presence of unit staff 4 Obtain permission from the client to access his or her medical record ANS: 1 When nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, they obtain appropriate authorization according to agency policy. Nursing students and faculty may be required to present identification indicating access to the record is authorized. The remaining options are not required if the student is properly identified and shows need to access the material. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 385 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 17. Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care? 1 Notifying the client of the institutions privacy policy 2 Denying nonessential personal access to the clients medical records 3 Acquiring the clients verbal consent to share his or her medical record with essential personnel 4 Requiring that the client sign the Health Insurance Portability and Accountability Act (HIPAA) form ANS: 1 Under new regulations, Health Insurance Portability and Accountability Act (HIPAA), in order to eliminate barriers that could delay access to care, required only that health care providers notify clients of their privacy policy and make a reasonable effort to get written acknowledgment of this notification. DIF: A REF: 385 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 18. When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider, this is called a: 1 Referral 2 Consultation 3 Transfer report 4 Multidisciplinary meeting ANS: 1 Referrals are the request for services by another care provider usually for the purpose of determining appropriate client care. Consultations are a form of discussion whereby one professional caregiver actually gives formal advice about the care of a client to another caregiver. The remaining options are methods of exchanging general information regarding a client. DIF: A REF: 386 OBJ: Comprehension WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 19. Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data? 1 2 Client was angry because breakfast was not to her liking. Client is depressed; was observed crying while alone in room. 3 Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists. 4 Client was verbally abusive to staff when approached concerning clients continued attempts to smoke in the bathroom. ANS: 3 Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objectively describe the noted client behavior. DIF: C REF: 388-389 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 20. Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data? 1 Client was angry because breakfast was not to her liking. 2 Client is depressed; was observed crying while alone in room. 3 Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists. 4 Client was verbally abusive to staff when approached concerning clients continued attempts to smoke in the bathroom. ANS: 2 Do not write personal opinions. Document observable, measurable client-oriented data only. Recording that the client is depressed based on the observation of tears is not objective and so is not acceptable. While one option does report only observable, measurable behavior, the remaining options, while noting observed client behavior, do fail to objectively describe the noted client behavior. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 388-389 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 21. Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation? 1 The fact that the client refused the prescribed antidepressant medication was noted in his chart. 2 I provided a detailed description of the dressing change in the clients chart in order to show it was done as prescribed. 3 The clients wife told me he often develops a rash when he comes into contact with scented soaps, so I noted that in his chart. 4 I had a long conversation with the client concerning his fears about his upcoming surgery and I mentioned his concerns in my nursing note. ANS: 2 Common charting mistakes that can result in malpractice include the following: (1) failing to record pertinent health or drug information; (2) failing to record nursing actions; (3) failing to record that medications have been given; (4) failing to record drug reactions or changes in clients condition; (5) writing illegible or incomplete records; and (6) failing to document a discontinued medication. Detailed descriptions of procedures are not included in the nursing notes. DIF: C REF: 388 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 22. The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a clients medical record is: 1 James Thicket, NS, WVU 2 J. Jones, NS, Montclair Shores College 3 N.H, SN, Bellfield City Community College 4 Linda Mozden, SN, Fairmont State University ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material A nursing student enters full name, student nurse abbreviation (e.g., SN or NS), and educational institution, such as David Jones, SN (student nurse), CMTC (Central Maine Technical College). DIF: A REF: 389 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment 23. The nurse realizes that the incorrect spelling of terms in the medical record most importantly: 1 2 Shows a lack of competency Displays little attention to detail 3 Contributes to serious treatment errors 4 Negatively affects the accuracy of the documentation ANS: 3 Spelling errors can result in serious treatment errors; for example, the names of certain medications such as digitoxin and digoxin or morphine and Numorphan are similar. Misspelling such terms can result in medication errors that may cause serious harm to a client. The other options are correct but do not have the seriousness of client care errors. DIF: C REF: 389 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 24. Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem? 1 His surgery corrected the mobility problem, so I drew a line through it and dated it. 2 The clients problem list has several resolved problems on it; should I take them off? 3 The client no longer has anxiety issues so I highlighted that problem on his problem list. He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list. 4 ANS: 4 New problems are added as they are identified. When a problem has been resolved, record the date and highlight it or draw a line through the problem and its number. Erasure is not an acceptable method of showing that a problem has been resolved. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: A REF: 390-391 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 25. Which of the following is an example of a problem statement used in the ProblemIntervention-Evaluation documentation method? 1 2 Risk for injury related to falling due to dizziness Client fell while walking to bathroom unassisted 3 Client continues to report periods of dizziness upon sitting up 4 Educated to the purpose of dangling on the bedside before standing ANS: 1 The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment 26. Which of the following is an example of an intervention used in the Problem-InterventionEvaluation documentation method? 1 Risk for injury related to falling due to dizziness 2 Client fell while walking to bathroom unassisted 3 Client continues to report periods of dizziness upon sitting up Educated to the purpose of dangling on the bedside before standing 4 ANS: 4 The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. DIF: A REF: 391 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 27. Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem? 1 His surgery corrected the mobility problem, so I draw a line through it and dated it. 2 The clients problem list has several resolved problems on it; should I take them off? The client no longer has anxiety issues so I highlighted that problem on his problem list. 3 4 He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list. ANS: 4 New problems are added as they are identified. When a problem has been resolved, record the date and highlight it or draw a line through the problem and its number. Erasure is not an acceptable method of showing that a problem has been resolved. DIF: A REF: 387 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 28. Which of the following is an example of a problem statement used in the ProblemIntervention-Evaluation documentation method? 1 Risk for injury related to falling due to dizziness 2 Client fell while walking to bathroom unassisted 3 Client continues to report periods of dizziness upon sitting up 4 Educated to the purpose of dangling on the bedside before standing ANS: 1 The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. DIF: A REF: 385 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 29. Which of the following is an example of an intervention used in the Problem-InterventionEvaluation documentation method? 1 2 Risk for injury related to falling due to dizziness Client fell while walking to bathroom unassisted 3 Client continues to report periods of dizziness on sitting up 4 Educated to the purpose of dangling on the bedside before standing ANS: 4 The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention. DIF: A REF: 390 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. Nursing documentation should fulfill which of the following criteria? (Select all that apply.) 1 Accurate 2 Inclusive 3 Well organized 4 Show continuity of care 5 Record nursing opinion 6 Identify client outcomes ANS: 1, 2, 3, 4, 6 Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Nursing documentation should include nursing observations, not nursing opinions. DIF: C REF: 390-391 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 2. The nurse realizes that effective nursing documentation encourages: (Select all that apply.) 1 Safe nursing practice WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Continuity of client care 3 Positive client outcomes Efficient time management 4 5 6 Cost-conscious nursing care Effective nurse-client relationships ANS: 1, 2, 4 Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors. While important, the remaining options are not criteria for effective nursing documentation. DIF: C REF: 391 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment 3. Problem Oriented Medical Record (POMR) method of documentation includes which of the following sections? (Select all that apply.) 1 Database 2 Care plan Evaluations 3 4 5 Problem list Interventions 6 Progress notes ANS: 1, 2, 4, 6 The POMR has the following major sections: database, problem list, care plan, and progress notes. Interventions and evaluations are documentation sections related to PIE (Problem, Interventions, and Evaluation) charting. Chapter 27. Patient Safety and Quality MULTIPLE CHOICE 1. The nurse has investigated safety hazards and recognizes that which one of the following statements is accurate regarding safety needs? 1 Bacterial contamination of foods is uncontrollable. 2 Fire is the greatest cause of unintentional death. 3 Carbon dioxide levels should be monitored in home settings. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Temperature extremes seldom affect the safety of clients in acute care facilities. ANS: 3 Annual inspections of heating systems, chimneys, and appliances should be done in private homes. Carbon monoxide detectors are available but should not be used as a replacement for proper use and maintenance of fuel-burning appliances. Bacterial contamination of foods is controllable. The FDA is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances. Motor vehicle accidents are the leading cause of unintentional death, not fire. Temperature extremes can affect the safety of clients in acute care facilities, especially the elderly. PTS: 1 DIF: A REF: 812 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 2. An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimers disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is: 1 Confusion 2 3 Impaired judgment Sensory deficits 4 History of falls ANS: 4 According to the falls assessment tool, the greatest indicator of risk is a history of falls. According to the falls assessment tool, the second leading risk factor for falls is confusion. According to the falls assessment tool, impaired judgment is the fourth leading risk factor for falls. According to the falls assessment tool, sensory deficit is the fifth leading risk factor for falls. PTS: 1 DIF: A REF: 817 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 3. An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. During the program, the mitigation phase is described. The nurse is informed that this phase includes: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Determination of hazard vulnerability and the impact of the emergency situation 2 3 Steps taken to manage the effects of the event and an inventory of available resources Steps taken by staff to triage victims 4 Restoration of essential services ANS: 1 The mitigation phase consists of the assessment process to determine hazard vulnerability for the hospitals service area. This includes an identification of the kinds of emergency situations that are most likely to occur and their probable impact. During the preparedness phase, steps are taken to manage the effects of the event, and an inventory of available resources is taken. During the response phase, steps are taken by staff to triage victims. During the recovery phase, steps are taken to restore essential services. PTS: 1 DIF: A REF: 821 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 4. An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. An important aspect of the program is the recognition of the signs and symptoms of bacterial and viral infections. A practice drill is held and the nurse recognizes that the clients admitted with possible anthrax will demonstrate: 1 Abdominal cramping, diarrhea, drooping eyelids, jaw clench, and difficulty swallowing 2 Flulike symptoms, gastrointestinal distress, and papular lesions 3 Fever, cough, chest pain, and hemoptysis Vesicular skin lesions on the face and extremities 4 ANS: 2 Clinical features of anthrax include flulike symptoms, gastrointestinal distress, and papular lesions. Abdominal cramping, diarrhea, drooping eyelids, jaw clench, and difficulty swallowing are clinical features of botulism. Fever, cough, chest pain, and hemoptysis are characteristic of plague. Vesicular skin lesions on the face and extremities are seen with smallpox. PTS: 1 DIF: A REF: 821 OBJ: Comprehension WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 5. A 1-year-old child is scheduled to receive an IV line. The most appropriate type of restraint to use for this client to prevent removal of the IV line would be a(n): 1 2 Wrist restraint Jacket restraint 3 Elbow restraint 4 Mummy restraint ANS: 4 A mummy restraint is used short-term for a small child or infant for examination or treatment involving the head and neck. This would be the most appropriate type of restraint to use for a 1year-old child who is going to receive an IV line. The wrist restraint maintains immobility of an extremity to prevent the client from removing a therapeutic device, such as an IV tube. It would not be the best choice for starting an IV on a 1-year-old child. The jacket restraint is often used to prevent a client from getting up and falling. It is not the best choice for starting an IV line. An elbow restraint is commonly used with infants and children to prevent elbow flexion, such as after an IV line is in place. PTS: 1 DIF: A REF: 832 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 6. A 79-year-old resident in a long-term care facility is known to wander at night and has fallen in the past. Which of the following is the most appropriate nursing intervention? 1 An abdominal restraint should be placed on the client during sleeping hours. 2 The client should be checked frequently during the night. 3 A radio should be left playing at the bedside to assist in reality orientation. 4 The client should be placed in a room that is away from the activity of the nurses station. ANS: 2 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Alternatives to restraints should be attempted first. (A physicians order is required for restraints to be applied.) The most appropriate intervention is to check on the client frequently. Alternatives to restraints should be attempted first before an abdominal restraint while sleeping. A radio may help orientate a client to reality. However, the most appropriate intervention for the client who wanders is to check on the client frequently. Clients who wander should be assigned to rooms near the nurses station and checked on frequently. PTS: 1 DIF: C REF: 832 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 7. The workmen cause an electrical fire when installing a new piece of equipment in the intensive care unit. A client is on a ventilator in the next room. The first action the nurse should take is to: 1 2 3 4 Pull the fire alarm Attempt to extinguish the fire Call the physician to obtain orders to take the client off the ventilator Use an Ambu-bag and remove the client from the area ANS: 4 If there is a fire, and the client is on life support, the nurse should maintain the clients respiratory status manually with an Ambu-bag and move the client away from the fire. The first action of the nurse is not to pull the fire alarm. The workmen could do that. The workman can attempt to extinguish the fire. The nurse should attend to the client who is closest to the fire in the next room. The nurse should not call the doctor to obtain orders to take the client off the ventilator because this will take valuable time. The client needs to be moved away from the fire, and the source of oxygen needs to be discontinued, as it is combustible. The client will need to be manually resuscitated with an Ambu-bag. PTS: 1 DIF: C REF: 839 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 8. In a nursing home an elderly client drops his burning cigarette in a trash can and starts a fire. The most appropriate type of fire extinguisher for the nurse to use is the: 1 Type A 2 Type B WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Type C 4 Type D ANS: 1 Type A fire extinguishers are used for ordinary combustibles such as wood, cloth, paper, and plastic. A trash can fire would require a type A fire extinguisher. Type B fire extinguishers are used for flammable liquids such as gasoline, grease, paint, and anesthetic gas. Type C fire extinguishers are used for electrical equipment. There is no type D fire extinguisher. PTS: 1 DIF: A REF: 840 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 9. A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of risk for injury related to decreased vision. Based on this assessment, the client will benefit the most from: 1 Installing fluorescent lighting throughout the house 2 3 Becoming oriented to the position of the furniture and stairways Maintaining complete bed rest in a hospital bed with side rails 4 Applying physical restraints ANS: 2 Orienting the client to the position of furniture in the room and stairways is the best intervention to help prevent falls for the client with decreased vision. Attempts should be made to reduce glare. Light bulbs that are 60 watts or less may be increased to 75 watts to help improve visibility. The best intervention to prevent falls is to first orient the client to the surroundings. Maintaining complete bed rest is not the best option. Complete bed rest can cause other health problems resulting from a lack of mobility. The client should not be restrained for poor vision. Attempts should be made to help compensate for the decreased vision in order to prevent falls. PTS: 1 DIF: C REF: 819 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 10. Which one of the following statements by the parent of a child indicates that further teaching by the nurse is required? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Now that my child is 2 years old, I can let her sit in the front seat of the car with me. 2 3 I make sure that my child wears a helmet when he rides his bicycle. I have spoken to my child about safe sex practices. 4 My child is taking swimming classes at the community center. ANS: 1 This statement indicates that further teaching is required. Children weighing less than 80 pounds or who are under 8 years of age should always be in an age/weight-appropriate car seat that has been installed according to manufacturers directions. In cars with a passenger air bag, children under 12 should be in the back seat. Answer 2 is an appropriate safety measure to reduce injuries from falling off a bike or being hit by a car. Answer 3 is an important safety measure because many adolescents begin sexual relationships. Answer 4 is an appropriate safety measure that may someday save a childs life. PTS: 1 DIF: C REF: 827 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 11. The nurse assesses that the client may need a restraint and recognizes that: 1 An order for a restraint may be implemented indefinitely until it is no longer required by the client 2 Restraints may be ordered on an as-needed basis 3 No order or consent is necessary for restraints in long-term care facilities 4 Restraints are to be periodically removed to have the client reevaluated ANS: 4 Restraints must be periodically removed, and the nurse must assess the client to determine if the restraints continue to be needed. Answer 1 is not a true statement. A physicians order for restraints must have a limited time frame. If the orders are renewed, it should be done so within a specified time frame according to the agencys policy. Restraints are not to be ordered prn (as needed). The use of restraints must be part of the clients medical treatment. An order or consent is necessary for restraints in long-term care facilities. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material PTS: 1 DIF: A REF: 831 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 12. On entering the clients room, the nurse sees a fire burning in the trash can next to the bed. The nurse removes the client and calls in the fire. The next action of the nurse is to: 1 2 3 4 Extinguish the fire Remove all of the other clients from the unit Close all the doors of client rooms Move the trash can into the bathroom ANS: 3 The next action the nurse should take is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment. The nurse should extinguish the fire using an extinguisher after closing the doors of the client rooms. After activating the alarm, the nurse should close all the doors, not remove all of the other clients from the unit. Answer 4 would not be an appropriate action because the nurse could get burned in attempting to move the trash can. PTS: 1 DIF: A REF: 839 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 13. A mother of a young child enters the kitchen and finds the child on the floor. There is a bottle of cleanser next to the child and particles of the substance around the childs mouth. The parents first action should be to: 1 Call the Poison Control unit 2 Provide ipecac syrup 3 Check the childs airway and breathing 4 Remove the particles of cleanser from the mouth ANS: 3 The first action is to assess for airway patency, breathing, and circulation. After checking the childs airway, breathing, and circulation, the parent should remove any particles of cleanser from the mouth. The parent should identify the type and amount of substance ingested and then call the Poison Control unit. The parent should only administer ipecac syrup if instructed to induce vomiting by the Poison Control unit. Administering ipecac is not the parents first action. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Removing the particles of cleanser is not the parents first action. The parent may do so after assessing the childs airway, breathing, and circulation. PTS: 1 DIF: C REF: 840 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 14. Which of the following nursing assessment data are most reflective of hypothermia? 1 Cyanotic lips, fingers, and toes 2 Rectal temperature of 35 C (95 F) 3 Bradycardia of 56 beats per minute Exposure to outdoor temperatures of <32 F 4 ANS: 2 Hypothermia occurs when the core body temperature is 35 C (95 F) or below. While the remaining options are not incorrect, they may be due to other factors. PTS: 1 DIF: A REF: 812 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 15. Which of the following clients who is experiencing the heat of mid-August is at greatest risk for heatstroke or heat exhaustion? 1 A 65-year-old diagnosed with COPD 2 A 35-year-old novice marathon runner 3 A 15-year-old playing in an outdoor tennis tournament 4 A 9-month-old whose bedroom is cooled with a mechanical fan ANS: 1 Exposure to extreme heat raises the core body temperature, resulting in heatstroke or heat exhaustion. Chronically ill clients, older adults, and infants are at greatest risk for injury from extreme heat. These clients need to avoid extremely hot, humid environments. While the remaining options reflect a risk, it is not as high as the answer. PTS: 1 DIF: C REF: 812 OBJ: Analysis TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 16. The nurse should recognize which of the following clients as being at greatest risk for an unintentional death? 1 2 3 4 A 58-year-old who skis regularly A 44-year-old alcoholic who lives alone A 72-year-old identified as at high risk for falls A 34-year-old diagnosed with chronic depression ANS: 3 Among older adults 65 years and older, falls are the leading cause of unintentional death. While the remaining options reflect clients at risk, the probability is not as great. PTS: 1 DIF: C REF: 813 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 17. Which of the following nursing interventions has the greatest likelihood of minimizing the risk of injury for a client who frequently gets out of bed at night to go into the bathroom? 1 Limiting fluid intake after 6 PM 2 Illuminating the pathway to the bathroom 3 Toileting the client whenever awake at night Checking on the client at least hourly during the night 4 ANS: 2 While checking on the client frequently is not incorrect, night-lights in dark halls, bathrooms, and the rooms of children and older adults help maintain safety by reducing the risk of falls. The remaining options are more directed at controlling urinary output than preventing injury. PTS: 1 DIF: C REF: 813 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 18. When discussing the prevention of fire-related injuries and deaths, the nurse should place the greatest emphasis on the: 1 Prevention role smoke detectors play WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Dangers of careless smoking habits 3 Supervision of children around open flames Importance of readily accessible fire extinguishers 4 ANS: 2 The leading cause of fire-related death is careless smoking. While the other options reflect risk, they are not as highly prioritized as the answer. PTS: 1 DIF: C REF: 813 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 19. The nurse recognizes that the leading cause of death for the otherwise healthy 1-year-old is: 1 Physical abuse 2 Accidental injury 3 Contagious diseases 4 Stranger abduction ANS: 2 Injuries are the leading cause of death in children older than 1 year of age and cause more deaths and disabilities than do all diseases combined. PTS: 1 DIF: A REF: 814 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 20. The nurse is preparing a safety-related program for a group of parents of 5- to 14-year-olds. Which of the following topics is most likely to positively impact the leading cause of injury for this age-group? 1 Keeping them safe while they play sports 2 3 Bicycle riding with safety in mind Safety first when around water 4 Dont let fire hurt your child ANS: 2 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Children 5 to 14 years of age account for nearly one third of bicyclists killed in traffic accidents. While the remaining options deal with risk factors, the priority relates to bicycle-oriented accidents. PTS: 1 DIF: C REF: 815 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 21. The nurse recognizes which of the following clients is at greatest risk for an accidental death? 1 2 A 60-year-old who is a weekend alcoholic A 40-year-old who is a professional mountain climber 3 A 35-year-old who commutes 35 miles to work each morning 4 A 50-year-old who recently lost his job because of a workrelated injury ANS: 4 The adult experiencing a high level of stress is more likely to have an accident or illness such as headaches, gastrointestinal (GI) disorders, and infections. While the remaining options identify risks, they are not a high as that of the stressed adult. PTS: 1 DIF: C REF: 815 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 22. A client who is experiencing a generalized clonic-tonic seizure is at greatest risk for injury caused by: 1 The physical collapse that occurs at the onset of the seizure 2 Muscle strains that result from the severe muscle jerking during the seizure 3 The tongue laceration that occurs from jaw clenching during the seizure Aspiration resulting from the temporary loss of consciousness after the seizure 4 ANS: 1 During a fall, or as a result of muscle jerking, musculoskeletal injuries can occur. The fall is the most problematic since is occurs in the vast majority of the seizure events. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material PTS: 1 DIF: C REF: 817 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 23. Which of the following clients is at greatest risk for injury related to medical diagnoses and conditions? 1 2 A history of asthma and alcohol abuse A history of heart failure and urinary urgency 3 A history of hypertension and wearing corrective lenses 4 A history of chronic bronchitis and impaired hearing ANS: 2 This client is likely using diuretics that increase the frequency of voiding and result in the client having to use toilet facilities more often. Falls often occur with clients who have to get out of bed quickly because of urinary urgency. PTS: 1 DIF: C REF: 817 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 24. The nurse is conducting an admission interview and assessment on a cognitively impaired, uncooperative client for the risk for injury. Which of the following options will most likely provide the information to confirm the diagnosis? 1 Base the degree of risk on observable data at the time of the clients current hospital admission. 2 Closely monitor the clients behavior and habits until risk for injury can be reasonably determined. Make certain critically sound assumptions are based on the clients developmental stage and current cognitive stasis. 3 4 Interview the clients family, friends, and/or caregivers regarding prehospitalization risk factors. ANS: 4 In many cases family members are important resources in assessing a clients fall risk. Families often are able to report on the clients level of confusion and ability to ambulate. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material PTS: 1 DIF: C REF: 818 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 25. A nurse working in an acute care facilitys emergency department should recognize which of the following client reports as being most suspicious of a terrorist attack? 1 Four deaths resulting from a privately owned airplane crashing into a four-story building 2 Numerous reports of respiratory distress among older adults who attended an outdoor musical event 3 15 cases of nausea and vomiting reported over a 2-day period when 4 cases would be within normal for the facility 4 10 children, all who attended a child-oriented arts and crafts fair, presenting with rashes on their hands and faces ANS: 3 An unusual increase in the number of people seeking care, especially with fever, respiratory, or gastrointestinal complaints, is a classic indicator of such an event. While the other options present possible indicators, there are other possible reasons for the incidents. PTS: 1 DIF: C REF: 820 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 26. The nurse is discussing safety issues with the mother of three children. Which of the following statements has the greatest possibility for decreasing the potential for injury among the children? 1 Where do you see a need for safety improvements in your home? 2 Keep all toxic liquids capped and stored out of reach of the children. 3 Installing safety gates at the top and bottom of each set of stairs will help minimize falls. Take great care to keep the children away from kitchen appliances and tools that can hurt them. 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 1 Clients generally expect to be safe in their homes and health care settings. However, there are times when a clients view of what is safe does not agree with that of the nurse. For this reason, any assessment needs to include the clients understanding of his or her perception of risk factors. The remaining options are directed toward specific safety issues. PTS: 1 DIF: C REF: 824 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 27. The nurse recognizes that the greatest benefit of engaging the mother of two small children into a discussion about child-proofing her home is that: 1 2 The home will be safe for the immediate time being If an accident occurs, it will likely be minor in nature 3 She is likely to monitor the house for safety issues in the future 4 She will serve as a role model regarding safety issues for her children ANS: 3 The client who is an active participant in reducing threats to safety becomes more alert to potential hazards. PTS: 1 DIF: C REF: 824 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 28. The nurse and a mother of two small children are discussing child safety issues. Which of the following nursing interventions has the greatest potential for using collaboration to help ensure the childrens safety? 1 Arranging to teach the children how to react in the case of a fire in the home 2 Teaching the children to telephone 911 if there is ever an emergency in the home Helping the mother identify an emergency person for the children to telephone in the case of an emergency 3 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Helping the mother create a list of emergency telephone numbers to be posted next to the homes telephone ANS: 4 Clients need to learn how to identify and select resources within their community that enhance safety (e.g., neighborhood block homes, local police departments, and neighbors willing to check on a clients well-being).The remaining options deal with individual aspects of a complete plan. PTS: 1 DIF: C REF: 824 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 29. When preparing a safety workshop for early teens (13 to 15 years old), the nurse recognizes that which of the following active strategy topics has the greatest potential for decreasing injuries in this population by affecting lifestyle changes? 1 Avoiding the nicotine habit 2 Keeping immunizations up to date 3 Eating a well-balanced, low-fat diet Wearing a seat belt when riding in an automobile 4 ANS: 4 To promote an individuals health, it is necessary for the individual to be in a safe environment and to practice a lifestyle that minimizes risk of injury. Active strategies are those in which the individual is actively involved through changes in lifestyle (e.g., wearing seat belts or installing outdoor lighting) and participation in wellness programs. Accidents involving automobiles account for the most substantial number of injuries and deaths among this population from among the options provided. PTS: 1 DIF: C REF: 824 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 30. The nurse is discussing measures to minimize the risk of injury from an automobile accident with an 83-year-old adult client who lives alone and claims to drive only to church, the doctors office, and for groceries. Which of the following suggestions has the greatest potential for affecting this clients safety? 1 Take public transportation whenever it is available. 2 Plan errands around church or doctors appointments. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Plan driving for short trips and only during the daylight hours. 4 Arrange for family or friends to drive you whenever it is possible. ANS: 3 The nurse educates clients regarding safe driving tips (e.g., driving shorter distances or only in daylight, using side and rearview mirrors carefully, and looking behind them toward their blind spot before changing lanes). The other options, while not incorrect, may not be realistic or appealing to an independent client. PTS: 1 DIF: C REF: 824 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 31. Which of the following assessment findings is most critical in a client who is currently being restrained with mechanical wrist restraints? 1 Angry, loud crying 2 3 Urinary incontinence Reddened areas on wrists 4 Hands are cool to the touch ANS: 4 While the use of any restraint may be associated with serious complications, including pressure ulcers, constipation, pneumonia, urinary and fecal incontinence, and urinary retention, the most serious are contractures, nerve damage, and circulatory impairment. The coolness of the clients hands indicates poor circulation and can result in permanent damage. PTS: 1 DIF: C REF: 837 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 32. The nurse is discussing a newly ordered diuretic with an older adult client who is homebound. Which of the following suggestions has the greatest potential for minimizing the clients risk for injury related to urinary urgency or incontinence? 1 Consider decreasing fluid intake after 6 PM. 2 Illuminate the path to the bathroom at night. 3 Encourage the client to urinate immediately before bed. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Encourage the client to take the medication early in the morning. ANS: 4 Nocturia and incontinence are more frequent in older adults. Give diuretics in the morning. While the other options may have value, they do not have an impact on the situation as directly as the administration of the medication. PTS: 1 DIF: C REF: 813 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control 33. A nurse caring for an elderly client who has had surgery and is in the hospital knows that the client is at high risk for developing a nosocomial infection. One of the most important things that the nurse can do to prevent this client from obtaining a nosocomial infection is to: 1 Practice appropriate hand hygiene 2 Request prophylactic antibiotics for the client 3 Place the client in isolation 4 Encourage the client to turn, cough and deep breath every 2 hours ANS: 2 Antibiotics should be used appropriately to prevent resistant organisms. The best way to prevent nosocomial infections is to perform hand hygiene before and after each client encounter and after contact with contaminated objects. Isolation will not in itself prevent a nosocomial infection. Answer 4 will help prevent atelectasis, but not necessarily a nosocomial infection. PTS: 1 DIF: B REF: 829 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 34. The nurse caring for an elderly client in the hospital notes on assessment that the client has a scald burn on her foot. On questioning the client, the nurse learns that the client scalded her foot when adding hot water from the tap to her bath while she was in the tub. The nurse should do which of the following? 1 Report the incident as suspected elder abuse. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Suggest that the temperature of the hot water heater be lowered. 3 Instruct the client that she should not be taking tub baths to prevent this from happening again. Discuss the incident with social services so that arrangements can be made for the client to go to a nursing home on discharge from the hospital. 4 ANS: 2 Hot water from the tap should not have the potential to scald, because it is a safety hazard. The client had a plausible explanation for the incident without other signs to indicate abuse. There is no reason that the client should not be able to continue to take tub baths if the water temperature is within a safe range. The client has no other indications that she is in any danger of caring for herself; thus Answer 4 is not appropriate. PTS: 1 DIF: A REF: 824 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 35. A nurse in the emergency department (ED) of a community hospital notes that an unusually high number of clients have presented in the ED with flulike symptoms, abdominal pain, nausea, vomiting, bloody diarrhea, hematemesis and itching of the hands, forearms, and head. The nurse is concerned with bioterrorism, reports this to the supervisor, and suspects an outbreak of: 1 Botulism 2 Anthrax 3 Plague 4 Smallpox ANS: 2 The symptoms of the clients all point to an endemic outbreak of anthrax. PTS: 1 DIF: A REF: 816 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 36. When discussing the new mothers pending discharge from the hospital, the nurse determines that additional client teaching needs to take place because of which of the following comments? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 My husband has installed the new car seat in the middle of the backseat of our car. 2 I cant wait to put my baby in her new crib with the ensemble that my mom made sheets, blankets, and bumper to match. I need to place my baby on her back to sleep, right? 3 4 I have checked all my babys toys to make sure that they dont contain lead paint. ANS: 2 Newborns should not be placed in cribs with loose comforters, bumper pads, etc. The middle of the back seat is the safest place to put the infant car seat. Babies should not be placed on their stomachs with their mouth and nose in close proximity to the mattress, which is associated with sudden death syndrome. Lead paint on infant toys can lead to brain damage. PTS: 1 DIF: A REF: 829 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Health Promotion and Maintenance 37. A confused client on a ventilator was restrained to prevent him from pulling out his endotracheal tube. Which of the following could be a possible alternative measure that the nurse could use to avoid the use of the restraints? 1 Orient the client to the environment and explain the need for the endotracheal tube. 2 Provide a trained sitter to continuously supervise the client. 3 Camouflage the endotracheal tube with stockinette dressing. 4 Promote relaxation techniques. ANS: 2 A trained sitter can prevent the client from pulling out the endotracheal tube. The client is confused and does not understand. The endotracheal tube cannot be camouflaged effectivelythe client feels it more than sees it. Because the client is confused, it may be very difficult to communicate relaxation techniques so that the client has an understanding. PTS: 1 DIF: C REF: 821 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 38. A confused client needs to have restraints to prevent him from pulling out his Foley catheter. Which of the following can the nurse delegate to the nursing assistive personnel? 1 2 3 4 Applying restraints Obtaining a physicians order to restrain the client Document the events that led to restraining the client Evaluating the effectiveness of the restraints ANS: 1 Although the nursing assistive personnel can apply the restraints under the nurses direction, they cannot document, evaluate, or take physicians orders. PTS: 1 DIF: A REF: 826 OBJ: Knowledge TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 39. A nurse finds that an electrical cord has shorted out in a clients room, causing a fire. The nurse should do which of the following actions first? 1 Activate the alarm. 2 Confine the fire by closing the clients door. 3 Remove the client from the room. Extinguish the fire. 4 ANS: 3 The mnemonic RACE should be used to help remember to rescue or remove all clients in immediate danger, activate the alarm, confine the fire, and extinguish the fire PTS: 1 DIF: A REF: 832 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 40. Which of the following statements indicates that the client is at risk for an electrical shock at home? 1 I had to cut off the third prong on the electrical plug so that it would fit in the extension cord. 2 My bread got stuck in my toaster this morning, and I unplugged it before trying to remove it. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 I always read the owners manual when I purchase a new electrical appliance. 4 I always make sure that I am standing in a dry area before operating electrical equipment. ANS: 2 The third prong is used to ground the piece of equipment. Improperly grounded equipment can cause electrical injury. PTS: 1 DIF: B REF: 834 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 41. The nurse is caring for a client with a history of epileptic seizures. The nursing assistive personnel notifies the nurse that the client is having a seizure. The first thing that the nurse should do when arriving in the room is to: 1 Raise the bed side rails 2 Put the bed in the lowest position 3 Position the client safely 4 Provide privacy ANS: 3 Although Answers 1, 2 and 3 are all important safety interventions, the priority is to safely position the client. It is important to provide privacy, but safety interventions are a priority. PTS: 1 DIF: B REF: 840 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control 42. A client with a history of epilepsy arrives in the emergency department experiencing status epilepticus. The nurse should never do which of the following? 1 Document sequence of events, including any adverse outcomes. 2 Prepare to initiate IV access. 3 Access oxygen and suctioning equipment. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Open clients mouth by placing fingers on jaw and inserting thumb on bottom teeth to place oral airway between seizures. ANS: 4 Nurses should never put their fingers in or close to a clients mouth who is or has been experiencing seizure activity, to prevent being bitten in the event that the client should experience more seizure activity. The nurse is responsible for all of these measures in Answers 1, 2, and 3 to provide for the safety of the client, as well as document the sequence of events including any unexpected outcomes. PTS: 1 DIF: B REF: 842 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control MULTIPLE RESPONSE 1. The nurse caring for clients in an acute care facility recognizes that attending to the safety of each client is most likely to result in: (Select all that apply.) 1 Freedom from illness 2 A shorter hospital stay 3 4 Attention to the basic human needs A well-founded sense of well-being 5 Preservation of the optimal functioning level 6 Minimal exposure to bacterial cross-contamination ANS: 2, 3, 4, 5, 6 Safety in health care settings reduces the incidence of illness and injury, prevents extended length of treatment and/or hospitalization, improves or maintains a clients functional status, and increases the clients sense of well-being. A safe environment gives protection to the staff as well, allowing them to function at an optimal level. A safe environment includes meeting basic needs, reducing physical hazards, reducing the transmission of pathogens, maintaining sanitation, and controlling pollution. While a reduction of illness is an expectation, there is no assurance of the freedom from illness. PTS: 1 DIF: A REF: 843 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safe, Effective Care Environment/Safety & Infection Control WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2. The nurse recognizes that children living in older housing that may contain lead-based paints may exhibit which of the following signs and symptoms? (Select all that apply.) 1 2 3 Vomiting Anorexia 4 Headaches Bloody urine 5 Thoracic rash 6 Swollen joints ANS: 1, 2, 3 Signs and symptoms of lead poisoning typically include impaired hearing, vomiting, headaches, appetite loss, and learning and behavioral problems. The remaining options are not typically seen with this condition. Chapter 28. Infection Prevention and Control MULTIPLE CHOICE 1. The client has a 6-inch laceration on his right forearm. The arm develops an infection. Which of the following is a sign of an acute inflammatory process? 1 A blanching of the skin 2 A decrease in temperature at the site 3 A decrease in the number of white blood cells 4 A release of histamine trhat adds to the pain response ANS: 4 A sign of an acute inflammatory process is pain. The swelling of inflamed tissues increases pressure on nerve endings, causing pain. Chemical substances such as histamine also stimulate nerve endings, adding to the pain response. The skin is not blanched; but rather, with the increase in local blood flow; it is reddened. The symptom of localized warmth results from a greater volume of blood at the inflammatory site. The cellular response of acute inflammation involves WBCs arriving at the site. There is an increase in WBCs, rather than a decrease. DIF: A REF: 646 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 2. A female client has been undergoing diagnostic testing since admission to the medical unit in the hospital. The results of blood testing are sent back to the unit. Upon reviewing the results, the nurse will report which of the following findings to the physician, which is abnormal? WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Erythrocyte sedimentation rate (ESR) 35 mm/hr 2 3 White blood cell (WBC) count 8000/mm3 Neutrophils 65% 4 Iron 75 g/100 mL ANS: 1 The normal erythrocyte sedimentation rate for women is 20 mm/hr. The clients ESR is 35 mm/hr, indicating the presence of the inflammatory process. The normal WBC count is 5000-10,000/ mm3. The client is within normal limits at 8000/mm3. The normal neutrophil count is 55-70%. The client is within normal limits at 65%. The normal iron level is 60-90 g/100 mL. The client is within normal limits at 75 g/100 mL. DIF: A REF: 646 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 3. The nurse is observing the new staff member work with the client. Of the following activities, which one has the greatest possibility of contributing to a nosocomial infection and requires correction? 1 Washing hands before applying a dressing 2 Taping a plastic bag to the bed rail for tissue disposal 3 Placing a Foley catheter bag on the bed when transferring a client Using alcohol to cleanse the skin before starting an intravenous line 4 ANS: 3 The staff member who places the Foley catheter bag on the bed when transferring the client is placing the client at risk for a nosocomial infection because urine in the catheter or drainage tube may reenter the bladder (reflux). Washing hands before applying a dressing is a correct action to help prevent a nosocomial infection. Taping a plastic bag to the bed rail for tissue disposal is a correct action to aid the client in proper disposal of secretions. Using alcohol to cleanse the skin before starting an intravenous line is a correct action to prevent a nosocomial infection of the bloodstream. DIF: A REF: 648 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4. Droplet precautions will be instituted for the client admitted to the infectious disease unit with: 1 Streptococcal pharyngitis 2 3 Herpes simplex Pertussis 4 Measles ANS: 1 Droplet precautions are instituted when droplets are larger than 5 micrometers, such as in the case of streptococcal pharyngitis. Contact precautions are instituted for herpes simplex. Airborne precautions are instituted with pulmonary TB. Airborne precautions are instituted with measles. DIF: A REF: 662 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 5. In a small rural hospital they work with a wide variety of clients. Of this afternoon clients admitted, the nurse acknowledges the client with the highest susceptibility to infection is the individual with: 1 Burns 2 Diabetes 3 Pulmonary emphysema 4 Peripheral vascular disease ANS: 1 Burn clients have a very high susceptibility to infection because of the damage to skin surfaces. This would be the individual with the highest risk for infection. Victims of chronic diseases such as diabetes mellitus and multiple sclerosis are susceptible to infection because of general debilitation and nutritional impairment. Diseases that impair body system defenses, such as emphysema and bronchitis (which impair ciliary action and thicken mucus), increase susceptibility to infection. Diseases that impair body system defenses, such as peripheral vascular disease (which reduces blood flow to injured tissues), increase susceptibility to infection. DIF: C REF: 668-669 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 6. A nurse must display understanding of the mental implications of a client on isolation precautions when planning care to control the risk of: 1 2 3 4 Denial Aggression Regression Isolation ANS: 4 A sense of loneliness may develop because normal social relationships become disrupted. The nurse should plan care to control the risk of the client feeling isolated. Denial is not a risk related to isolation. Aggression is not a risk for the client on isolation precautions. Regression is not a risk related to isolation. DIF: A REF: 661 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 7. Surgical aseptic techniques are employed by a nurse when: 1 Inserting an intravenous catheter 2 Placing soiled linen in moisture-resistant bags 3 Disposing of syringes in puncture-proof containers 4 Washing hands before changing a dressing ANS: 1 Surgical asepsis should be used during procedures that require intentional perforation of the clients skin, such as with the insertion of IV catheters. The nurse is employing medical aseptic technique when placing soiled linen in moisture-resistant bags. The nurse is employing medical aseptic technique when disposing of syringes in puncture-proof containers. The nurse is employing medical aseptic technique when washing hands before changing a dressing. DIF: A REF: 669 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 8. A nurse is changing the dressing and accidentally drops the packing onto the clients abdomen. The client has a large, deep abdominal incision that is packed with sterile half-inch packing and covered with a dry 4 4 gauze. The nurse should: 1 Add alcohol to the packing and insert it into the incision WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Throw the packing away, and prepare a new one 3 Pick up the packing with sterile forceps, and gently place it into the incision Rinse the packing with sterile water, and put the packing into the incision with sterile gloves 4 ANS: 2 A sterile object (the packing) remains sterile only when touched by another sterile object. The clients abdomen is not sterile; therefore, the nurse should throw the packing away and prepare a new one. The nurse should not add alcohol to the packing and insert it into the incision. The packing is considered contaminated as it touched a nonsterile surface and should be discarded. The nurse should not rinse the packing with sterile water and put the packing into the incision as it is considered contaminated. It touched a nonsterile surface. The nurse should throw the packing away and prepare a new one. DIF: A REF: 669 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 9. A client has a viral infection. Which of the following is typical of the illness stage of the course of her infection? 1 There are no longer any acute symptoms. 2 An oral temperature reveals a febrile state. 3 The client was first exposed to the infection 2 days ago but has no symptoms. 4 The client feels sick but is able to continue her normal activities. ANS: 2 During the illness stage the client manifests signs and symptoms specific to the type of infection. The client with a viral infection would likely exhibit a fever. There are no longer any acute symptoms during the convalescent period. An example of a client in the incubation period is when the client was first exposed to the infection 2 days ago, but has no symptoms. The client who feels sick but is able to continue normal activities is in the prodromal stage of a course of infection. DIF: A REF: 646 OBJ: Comprehension TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safety and Infection Control 10. The nurse recognizes that special care must be taken in the handling of which of the following to prevent the transmission of hepatitis A? 1 2 Blood Feces 3 Saliva 4 Vaginal secretions ANS: 2 To prevent the transmission of hepatitis A, the nurse needs to take special care when handling feces. Hepatitis B and C may be found in blood. Hepatitis A is not found in saliva. Hepatitis A is not found in vaginal secretions. DIF: A REF: 643 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 11. The parent of a preschool child asks the nurse how chickenpox (varicella zoster) is transmitted. The nurse identifies that the virus is: 1 Carried by a vector organism 2 Carried though the air in droplets after sneezing or coughing 3 Transmitted through person-to-person contact 4 Acquired through contact with contaminated objects ANS: 2 Varicella zoster virus (chickenpox) is transmitted by droplets carried through the air after sneezing or coughing. Varicella zoster virus (chickenpox) is not transmitted by a vector. Person-to-person contact is not responsible for varicella zoster virus (chickenpox) transmission. The transmission of varicella zoster virus (chickenpox) does not occur by contact with contaminated objects. DIF: A REF: 643 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 12. While working with clients in the postoperative period, the nurse is very alert to the results of laboratory tests. Which one of the following results is indicative of an infectious process? 1 Iron 80 g/100 mL WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Neutrophils 65% 3 White blood cells (WBC) 18,000/mm3 Erythrocyte sedimentation rate (ESR) 15 mm/hr 4 ANS: 3 An elevated WBC count is indicative of an acute infection. The normal WBC count is 5000 to 10,000/mm3. The normal neutrophil count is 55%-70%. The client is within normal limits at 65%. The normal iron level is 60-90 g/100 mL. The client is within normal limits at 80 g/100 mL. The normal erythrocyte sedimentation rate (ESR) is up to 15 mm/hr for men and up to 20 mm/hr for women. The client is within normal limits at 15 mm/hr. DIF: A REF: 651 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 13. Which of the following is an example of a nursing intervention that is implemented to reduce a reservoir of infection for a client? 1 Covering the mouth and nose when sneezing 2 Wearing disposable gloves 3 Isolating clients articles 4 Changing soiled dressings ANS: 4 To control or eliminate reservoir sites for infection, the nurse eliminates or controls sources of body fluids, drainage, or solutions that might harbor microorganisms. The nurse also carefully discards articles that become contaminated with infectious material such as in changing soiled dressings. Covering the mouth and nose when sneezing is an intervention to control a portal of exit. Wearing disposable gloves helps protect the susceptible host. Isolating clients articles is an intervention to control transmission. DIF: A REF: 643 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 14. In preventing and controlling the transmission of infections, the single most important technique is: 1 Hand hygiene 2 The use of disposable gloves WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 The use of isolation precautions 4 Sterilization of equipment ANS: 1 The most important and most basic technique in preventing and controlling transmission of infections is hand hygiene. Use of disposable gloves may help reduce the transmission of infections, but is not the single most important technique to prevent and control the transmission of infections. The use of isolation precautions is not the single most important technique to prevent and control the transmission of infections. Sterilization of equipment is not the single most important technique to prevent and control the transmission of infections. DIF: A REF: 655 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 15. A client with active tuberculosis is admitted to the medical center. The nurse recognizes that admission of this client to the unit will require the implementation by the staff of: 1 2 Airborne precautions Droplet precautions 3 Contact precautions 4 Reverse isolation ANS: 1 A client with active tuberculosis requires airborne precautions. A client with active tuberculosis does not require droplet precautions, as the droplet nuclei of tuberculosis are smaller than 5 micrometers. Contact precautions are not necessary for the client with active tuberculosis. Reverse isolation is not required for the client with active tuberculosis DIF: A REF: 645 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 16. The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with sterile asepsis? 1 Clean forceps may be used to move items on the sterile field. 2 Sterile fields may be prepared well in advance of the procedures. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 The first small amount of sterile solution should be poured and discarded . 4 Wrapped sterile packages should be opened starting with the flap closest to the nurse. ANS: 3 Before pouring the solution into the container, the nurse pours a small amount (1 to 2 mL) into a disposable cap or plastic-lined waste receptacle. The discarded solution cleans the lip of the bottle. This action is consistent with sterile asepsis. Sterile forceps should be used to move items on a sterile field when using sterile asepsis. Sterile fields should not be prepared well in advance of a sterile procedure. A sterile object or field becomes contaminated by prolonged exposure to air. Wrapped sterile packages should be opened starting with the flap farthest away from the nurse (i.e., the top flap). DIF: A REF: 674 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 17. Older adult clients may react differently to infectious processes and a nurse suspects that her older adult client may be experiencing hypostatic pneumonia. The nurse must be alert to atypical signs and symptoms, such as: 1 Hypotension 2 3 Confusion Erythema 4 Chills ANS: 2 An infection in older adults may not present with typical signs and symptoms. Atypical symptoms such as confusion, incontinence, or agitation may be the only symptoms of an infectious illness. An unexplained increased heart rate, confusion, or generalized fatigue may be the only symptoms of pneumonia in the older adult. Hypotension is not one of the atypical symptoms of an older adult experiencing infection. It may be a symptom of a systemic infection related to an elevation in body temperature (regardless of age). Erythema is a typical symptom of a localized infection. Chills are a typical symptom of a systemic infection. DIF: A REF: 649-650 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 18. What is the correct order for a nursing assistant for putting on the protective equipment when caring for a client in isolation? 1 Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves 2 Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves 3 Wash her hands, put on the gown, apply the mask and eyewear, and then apply the gloves 4 Put on the gown, apply the mask and eyewear, wash her hands, and then apply gloves ANS: 1 The correct sequence for putting on protective equipment is to perform hand hygiene, apply the mask and eyewear, apply gown, and then apply gloves. Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves; wash her hands, put on the gown, apply the mask and eyewear, and then apply the gloves; put on the gown, apply the mask and eyewear, wash her hands, and then apply gloves are not the correct sequences for putting on protective equipment. DIF: A REF: 664 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 19. A client has requires a mid-abdominal surgical incision which necessitates a sterile dressing. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: 1 Put sterile gloves on before opening sterile packages 2 Discard packages that may have been in contact with the area below waist level 3 Place the cap of the sterile solution well within the sterile field Place sterile items on the very edge of the sterile drape 4 ANS: 2 A sterile object held below a persons waist is considered contaminated. To maintain sterile asepsis, packages that may have been in contact with the area below waist level should be discarded. Sterile gloves are not put on before opening sterile packages as the outside of the packages is not sterile. The nurse uses hand hygiene and opens sterile packages, being careful to keep the inner contents sterile. After a cap or lid is removed, it is held in the hand or placed sterile side (inside) up on a clean surface. A bottle cap or lid should never rest on a sterile WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material surface, even though the inside of the cap is sterile. The edges of a sterile field are considered to be contaminated. Sterile items should be placed in the middle of the sterile field to maintain sterile asepsis. DIF: A REF: 669 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 20. The nurse is preparing to assist with a sterile procedure in the surgical suite. An appropriate technique that the nurse includes in the surgical scrub is to: 1 Keep the hands below the elbows throughout the scrub 2 3 Use a brush on the palms and dorsal surface of the hands Maintain the scrub for at least 2 to 5 minutes 4 Wash well around all jewelry ANS: 3 A surgical scrub should be maintained for at least 2 to 5 minutes. To avoid contamination during a surgical hand scrub, the nurse holds the hands above the elbows. Several studies suggest that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands, especially when an alcohol-based product is used. For maximum elimination of bacteria, all jewelry should be removed. DIF: A REF: 675 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 21. An appropriate isolation procedure for the nurse to implement when working with a client who is found to have methicillin-resistant Staphylococcus aureus (MRSA) is to: 1 Leave all linen in the clients room 2 Place specimen containers in plastic bags for transport 3 Wipe the stethoscope off before removing it from the room 4 Remove the mask and goggles first when leaving the clients room ANS: 2 Specimen containers should be placed in plastic bags for transport with a label on the outside of the bag. Linen should be placed in an impervious linen bag and may be removed from the clients room. Bags should be tied securely at the top with a knot. For the person infected with MRSA, WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material equipment remains in the room. After discharge or with the discontinuation of isolation, client care equipment is properly cleaned and reprocessed, and single-use items are discarded. Gloves should be removed first when leaving the clients room. DIF: A REF: 667 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 22. A client is found to have a bacterial infection of Escherichia coli. The nurse, recognizing the effects of this bacterium, anticipates that the client will demonstrate: 1 Diarrhea 2 3 Coughing Cold sores around the mouth 4 Discharge from the eyes ANS: 1 Escherichia coli causes gastroenteritis and urinary tract infections. The client with E. coli infection is likely to demonstrate diarrhea. E. coli is found in the colon, not the respiratory tract. Cold sores are seen with herpes simplex virus (type 1), not with E. coli. Discharge from the eyes is not seen with E. coli infection. It may be seen with Neisseria gonorrhoeae. DIF: A REF: 643 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 23. Which of the following clients is at greatest risk for acquiring an infection? 1 A 56-year-old with a urinary catheter 2 days after prostatectomy 2 A 27-year-old diagnosed with human immunodeficiency virus (HIV) 3 A 43-year-old who is 3 days post appendectomy and is currently afebrile A 16-year-old with a compound fractured femur as a result of a bike accident 4 ANS: 4 Clients are at risk for acquiring infections because of lower resistance to infectious microorganisms, increased exposure to numbers and types of disease-causing microorganisms, WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material and invasive procedures. The exposure to earth-bound microorganisms makes the compound fracture client at the greatest risk since that risk is uncontrollable. DIF: C REF: 644 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 24. A nurse is caring for a client who has colonized methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements reflects the best understanding of the clients condition? 1 This client has the bacteria present but it hasnt become infected. 2 This makes the clients MRSA very infectious and so a danger to others. Just be sure to follow standard precautions and there wont be a problem. 3 4 The client needs to be watched closely for a conversion to active MRSA. ANS: 1 If a microorganism is present or invades a host, grows, and/or multiplies but does not cause infection, this is referred to as colonization. DIF: C REF: 643 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 25. The greatest drawback to the routine use of antibacterial hand soaps and gels is that they: 1 Are expensive 2 Irritate the skin 3 Kill resident flora 4 Encourage resistant bacteria ANS: 2 Antibacterial products kill resident flora and that can lead to the development of infection. The remaining options may be true but they are not the primary negative outcome of the regular use of antibacterial hand cleansing products. DIF: C REF: 646 OBJ: Analysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 26. The nurse knows that Staphylococcus aureus found normally on the skin of a client who has had surgery poses a particular risk for that client developing: 1 2 3 4 A cold sore Gastroenteritis A wound infection A urinary tract infection ANS: 3 Staphylococcus aureus found normally on/in skin, hair, anterior nares, and the mouth can result in wound infections, pneumonia, food poisoning, and cellulitis. Streptococcus (-hemolytic group B) organisms may result in urinary tract infections or gastroenteritis while herpes simplex is viral in nature. DIF: A REF: 669 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 27. What is the most appropriate answer to the clients question, Whats the difference between antibacterial and antimicrobial hand soaps? 1 There is no real difference; use the less expensive. 2 Antibacterial soaps are more effective at preventing infections. 3 Antimicrobial soap is better since it wont kill the good bacteria on the skin. 4 Any soap will do; its the technique for proper hand washing that is the key. ANS: 3 The use of antimicrobial hand hygiene products is recommended because they remove transient organisms but leave resident flora intact. There is a difference in the products and it is true that the effectiveness of hand hygiene is dependent on proper technique, but the clients question is best answered by the information provided in option 3. DIF: C REF: 646 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 28. A presurgical client asks the nurse why it seems so easy to get an infection in the wound after surgery. The nurses most appropriate response to this question is: 1 The contaminated dressing acts as a breeding ground for microorganisms that then infect the wound. 2 The bodys immune system is weakened by the surgery and cant fight off the infection as effectively. 3 While infections occur, there are many very effective antibiotics available to help minimize the risk of that happening. 4 The surgical wound provides the microorganisms on the surrounding skin a path to enter deep into the bodys tissues. ANS: 4 Resident skin microorganisms are not virulent. However, they can cause serious infection when surgery or other invasive procedures allow them to enter deep tissues. While the other options are not incorrect, they do not answer the clients question as effectively. DIF: C REF: 643 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 29. The nurse obtains a new, dry nebulizer when preparing to give an elderly asthmatic client a nebulizer treatment because the risk of infection is increased because: 1 The clients age increases the risk factor for potential infection 2 The clients immune system is compromised as a result of asthma There is a potential presence of Pseudomonas organisms in the reservoir 3 4 There is a chance for microorganisms to enter the body via the respiratory system ANS: 3 Pseudomonas organisms survive and multiply in nebulizer reservoirs used in the care of clients with respiratory problems. While the remaining options are correct, they are not the primary reason for getting a new, dry nebulizer. DIF: C REF: 643 OBJ: Analysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 30. A client is told that he is a carrier of the hepatitis B virus. When asked to explain this situation in more detail, the nurses best response is: 1 2 You need to be careful not to pass the virus to other people. You arent sick, but you do have the virus within your body. 3 Be tested often so as to monitor whether the virus becomes active. 4 While you show no signs of the illness, you can pass the virus to others. ANS: 4 Carriers are persons who show no symptoms of illness but who have pathogens on or in their bodies that are transferred to others. While the other options are not incorrect, they do not address the clients questions as directly as does the answer. DIF: C REF: 643 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 31. The nurse can best minimize the risk for infection when initiating an intravenous site by: 1 Proper vein site selection 2 Effective topical skin preparation 3 Appropriate site dressing 4 Gloving for the procedure ANS: 2 When a needle pierces a clients skin regardless of the location, organisms enter the body if proper skin prepping was not performed. The remaining options have an effect on infection control but not to the degree that skin prepping does. DIF: C REF: 644-645 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 32. A client enters a neighborhood walk-in clinic reporting the symptoms of a head cold. When the health care provider does not prescribe an antibiotic, the client asks the nurse to explain why not. The nurses most appropriate response is: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Antibiotics arent usually necessary for colds, and they are really very expensive if you dont have insurance. 2 You know what they say; a cold will go away with medication in 2 weeks; without medication in 14 days. Your health care provider believes in treating the symptoms since there are so many different strains of the common cold. 3 4 Common colds dont usually require an antibiotic, and taking one results in making it harder to treat infections when they do occur. ANS: 4 Organisms with resistance to key antibiotics are becoming more common in acute care settings. This is associated with the frequent and sometimes inappropriate use of antibiotics. While the remaining options are not incorrect, they may seem insensitive or incomplete in answering the clients question. DIF: C REF: 646 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 33. The nurse is caring for a postoperative client with a localized sinus infection. The most appropriate means by which the nurse can minimize the risk of this client developing a systemic infection is to: 1 Adhere strictly to standard precaution techniques 2 Dispense prescribed anti-infective medication as ordered 3 Monitor the client regularly for exacerbation of the sinus infection Review lab work daily to determine the presence of increased white cell count 4 ANS: 1 If an infection is localized (e.g., a wound infection), use of standard precautions and personal protective equipment (PPE) will block the spread of infection to other sites, thus preventing an infection that affects the entire body instead of just a single organ or part (systemic). While the other options are not incorrect, they are not as directed at minimizing the risk of infection as is the answer. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material DIF: C REF: 645 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 34. The nurse and a client are discussing the clients tendency to develop numerous colds during the winter months. The clients health history reveals that he is a 1 pack a day smoker. Which of the following nursing statements is most appropriate regarding the possible relationship between the clients cigarette smoking and the frequency of winter colds? 1 2 3 4 Smoking decreases your bodys immune system, and so you cant fight off the colds as effectively. If you stopped smoking you would have fewer colds and just generally feel better all year around. The nicotine in the cigarettes has an effect on your blood vessels, decreasing the circulation of antibodies that would attack the cold viruses. Smoking damages the little hairs in your nose and airways so they cant trap the airborne cold viruses and keep them from entering your body. ANS: 4 Cilia lining the upper airway trap inhaled microbes and sweep them outward in mucus to be expectorated or swallowed. Smoking appears to paralyze these tiny hairs, and so they are not able to function effectively. Consequently, microbes including the cold viruses are able to enter into the respiratory tract. The other options present unproven theories, generalized statements, or less thorough explanations of the relationship between smoking and respiratory illnesses. DIF: C REF: 647 OBJ: Analysis TOP: Nursing Process: Implantation MSC: NCLEX test plan designation: Safety and Infection Control 35. Which of the following clients is at greatest risk for acquiring a health careassociated (nosocomial) infection? 1 A 32-year-old hospitalized for 2 days for migraine headaches 2 A client with type 1 diabetes who has been experiencing hypoglycemia 3 A trauma victim taken directly from the ED to surgery and then to the postsurgical unit WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 A pregnant 24-year-old diagnosed with both sinusitis and otitis media and prescribed an oral antibiotic ANS: 3 The number of health care employees having direct contact with a client, the type and number of invasive procedures, the therapy received, and the length of hospitalization influence the risk of infection. The other options do not have the potential for infection as does the client who has been treated in various locations within the health care facility. DIF: C REF: 648 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 36. A client is admitted for treatment of various poorly healing, infected leg ulcers. The nurse recognizes that the clients nutritional history is of primary importance since: 1 Nutrition is vital to the clients overall health status 2 The clients food intake will likely be decreased as a result of the illness 3 Wound healing and infection prevention are negatively impacted by poor nutrition The clients habits regarding food intake are directly related to this hospitalization 4 ANS: 3 A reduction in protein, carbohydrates, and fats as a result of illness, inadequate diet, or debility increases a clients susceptibility to infection and delays wound healing. While the other options are not incorrect, they are not as directly related to the cause of the clients poorly healing, infected wounds. DIF: C REF: 650 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 37. A client admitted for an abdominal hysterectomy reports that she has been under a lot of stress since the death of her mother and wonders how that will affect her surgery and recovery. Which of the following nursing statements reflects the most therapeutic response to the clients question? 1 Being under stress isnt going to help your recovery; you need to relax and focus on yourself and getting well. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Your mothers death must be very stressful for you but she would want you to concentrate on getting healthy. 3 Stress does have a negative effect on the bodys ability to heal; is there anything I can do to help you minimize the stress you feel? Your health care provider can prescribe you some medication to help you cope with the stress; would you like me to mention it? 4 ANS: 3 Increased stress elevates cortisone levels, causing decreased resistance to infection and the ability to heal. While the other options may not be incorrect, they do not have the degree of therapeutic value as does the answer since it explains the effects of stress and also offers support. DIF: C REF: 650 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 38. A client admitted for an abdominal hysterectomy reports that she has been under a lot of stress since the death of her mother and wonders how that will affect her surgery and recovery. Which of the following nursing interventions reflects the most therapeutic understanding of the relationship stress has on the body and its ability to recover from surgery? 1 Suggest a demonstration of relaxation techniques 2 Arrange for the hospital chaplain to visit the client 3 Offer to call and get an order for an antianxiety medication 4 Share a personal antidote concerning a similarly stressful situation ANS: 1 Increased stress elevates cortisone levels, causing decreased resistance to infection and the ability to heal. Reinforcement of relaxation techniques would be the most therapeutic response because it would provide the client with a long-term, self-initiated coping mechanism. It would not be appropriate to arrange for a clergy visit without first discussing it with the client. Sharing a similar personal situation would have little therapeutic value, and such a personal nurseoriented conversation should be avoided. While facilitating antianxiety medication may not be incorrect, it is premature at this time. DIF: C REF: 650 OBJ: Analysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Safety and Infection Control 39. The nurse is providing care for a client who postoperatively has developed an infected incisional wound and is depressed and anorexic. Which of the following nursing interventions has priority? 1 Sterile wound care 2 3 Frequent small meals Administration of antidepressant medication 4 Educating the client regarding wound care at home ANS: 1 The priority of administering therapies to promote wound healing overrides the goal of educating the client to assume self-care therapies at home. While the other options reflect appropriate interventions for this client, none has priority over wound care. DIF: C REF: 652 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control 40. The nurse is educating a client diagnosed with type 2 diabetes, who is susceptible to foot wounds, on how to minimize the risk for infection related to poor wound healing by not being a susceptible host. The most appropriate suggestion would be to: 1 Inspect feet and legs daily for skin breakdown 2 See a podiatrist regularly for appropriate foot care 3 Keep blood sugar levels within normal range to maximize the ability to heal 4 Eat well-balanced meals in order to provide the nutrients necessary for healing ANS: 4 Good infection control begins with prevention. Review with clients and their families preventive measures to strengthen their defenses. In the case of a diabetic client, keeping blood sugar levels within normal limits maximizes the clients ability to both heal and fight infection. While the other options are not incorrect, they are more directed towards healing than prevention. DIF: C REF: 652 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Safety and Infection Control WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MULTIPLE RESPONSE 1. For infectious organisms to grow and multiply enough to cause illness, they need an environment that has appropriate amounts of: (Select all that apply.) 1 2 Food Space 3 Water 4 Oxygen 5 Warmth 6 Darkness ANS: 1, 3, 4, 5, 6 To thrive, organisms require a proper environment, including appropriate food, oxygen, water, temperature, pH, and light. Space does not generally affect microorganism growth. DIF: C REF: 643-644 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Safety and Infection Control 2. Which of the following are considered portals of exit in the chain of infection? (Select all that apply.) 1 A bleeding cut 2 A hardy sneeze 3 A kiss on the lips 4 5 A urinary catheter A scraped knuckle 6 A friendly handshake ANS: 1, 2, 3, 4, 5 After microorganisms find a site to grow and multiply, they must find a portal of exit if they are to enter another host and cause disease. Portals of exit include sites such as blood, skin/mucous membranes, respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus). Unless the skin of the hands was broken (not intact), this contact would not be considered a portal of exit. DIF: C REF: 644 OBJ: Analysis TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Safety and Infection Control 3. Which of the following assessment data indicate the presence of a local inflammatory process? (Select all that apply.) 1 2 Client reports being cold Left elbow warm to the touch 3 Elevated white blood cell (WBC) count 4 Pitting edema of +2 around the right ankle 5 Client reports knee pain of 5 on a scale of 1 to10 6 Client observed grimacing while raising shoulder to brush hair ANS: 2, 4, 5, 6 Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. When inflammation becomes systemic, other signs and symptoms develop, including fever, leukocytosis, malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure. Chapter 29. Vital Signs MULTIPLE CHOICE 1. A client has developed pneumonia, and his temperature has increased to 37.7 C. The client is shivering and feels uncomfortable. The nurse should: 1 Apply hot packs to the axilla and groin 2 Wrap the clients four extremities 3 Restrict oral fluid consumption 4 Apply a hypothermia mattress ANS: 3 Wrapping the clients extremities has been recommended to reduce the incidence and intensity of shivering. Hot packs should not be applied to the clients axilla and groin. Fluids should not be restricted, but increased to replace fluids lost as a result of the fever. Hypothermia blankets may be used to reduce fever, but if the client is already shivering, a hypothermia blanket is not used, as further stimulation of shivering should be avoided. DIF: A REF: 506 OBJ: Comprehension TOP: Nursing Process: Application MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2. The client comes to the emergency department after having been in the sun for an extended period of time. The nurse also determines that the client is taking a diuretic. Heatstroke is suspected and the nurse observes for: 1 Diaphoresis 2 3 Confusion Temperature of 36 C 4 Decreased heart rate ANS: 2 Confusion is a symptom of heatstroke, along with delirium, nausea, muscle cramps, visual disturbances, and even incontinence. The most important sign of heatstroke is hot, dry skin, not diaphoresis. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction. A normal temperature is 36 to 38 C. With heatstroke the clients body temperature may reach as high as 45C. The heart rate is increased with heatstroke, not decreased. DIF: A REF: 507 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 3. A construction worker is seen in the emergency department with low blood pressure, normal pulse rate, diaphoresis, and weakness. These are clinical signs of: 1 Heatstroke 2 Heat cramp 3 Hypothermia 4 Heat exhaustion ANS: 4 The client is exhibiting signs of heat exhaustion (e.g., symptoms of fluid volume deficit). If the client were experiencing heatstroke, the client would have an increased pulse rate and would not be sweating. Muscle cramps are related to heatstroke. The client is not exhibiting signs consistent with heatstroke. The client is not exhibiting signs of hypothermia such as shivering, loss of memory, or cyanosis. DIF: A REF: 508 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 4. A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An appropriate action would be to: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Take the rectal temperature 2 3 Take the oral temperature as planned Have the child rinse out the mouth with warm water 4 Wait 20 minutes before assessing the oral temperature ANS: 4 The nurse should wait 20 to 30 minutes before measuring the oral temperature. The nurse should wait, rather than measuring the childs temperature rectally, as this is not an emergency situation. Taking the oral temperature at this time would result in an inaccurate reading. Rinsing the mouth with warm water may also provide an inaccurate reading of the childs actual body temperature. The nurse should wait 20 minutes and measure the childs oral temperature. DIF: A REF: 510 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 5. The client is seen in the emergency center for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include: 1 Replacement of fluid and electrolytes 2 Initiation of oral antibiotic therapy 3 Application of hypothermia wraps 4 Alcohol sponge baths ANS: 1 The treatment of heat exhaustion includes transporting the client to a cooler environment and restoring fluid and electrolyte balance. Antibiotic therapy is not warranted. Hypothermia wraps are not used to treat heat exhaustion. Alcohol baths are not recommended. DIF: A REF: 508 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 6. The appropriate site for taking the pulse of a 2-year-old is: 1 Radial 2 Apical 3 Femoral 4 Pedal WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 The brachial or apical pulse is the best site for assessing an infants or young childs pulse because other peripheral pulses are deep and difficult to palpate accurately. The radial pulse is not the best site for assessing a 2-year-olds pulse. The femoral pulse is not the best site for assessing a 2year-olds pulse. The pedal pulse is not the best site for assessing a 2-year-olds pulse. DIF: A REF: 521 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 7. The client appears to be breathing faster than before. The nurse should: 1 Ask the client if he has felt stressful 2 3 Have the client lay down on the bed Count the clients rate of respirations 4 Palpate the clients own radial pulse ANS: 3 The first action the nurse should take is to assess the clients respiratory rate. The nurse can then determine if it is within normal limits and will be able to compare it to the previous measurement to determine if the client is breathing faster than before. Stress may increase an individuals respiratory rate. The nurse should first make the objective measurement of the clients rate. Having the client lay down may decrease a clients respiratory rate, but the nurse should first assess the client before implementing any nursing measures. The nurse should count the respiratory rate. Based on these findings the nurse may or may not need to take the clients pulse. Assessing the pulse will not verify if the client is breathing faster. DIF: A REF: 529 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 8. A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurses most appropriate action is to: 1 Give the medication 2 Ask if the client is anxious 3 Check the clients dressing for bleeding 4 Recheck the clients vital signs in 30 minutes WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 1 The clients vital signs are consistent with the client being in pain. It would be safe and appropriate for the nurse to give the pain medication. Asking if the client is anxious is not the most appropriate action. The client is not demonstrating signs of shock (e.g., decreased blood pressure, increased pulse). The most appropriate action is for the nurse to administer pain medication. Rechecking would not be the most appropriate action. The nurse should medicate the client for pain. DIF: C REF: 529 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 9. The client has bilateral casts on the upper extremities, so the nurse will be measuring the blood pressure in the leg. The nurse expects the diastolic pressure to be: 1 10 to 40 mm Hg higher than in the brachial artery 2 3 20 to 30 mm Hg lower than in the brachial artery 40 to 50 mm Hg higher than in the brachial artery 4 Essentially the same as that in the brachial artery ANS: 4 When measuring the blood pressure in the legs, systolic pressure is usually higher by 10 to 40 mm Hg than that in the brachial artery, but the diastolic pressure is the same. The systolic pressure, not the diastolic pressure, is 10 to 40 mm Hg higher than that in the brachial artery. Measurements of 20 to 30 mm Hg lower and 40 to 50 mm Hg higher are not true statements. DIF: A REF: 546 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 10. An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age? 1 BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min 2 BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min 3 BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min 4 BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material These measurements are within the expected limits for an older client. An adults average blood pressure is 120/80 mm Hg. The systolic pressure may increase with age, but the blood pressure should not exceed 140/90 mm Hg. The range for an adults pulse is 60-100 beats/min. The expected respiratory rate is 16-25 breaths/min. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min; BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min; and BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min are not within the expected limits for a client of this age. DIF: A REF: 527 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 11. The student nurse is assessing the vital signs of a 10-year-old client. The expected values for a client of this age are: 1 P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg 2 3 P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg 4 P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg ANS: 3 These are expected findings of a 10-year-old client. The normal pulse range for a 10-year-old is 75-100 beats/min; the normal respiratory rate is 20-30 breaths/min. The expected blood pressure range for a 7-year-old is 87-117/48-64 mm Hg; children who are larger (e.g., heavier and/or taller) have higher blood pressures. The average blood pressure for a 10-year-old is 110/65 mm Hg mm Hg. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg; P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg; and P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg are not expected values of a 10-year-old client. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 12. The nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse will report the following finding that is out of the expected range for a client of this age: 1 T = 37.4 C 2 P = 110 beats/min 3 R = 20 breaths/min 4 BP = 120/76 mm Hg WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 The expected pulse range for an adult is 60-100 beats/min. This clients pulse is elevated at 110 beats/min. This clients temperature is within the normal range of 36 to 38 C for an adult. This clients respiratory rate is within the normal range of 12-20 breaths/min for an adult. This clients blood pressure reading is within the normal range of 120/80 mm Hg for an adult. DIF: A REF: 527 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 13. When using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 1/2-year-old child to: 1 2 Hold the thermometer at the bulb end Cleanse the thermometer in hot water 3 Assess the thermometer for 5 minutes 4 Allow the child to hold the thermometer ANS: 3 When assessing a clients axillary temperature with a glass thermometer, the thermometer should be left in place for 3 to 5 minutes. The thermometer should be held at the opposite end of the bulb. The thermometer should be covered with a plastic sheath when in use and after used the plastic sheath is discarded. If the thermometer requires cleaning, the nurse should not use hot water, as it could cause the thermometer to break. The parent should hold the thermometer, not the child. A 1 1/2-year-old client may drop the thermometer, creating a mercury spill. DIF: A REF: 630 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 14. The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should: 1 Retake the vital signs in 30 minutes 2 Continue with care as planned 3 Administer a stimulant 4 Notify the physician ANS: 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material The nurse should notify the physician, as these are abnormal findings. The clients respirations are becoming dangerously low at 8 breaths/min (normal 12-20 breaths/min). The clients pulse rate is low at 54 beats/min (expected 60-100 beats/min), and the blood pressure should be =120/80 mm Hg, which it is at 110/68 mm Hg. The additional assessment findings are also not normal, and should be reported to the physician. The nurse should not wait another 30 minutes to retake vital signs. The present readings warrant notifying the physician. These are abnormal findings. The nurse should not continue with care as planned. The nurse should first notify the physician. Administering a stimulant would require a physicians order and may not be what the client requires. For example, the client may need a narcotic antagonist rather than a stimulant. DIF: B REF: 504 OBJ: Application TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 15. A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, I feel dizzy. The nurse should: 1 Go for help 2 3 Take the clients blood pressure Assist the client into a sitting position 4 Tell the client to take several deep breaths ANS: 3 The nurses primary concern should be the patients safety and preventing an accidental fall. If the client just got up from bed and is complaining of dizziness, the client may be experiencing orthostatic hypotension. The nurse should first assist the client to sit down before performing any other assessment. The nurse should not leave the client and go for help. The nurse should assist the client to a sitting position. If help is required, the nurse can then put on the clients call light. The nurse may take the clients blood pressure after assisting the client to a sitting position to prevent the client from falling. The nurse should first assist the client to sit down to prevent the client from falling accidentally. The nurse may then assess the client. If the nurse finds during the assessment that the clients pulse oximetry is low, the nurse may instruct the client to take deep breaths. DIF: B REF: 538 OBJ: Application TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 16. A false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant: 1 Wraps the cuff too loosely around the arm 2 Deflates the blood pressure cuff too quickly WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Repeats the blood pressure assessment too soon 4 Presses the stethoscope too firmly in the antecubital fossa ANS: 1 If the cuff is wrapped too loosely or unevenly around the arm, the effect on the blood pressure measurement may be a false high reading. A false low systolic and false high diastolic blood pressure reading may occur if the cuff is deflated too quickly. A false high systolic reading may be obtained if the blood pressure assessment is repeated too soon. A false low diastolic reading may be obtained if the stethoscope is applied too firmly against the antecubital fossa. DIF: A REF: 541 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 17. The client is febrile, and the temperature needs to be reduced. The nurse anticipates that treatment will include: 1 2 An alcohol and water bath Ice packs to the axillae and groin 3 Tepid, plain water sponge down 4 Application of a cooling blanket ANS: 4 Blankets cooled by circulating water delivered by motorized units increase conductive heat loss. Cooling blankets are used to reduce a fever. Bathing with an alcohol/water solution is not recommended because it may lead to shivering. Shivering is counterproductive and can increase energy expenditure up to 400%. Application of ice packs to the axillae and groin is no longer recommended because they may induce shivering (which is counterproductive and increases the clients energy expenditure), and because they have no advantage over antipyretic medications. Tepid sponge baths are no longer recommended because it may lead to shivering and is no more advantageous than administering antipyretics. DIF: A REF: 520 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 18. The nurse is alert to which of the following factors that lowers the blood pressure? 1 Stress-producing anxiety 2 Heavy alcohol consumption 3 Cigarette, cigar, or pipe smoking WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 Prescribed diuretic administration ANS: 4 Diuretics lower blood pressure by reducing reabsorption of sodium and water by the kidneys, thus lowering circulating fluid volume. The effects of sympathetic nerve stimulation, such as with anxiety, increase blood pressure. Heavy alcohol consumption has been linked to hypertension. Cigarette smoking has been linked to hypertension. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 19. While the nurse is taking the clients blood pressure, the client asks if the reading is high. In accordance with the newest guidelines, the nurse informs the client that a blood pressure measurement that is consistent with hypertension is: 1 120/70 mm Hg 2 3 130/84 mm Hg 120/78 mm Hg 4 118/80 mm Hg ANS: 2 The diagnosis of prehypertension in adults is made when an average of two or more diastolic readings on at least two subsequent visits is between 80 and 89 mm Hg or when the average of multiple systolic blood pressures on two or more subsequent visits is between 120 and 139 mm Hg. Hypertension is noted with diastolic readings greater than 90 mm Hg and systolic readings greater than 140 mm Hg. According to the newest guidelines, this clients blood pressure reading (130/84 mm Hg) would fall into the pre-hypertension category. Normal is 120/80 mm Hg; this is a normal blood pressure reading. Normal is 120/80 mm Hg; this is a normal blood pressure reading. Normal is 120/80 mm Hg; this is a normal blood pressure reading. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 20. After measuring the clients vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5 C. The nurse should: 1 Retake the blood pressure WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 Retake the clients temperature 3 Report all of the findings immediately Record the findings as within normal limits 4 ANS: 1 The normal blood pressure reading is 120/80 mm Hg. This clients blood pressure is significantly higher at 180/100 mm Hg, and may be an indication of hypertension. (One elevated blood pressure measurement does not qualify as a diagnosis of hypertension; it would have to be elevated on at least two separate occasions). The nurse should retake the blood pressure. The clients temperature is within normal limits for a rectal temperature. The average rectal temperature is 37.5 C. The nurse should repeat the blood pressure measurement to confirm the reading before reporting the findings. The blood pressure reading is not within normal limits. The pulse rate, respiratory rate, and temperature are within normal limits. DIF: B REF: 537 OBJ: Application TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 21. The client is identified by the nurse as having a remittent fever. The student asks what that means and the nurse explains that a remittent fever is: 1 2 3 4 A constant body temperature above 100.4 F with little fluctuation Spikes that are interspersed with normal temperatures within 24 hours Spikes and falls in temperature, but temperature does not return to the normal limits Periods of febrile episodes interspersed with normal body temperatures ANS: 3 A remittent fever spikes and falls without a return to normal temperature levels. A sustained fever is a constant body temperature continuously above 38 C (100.4 F) that demonstrates little fluctuation. An intermittent fever has fever spikes interspersed with usual temperature levels. Temperature returns to acceptable levels at least once in 24 hours. A relapsing fever has periods of febrile episodes interspersed with acceptable temperature values. DIF: A REF: 508 OBJ: Comprehension TOP: Nursing Process: Planning WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 22. The nurse is working in the newborn nursery. In planning for temperature measurement, the nurse will obtain the reading on the infants by using the: 1 2 Oral site Rectal site 3 Axillary site 4 Tympanic site ANS: 3 The axillary site can be used with newborns and uncooperative clients. The oral site should not be used with infants. The rectal site should not be used for routine vital signs in newborns. The tympanic site is questioned as being accurate in newborns. DIF: A REF: 515 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 23. A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by: 1 The placement of the sensor on the extremity 2 A diagnosis of peripheral vascular disease 3 A reduced amount of artificial light in the room 4 The increased ambient temperature of the clients room ANS: 2 Peripheral vascular disease can reduce pulse volume, which may affect the pulse oximetry reading. The sensor should be placed on an extremity site (such as an earlobe or digit) with adequate local circulation and the site should be free of moisture. Reduced light in the room will not affect the oximetry reading. Outside light sources can interfere with the oximeters ability to process reflected light. An increased temperature of the room will not affect the oximetry reading. If the room was very cold, the clients peripheral blood flow may decrease, affecting the oximetry reading. DIF: A REF: 533 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 24. An individual contacts the emergency department of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia. The victim is alert and able to respond to questions. The nurse instructs the individual who has called to have the victim: 1 Take sips of brandy 2 3 Drink a bowl of warm soup Drink a cup of very hot coffee 4 Run the affected extremities under hot water ANS: 2 A conscious client benefits from drinking hot liquids such as soup. Alcohol should be avoided. Caffeinated fluids should be avoided. Extremities should be warmed gradually. Tissue damage could occur if placed under hot water. The entire body should be warmed, such as by putting heating pads next to the head and neck that lose heat the quickest. DIF: B REF: 508 OBJ: Application TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 25. A spouse assists the nurse evaluating the measurement of the clients blood pressure. The nurse feels additional teaching is required if the spouse is observed: 1 Deflating the cuff at 2 mm Hg/second 2 Having the client sit down for the measurement 3 Using the same time each day for the measurement Taking the blood pressure after the client comes back from a walk 4 ANS: 4 The clients blood pressure should not be measured after the client has exercised, smoked, or ingested caffeine. The client should wait 30 minutes before assessment of the blood pressure. The cuff should be deflated at a rate of 2 mm Hg per second. When possible, the client should be sitting in a chair. The blood pressure should be assessed at the same time each day. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 26. The nurse measures the blood pressure in the leg due to the fact that the client has bilateral casts on the upper extremities. The nurse palpates the pulse before the measurement at the: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Popliteal fossa behind the knee 2 Inner side of the ankle below the medial malleolus Top of the foot between the extension tendons of the great toe 3 4 Inguinal ligament midway between the symphysis pubis and the anterior superior iliac spine ANS: 1 The popliteal artery, palpable behind the knee in the popliteal space, is the site for auscultation when taking the blood pressure in the leg. The inner side of the ankle, top of the foot, and inguinal ligament are not the correct sites for assessment. DIF: A REF: 546 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 27. The clients apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the: 1 Second to third intercostal space 2 Third to fourth intercostal space 3 Fourth to fifth intercostal space Fifth to sixth intercostal space 4 ANS: 3 An apical pulse should be assessed at the clients PMI. The PMI is located at the fourth to fifth intercostal space at the left midclavicular line. Second to third intercostals space is not the correct placement for auscultating a clients apical pulse. The PMI is higher and more medial in children under 8 years old, thus the third to fourth is incorrect. The client is not identified as being a child. Fifth to sixth is not the correct placement for auscultating a clients apical pulse. DIF: A REF: 525 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 28. The nurse enters the room to measure the clients pulse rate. The nurse recognizes that the clients rate may be increased as a result of: 1 A febrile condition 2 Administration of digoxin WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 The clients athletic conditioning 4 Unrelieved severe postoperative pain ANS: 1 Fever and heat may increase a clients pulse rate. Digoxin is a negative chronotropic drug; it will decrease the clients pulse rate. A conditioned athlete who participates in long-term exercise will have a lower heart rate at rest. Unrelieved severe pain increases parasympathetic stimulation; decreasing the heart rate. DIF: A REF: 526 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 29. Upon entering the room, the nurse notes that the client has an irregular respiratory rate, with periods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse reports this respiratory assessment as: 1 Biots respirations 2 3 Kussmauls respirations Hyperpneic respirations 4 Cheyne-Stokes respirations ANS: 4 Cheyne-Stokes respirations are characterized by an irregular respiratory rate with alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to an abnormal rate and depth. The pattern then reverses, breathing slows and becomes shallow, and the pattern climaxes in apnea before respiration resumes. Biots respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea. Kussmauls respirations are abnormally deep, regular, and increased in rate. Hyperpneic respirations are labored, increased in depth, and increased in rate (>20 breaths/min); they normally occur during exercise. DIF: A REF: 532 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 30. The nurse has assigned the vital signs of the elderly clients residing in the facilitys assisted living unit to the nursing assistant. Which of the following statements made by the ancillary personnel requires immediate correction by the RN? 1 As you age your blood pressure may go up, but it doesnt have to if your vessels are healthy. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 2 If anyones oral temperature is over 100 F, Ill let you know right away since that means they have a fever. 3 I always wait a good 30 minutes after returning the older client back to bed before I count their pulse. I watch the elderly clients stomach and count the number of times it rises when I am counting respirations. 4 ANS: 2 RAT: The temperature of older adults is at the lower end of the normal temperature range, 36 to 36.8 C (96.9 to 98.3 F) orally and 36.6 to 37.2 C (98 to 99 F) rectally. Therefore temperatures considered within normal range sometimes reflect a fever in an older adult. The normal range for blood pressure is the same for older adults and younger people, while older adults depend more on accessory abdominal muscles during respiration than on weaker thoracic muscles, so observing the rise and fall of the abdomen would not be inappropriate. Once elevated, the pulse rate of an older adult takes longer to return to normal resting rate, so waiting 30 minutes would not be inappropriate. DIF: C REF: 506 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 31. The nurse appropriately instructs trained ancillary personnel to avoid using an electronic blood pressure cuff to take the blood pressure of which of the following clients? 1 2 3 4 A 25-year-old who was admitted for depression and anxiety A 69-year-old diagnosed with Parkinsons disease 5 years ago A 57-year-old prescribed antihypertensive medication 6 weeks ago An 80-year-old client whose systolic BP is routinely assessed in the low 90s ANS: 2 Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and the inability to cooperate are reasons to avoid using an electronic BP monitor. The clients Parkinsons disease causes tremors, so a manual cuff should be used when assessing this clients BP. DIF: C REF: 546 OBJ: Comprehension TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 32. The nurse appropriately instructs trained ancillary personnel to use an electronic blood pressure cuff to take the blood pressure of which of the following clients? 1 2 A 25-year-old who was admitted for alcohol detoxification A 69-year-old diagnosed with Parkinsons disease 5 years ago 3 A 57-year-old placed on antihypertensive medication therapy 2 months ago 4 An 80-year-old client whose systolic BP is routinely assessed in the high 80s ANS: 1 Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and inability to cooperate are reasons to avoid using an electronic BP monitor. The answer reflects the client whose BP is most stable and best assessable via electronic BP monitor. DIF: A REF: 546 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 33. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the units clients. Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings? 1 Ill ask the clients what their blood pressure usually runs. 2 Ill give you a list of all the readings I get before I chart them. 3 Ill chart the results and let you know whose pressure is high. 4 Ill recheck any pressure that seems higher than their normal. ANS: 2 The nurse is responsible for assessing the impact of changes in blood pressure and so must be aware of each clients reading, not merely the values that the assistive personnel believes to be high. Asking the client to share what their BP is routinely and/or retaking a questionable reading is appropriate but not directly related to effective communication of the findings. DIF: C REF: 539 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 34. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the units clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate communication of the BP readings? 1 Ill give you a list of all the readings after I chart them. 2 May I ask the clients what their blood pressure usually runs? 3 Ill chart the results and let you know whose pressure is running high. 4 Do you want me to take the readings before they get their medications? ANS: 3 The nurse is responsible for assessing the impact of changes in blood pressure and so must be promptly made aware of each clients reading, not merely the values that the assistive personnel believes to be high. The questions asked may reflect a need for further instruction, but the issues are not as critical as the need to report all readings for the nurse to evaluate. DIF: C REF: 539 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 35. The nurse has assessed a clients blood pressure (BP) using the left thigh because of bilateral upper arm casts. The clients precasting left arm BP was 108/70 mm Hg. The nurse expects the present BP reading to be: 1 10-40 mm Hg higher systolic pressure than before the casting 2 5-10 mm Hg higher reading in both systolic and diastolic pressures Representative of the original baseline established before the casting 3 4 A slight decrease in the diastolic pressure when compared to precasting pressure ANS: 1 Systolic pressure in the legs is usually higher by 10 to 40 mm Hg than in the brachial artery, but the diastolic pressure is the same. DIF: A REF: 546 OBJ: Comprehension TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 36. The nurse is using a manual cuff to assess the blood pressure of a client experiencing hypertension. To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately? 1 Review the clients chart for his last blood pressure reading. 2 Ask the client what his typical blood pressure reading is when taken manually. 3 Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated. 4 Take the clients blood pressure both sitting and standing and use the higher reading. ANS: 3 The examiner needs to be certain to inflate the cuff high enough to hear the true systolic pressure before the auscultatory gap. Palpation of the radial artery helps to determine how high to inflate the cuff. The examiner inflates the cuff 30 mm Hg above the pressure at which the radial pulse was palpated. Taking the blood pressure in various positions will not help eliminate the possible loss of auditory sound between the systolic and diastolic sounds. While asking the client and/or reviewing the chart may provide information concerning the clients pressure, these options are not the recommended method for minimizing the effect of the auditory gap on the assessment process. DIF: C REF: 541 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 37. The nurse is assessing an elderly clients blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg. The nurse determines that the clients pressure today is 134/70 mm Hg. The nurse recognizes that the most likely cause of the elevation is: 1 The difference between the monitoring equipment being used 2 The client may be experiencing mild anxiety regarding the check-up 3 The effects of aging on the clients ability to hear the first Korotkoff sound The client is not inflating the cuff sufficiently to detect the systolic pressure 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 2 Blood pressure measurements taken at the clients place of employment or in a health care providers office are higher than those taken at the clients home. The remaining options may be a factor but they are not the most likely. DIF: C REF: 537 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 38. The nurse is assessing a clients blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data: 1 2 3 4 Reflect a normal variation Should be reported to the clients health care provider Dictate that pressure should be monitored in the left arm Indicate that the client may be experiencing vascular problems ANS: 2 During the initial assessment, obtain and record the blood pressure in both arms. Normally there is a difference of 5 to 10 mm Hg between the arms (Lane and others, 2002). In subsequent assessments, measure the blood pressure in the arm with the higher pressure. Pressure differences greater than 10 mm Hg indicate vascular problems and are reported to the health care provider or nurse in charge. Reporting the assessment findings is the most appropriate outcome. DIF: C REF: 536 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 39. The nurse recognizes that which of the following clients present at the annual July 4th marathon is at greatest risk for hyperthermia and the resulting heatstroke? 1 A 34-year-old running for the first time in the July 4th marathon who is sweating profusely 2 A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gate 3 A 75-year-old who is prescribed medication for Crohns disease and who is sitting outdoors watching her granddaughter run the marathon WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 A 55-year-old diagnosed with bipolar disease and prescribed a phenothiazine (Serentil), who will be walking the marathon course ANS: 2 Clients at risk include those who are very young or very old and those who have cardiovascular disease, hypothyroidism, diabetes, or alcoholism. Also at risk are those who take medications that decrease the bodys ability to lose heat (e.g., phenothiazines, anticholinergics, diuretics, amphetamines, and beta-adrenergic receptor antagonists) and those who exercise or work strenuously (e.g., athletes, construction workers, and farmers). While all the options represent risk factors, the degree of exercise, medical history, and age are greatest for the 16-year-old client with diabetes. DIF: C REF: 506 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 40. The nurse recognizes that which of the following clients present at the annual July 4th marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke? 1 The 75-year-old who has forgot where the car is parked 2 The 16-year-old volunteer whose skin appears sunburned but dry 3 The 34-year-old who finished the race and is reporting leg cramps The 55-year-old observer who complains of nausea and being thirsty 4 ANS: 2 Signs and symptoms of heatstroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. Vital signs reveal a body temperature sometimes as high as 45 C (113 F) with an increase in heart rate and lowering of blood pressure. The most important sign of heatstroke is hot, dry skin. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction. If the condition progresses, the client with heatstroke becomes unconscious with fixed, unreactive pupils. Permanent neurological damage occurs unless cooling measures are rapidly started. DIF: C REF: 508 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 41. The nurse has assigned nursing assistive personnel to obtain the temperatures on the units clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally? 1 Are all the clients cooperative enough to take the temperatures orally? 2 Do you want me to take the temperature tympanically on everyone? Ill wait until breakfast is over so I wont distract them from eating. 3 4 Ill chart the results and let you know whose temperature is running high. ANS: 3 When taking oral temperature, wait 20 to 30 min before measuring temperature if the client has smoked or ingested hot or cold liquids or foods. The nurse needs to reinforce this information so that the assessment will occur before breakfast or to allow enough time to pass after breakfast so as not to affect the readings. The options containing a question reflect a need for knowledge but do not have priority over an obvious indication of possible poor assessment technique. The nurse needs to evaluate the readings and so should be sure to give the assistive personnel guidance as to what readings are running high. DIF: C REF: 510 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 42. Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)? 1 A polished ring finger of a client with pneumonia whose nail capillary refill time is 2.5 seconds 2 A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds The ring finger of a client with Parkinsons disease that has a capillary refill time of less than 3 seconds 3 4 An earlobe of a client who is experiencing moderate diaphoresis with a nail capillary refill time of 3.5 seconds ANS: 2 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Determine most appropriate client-specific site (e.g., finger, earlobe) for sensor probe placement by measuring capillary refill. If capillary refill is greater than 3 seconds, select an alternate site. Sites should be free of moisture and tremors, and the nail should be free of polish (no artificial nails). DIF: C REF: 534 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 43. The nurse has asked the assistive personnel to take the blood pressure of a client who experienced a left mastectomy 3 days ago. Which of the following statements by the assistive personnel shows the best understanding regarding the appropriate assessment technique for this particular client? 1 2 3 4 Is there anything affecting her right arm? Has she been experiencing any edema in that left arm? How long has it been since she had her breast removed? Ill wait until shes been medicated for pain before I take it. ANS: 1 Avoid applying the cuff to the extremity when intravenous fluids are infusing; an arteriovenous shunt or fistula is present; breast or axillary surgery has been performed on that side; or the extremity has been traumatized, diseased, or requires a cast or bulky bandage. The answer reflects an understanding that the right arm is the extremity of choice for monitoring this clients blood pressure. DIF: C REF: 539 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs MULTIPLE RESPONSE 1. The nurse is assisting the wife of a client who has been diagnosed with hypertension to monitor his blood pressure. The nurse states that the blood pressure should be taken: (Select all that apply.) 1 At the same time each day 2 On the same arm each time 3 In the same position each time 4 After the client has had a brief rest 5 After his blood pressure medication WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 6 Right before getting up in the morning ANS: 1, 2, 3, 4 Instruct the client or primary caregiver to take BP at same time each day and after the client has had a brief rest. Take BP sitting or lying down; use the same position and arm each time pressure is taken. The other options are not necessary because they do not affect blood pressure readings. DIF: C REF: 537 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 2. Which of the following factors make using a pulse oximeter on an elderly client challenging? (Select all that apply.) 1 Possibility of decreased cardiac output 2 3 Potential for peripheral vascular disease Existence of decreased red blood cell count 4 Uncooperative behavior related to senility 5 Inability to comprehend rationale for monitoring 6 Vasoconstriction related to impaired heat regulation ANS: 1, 2, 3, 6 Identifying an acceptable pulse oximeter probe site is difficult with older adults because of the likelihood of peripheral vascular disease, decreased cardiac output, cold-induced vasoconstriction, and anemia. It would be inappropriate to assume that the process is made more difficult because of the remaining options because they are not seen in the majority of the elderly population. DIF: C REF: 533 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 3. The nurse is providing a health promotion session regarding the factors that contribute to heatstroke for members of a college cross-country running team. Which of the following statements should the nurse include in the discussion? (Select all that apply.) WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Take frequent breaks to rest out of the sun. 2 The greater the humidity, the greater the hazard. Wear clothing that will absorb the perspiration. 3 4 5 The higher the temperature, the higher the risk. The more fluids you drink, the fewer chances you take. 6 Pay attention to pacing yourself when its hot and muggy. ANS: 2, 4, 5, 6 Teach clients risk factors for heatstroke: strenuous exercise in hot, humid weather; tight-fitting clothing in hot environments; exercising in poorly ventilated areas; sudden exposures to hot climates; poor fluid intake before, during, and after exercise. When paying close attention to avoiding risk factors for heatstroke, the remaining options are not required. DIF: C REF: 507-508 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 4. The nurse is discussing risk factors for hypertension with family members attending a selfhelp group meeting for clients in cardiac rehabilitation. Which of the following statements made by the nurse are relevant to this discussion on prevention of this disorder? (Select all that apply.) 1 2 3 4 Low fat foods are your blood pressures best friend. Have your triglycerides checked on a regular basis. Ideal weight is ideal for keeping blood pressure under control. Nicotine is a no-no when attempting to control blood pressure. 5 If they are prescribed, take your blood pressure medicine as suggested. 6 Keep alcohol consumption down and your blood pressure will be down. ANS: 1, 2, 3, 4, 6 Persons with a family history of hypertension are at significant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress are risk factors linked to hypertension. Medication compliance, while important, is related to the management of hypertension, not prevention. DIF: C REF: 537-538 OBJ: Analysis WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 5. The nurse is discussing the correct technique for taking a blood pressure with clients and their caregivers. Which of the following nursing statements would appropriately identify the most likely causes for experiencing difficulty actually hearing the blood pressure? (Select all that apply.) 1 2 3 The cuff cannot be too small or too big. Dont release the air out of the cuff to quickly. 4 Keep the arm you are using at the level of the heart. If you are having difficulty, try taking it in the other arm. 5 The stethoscope needs to be placed directly over a pulse point. 6 Remember to pump up the cuff until you can no longer feel the pulse. ANS: 1, 2, 5, 6 Instruct the client or primary caregiver that if it is difficult to hear the pressure, the cuff is probably too loose, not big enough, or too narrow; the stethoscope is not over an arterial pulse; the cuff was deflated too quickly or too slowly; or the cuff was not inflated enough for systolic readings. The remaining options do not directly affect the actual hearing of the blood pressure. DIF: C REF: 539 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs 6. The nurse is discussing the proper technique for obtaining an accurate blood pressure reading with assistive nursing personnel. Which of the following statements reflect techniques that will minimize the risk of a false high systolic reading? (Select all that apply.) 1 Slowly deflate the pressure from the cuff. 2 Wrap the cuff snuggly around the clients arm. 3 Always support the clients arm at the level of the heart. 4 5 Be sure that the cuff is wide enough for the clients arm. Allow the arm to rest before repeating the blood pressure. 6 Make sure your stethoscope is fitted in your ears appropriately. ANS: 2, 3, 4, 5 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Using a bladder or cuff that is too narrow or too short, wrapping the cuff too loosely or unevenly, resting the arm below heart level, and repeating assessments too quickly all contribute to a falsely high systolic reading. The rapid deflation of the cuff and an ill-fitted stethoscope will likely result in a falsely low systolic reading. Chapter 30. Health Assessment and Physical Examination MULTIPLE CHOICE 1. The position that maximizes the nurses ability to assess the clients body for symmetry is: 1 2 Sitting Supine 3 Prone 4 Dorsal recumbent ANS: 1 Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts. The supine position maximizes the nurses ability to assess pulse sites. The prone position is used only to assess extension of the hip joint. The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles. PTS: 1 DIF: A REF: 559 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 2. When assessing the pallor of a client with dark skin, the nurse will specifically look at the: 1 Buccal mucosa of the mouth 2 Dorsal surface of the hands 3 Ear lobe 4 Sclera ANS: 1 Pallor is more easily seen in the face, buccal mucosa of the mouth, conjunctiva, and nail beds. The palmar surface of the hands may be used to detect color hues in dark-skinned clients. The ear lobe is not a good site to assess for color changes, such as pallor, in a dark-skinned client. The best site to inspect for jaundice, not pallor, is the sclera. PTS: 1 DIF: A REF: 567 OBJ: Knowledge TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 3. A female client is seen in the outpatient clinic for numerous cuts, bruises, and apparent burns. In a discussion with the client, the nurse finds that the injuries are inconsistent with the stated cause. The client also states that she is having trouble sleeping, and she appears anxious. Based on these findings, the nurse suspects that the client may be experiencing: 1 2 3 4 Substance abuse Domestic violence Vascular disease Mental illness ANS: 2 Injuries and trauma that are inconsistent with the reported cause; multiple injuries including bruises, cuts, and burns; and behavioral findings of difficulty sleeping and appearing anxious are all indicators of possible domestic violence. The findings are not consistent with substance abuse. Indicators of substance abuse may include frequent missed appointments or emergency department visits, having a history of changing doctors, history of activities that place the client at risk for HIV infections, complaints of insomnia or chest pain, and a family history of addiction. People who abuse substances may have cuts, burns (especially of the fingers), needle marks, homemade tattoos, or increased vascularity of the face. These findings are not indicative of vascular disease. Symptoms of vascular disease may include edema, color changes of the lower extremities, and weakened pedal pulses. These findings are not indicative of mental illness. The client is coherent. PTS: 1 DIF: C REF: 563 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 4. A client in the clinic has been having severe headaches and some visual disturbances. The nurse performs an eye examination. Which of the following is true concerning the procedure for this assessment? 1 The red reflex should be assessed with the ophthalmoscope. 2 To evaluate the lower eyelids, the nurse uses a syringe with sterile water. 3 Accommodation is tested by asking the client to comply with the nurses requests. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 4 The lacrimal apparatus is assessed with a dull object to stimulate normal reflex conditions. ANS: 1 To visualize internal eye structures, the nurse uses an ophthalmoscope to focus on the red reflex. To evaluate the lower eyelids, the nurse asks the client to open the eyes for inspection. A syringe and sterile water are not necessary for this assessment. Accommodation is tested by asking the client to gaze at a distant object and then at a test object held by the nurse approximately 10 cm from the clients nose. The pupils normally converge and accommodate by constricting when looking at close objects. The lacrimal apparatus is best assessed by inspecting for edema and redness; and palpating it gently to detect tenderness, which cannot be felt normally. PTS: 1 DIF: A OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 5. In preparing to conduct a physical examination on a client, the nurse plans to: 1 Perform painful procedures at the end of the exam 2 Take long, detailed notes of all the findings during the exam 3 Keep the TV or radio on to distract the client throughout the exam Assess the dominant side of the clients body only in the examination 4 ANS: 1 In organizing a physical examination, the nurse should perform painful procedures near the end of the examination. The nurse should record quick notes during the examination to avoid keeping the client waiting. Observations can be completed at the end of the examination. The TV or radio should be turned off so as to not distract the client throughout the examination, and to provide an environment conducive to auscultation. Both sides of the body should be assessed for comparison to determine symmetry. A degree of asymmetry is normal in the dominant versus nondominant arm. PTS: 1 DIF: A REF: 562 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 6. The client has an enlarged thyroid gland and is currently admitted to a medical nursing unit. Which of the following is accurate regarding the procedure for a thyroid assessment for this client? 1 Deep palpation should be used anterior and posterior. 2 Swallowing sips of water causes the isthmus of the thyroid gland to rise. The posterior approach is used when the fingers are placed over the trachea. 3 4 The diaphragm of the stethoscope is best used for the auscultation of bruits. ANS: 2 During assessment of the thyroid gland, the client holds a cup of water and takes a sip to swallow once instructed by the nurse. As the client swallows, the isthmus of the thyroid gland rises. The nurse should feel if it is enlarged. Normally the thyroid gland is small, smooth, and free of nodules. Light, gentle palpation is needed to feel any abnormalities. For the posterior approach, both of the nurses hands are placed around the neck, with two fingers of each hand on the sides of the trachea just beneath the cricoid cartilage. The bell of the stethoscope is best for auscultation of bruits. PTS: 1 DIF: A REF: 591 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 7. When auscultating the clients lungs, a nurse notes normal vesicular sounds as: 1 Medium-pitched blowing sounds with inspirations that equal expirations 2 Loud, high-pitched, hollow sounds with expiration longer than inspiration 3 Soft, breezy, low-pitched sounds with longer inspiration 4 Sounds created by air moving through small airways ANS: 3 Normal vesicular sounds are soft, breezy, and low-pitched. The inspiratory phase is 3 times longer than the expiratory phase. Medium-pitched blowing sounds with inspiration equaling expiration are bronchovesicular breath sounds. Loud, high-pitched, hollow sounds with longer WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material expiration are bronchial breath sounds. Vesicular sounds are created by air moving through smaller airways. Abnormal breath sounds result from air passing through narrowed airways. PTS: 1 DIF: A REF: 596 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 8. The nurse could best auscultate the point of maximum impulse (PMI) in an 8-year-old child at the: 1 Fourth intercostal space, left of the midclavicular line 2 3 Fifth intercostal space, left of the midclavicular line Second intercostal space, right of the midclavicular line 4 Third intercostal space, right of the midclavicular line ANS: 2 By the age of 7, a childs PMI is in the same location as in adults; that is, the fifth intercostal space, left of the midclavicular line. The PMI of an 8-year-old child is more likely to be located at the fifth intercostal space, left of the midclavicular line. The PMI is not located to the right of the midclavicular line. The PMI of an infant is at the third or fourth intercostal space, left of the midclavicular line. PTS: 1 DIF: A REF: 598 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 9. The nurse suspects that the client may have vascular disease. During the examination, the nurse is alert to the clients complaints of: 1 Headache, dizziness, and tingling of body parts 2 Diplopia, floaters, and headaches 3 Leg cramps, numbness of extremities, and edema 4 Pain and cramping in the lower extremities relieved by walking ANS: 3 Leg cramps, numbness or tingling in extremities, sensation of cold hands or feet, pain in legs, or swelling or cyanosis of feet, ankles, or hands are indicative of vascular disease. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Headache, dizziness, and tingling of body parts are more likely associated with a neurological problem, not vascular disease. Diplopia, floaters, and headaches are indicative of an eye problem, not vascular disease. Pain and cramping in the lower extremities are usually worsened with activity in vascular disease. PTS: 1 DIF: A REF: 602 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 10. A 21-year-old woman asks when she should perform a breast self-examination during the month. The nurse should inform the client: 1 2 Any time you think of it. At the same time each month. 3 On the first day of your menstrual period. 4 Two to three days after your menstrual period. ANS: 4 The best time for a BSE is 2 to 3 days after the menstrual period ends, when the breast is no longer swollen or tender from hormone elevations. The woman should check her breasts the same time each month 2-3 days after the menstrual period ends. At the same time each month is partially true. The client also should be informed to perform the BSE 2 to 3 days after the menstrual period ends. On the first day of the menstrual period is not the best time for a woman to perform a BSE. The breasts will be enlarged and tender from hormone elevations. PTS: 1 DIF: A REF: 610 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 11. During an assessment of the clients integument, the nurse notes a flat, nonpalpable change in skin color that is smaller than 1 cm. This finding is documented by the nurse as a: 1 Macule 2 Papule 3 Vesicle Nodule 4 ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material This finding is consistent with the definition of a macule. A papule is a palpable, circumscribed, solid elevation in skin, smaller than 0.5 cm. A vesicle is a circumscribed elevation of skin filled with serous fluid, smaller than 0.5 cm. A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5-2.0 cm. PTS: 1 DIF: A REF: 570 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 12. The nurse asks a client to explain the meaning of the phrase, Every cloud has a silver lining. This part of the examination is designed to measure: 1 2 Knowledge Judgment 3 Association 4 Abstract thinking ANS: 4 Interpreting abstract ideas or concepts, such as in explaining the meaning of this phrase, reflects the capacity for abstract thinking. The client with altered mentation will likely interpret the phrase literally or merely rephrase the words. An example of assessing knowledge would be asking the client their reason for seeking health care. This example is not designed to measure knowledge. The nurse is not attempting to measure judgment. An example of assessing judgment would be to ask the client what they would do if they suddenly became ill when alone at home. The nurse is not attempting to measure association. An example of assessing association would be to ask the client to complete a phrase, such as a dog is to a beagle as a cat is to a . PTS: 1 DIF: A REF: 633 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 13. Measurement of the clients ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve? 1 Optic 2 Facial 3 Trigeminal 4 Oculomotor WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 3 The trigeminal nerve is tested by lightly touching the cornea with a wisp of cotton, by assessing the corneal reflex, and by measuring sensation of light pain and touch across the skin of the face. The optic nerve is tested by using the Snellen chart or asking the client to read printed material. The facial nerve is tested by having the client smile, frown, puff out cheeks, and raise and lower eyebrows while looking for asymmetry. Also, having the client identify salty or sweet taste on the front of the tongue tests the facial nerve. The oculomotor nerve is tested by assessing directions of gaze and testing papillary reaction to light and accommodation. PTS: 1 DIF: A REF: 634 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 14. Assessment of the clients skin reveals a fluid-filled circumscribed elevation of 0.4 cm. The nurse identifies this as a: 1 2 Nodule Macule 3 Vesicle 4 Wheal ANS: 3 This finding is consistent with the definition of a vesicle. A nodule is an elevated solid mass, deeper and firmer than a papule, 0.5-2.0 cm. A macule is a flat, nonpalpable change in skin color, smaller than 1 cm. A wheal is an irregularly-shaped, elevated area or superficial localized edema that varies in size. PTS: 1 DIF: A REF: 570 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 15. The expected appearance of the oral mucosa in a light-skinned adult is: 1 Pinkish-red, smooth, and moist 2 Light pink, rough, and dry 3 Cyanotic, with rough nodules 4 Deep red, with rough edges ANS: 1 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material Normal mucosa in a light-skinned adult is glistening, pinkish-red, soft, moist, and smooth. Oral mucosa may appear more dry in an older adult because of reduced salivation but is not rough. Cyanotic mucosa with rough nodules would be an abnormal finding. Oral mucosa should not appear deep red with rough edges in a light-skinned adult. PTS: 1 DIF: A REF: 587 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 16. The nurse notes an exaggeration of the posterior curvature of the thoracic spine, during the assessment of a 90-year-old client, as: 1 2 Lordosis Osteoporosis 3 Scoliosis 4 Kyphosis ANS: 4 Kyphosis is an exaggeration of the posterior curvature of the thoracic spine (hunchback). Lordosis is an increased lumbar curvature (swayback). Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone. Scoliosis is a lateral curvature of the spine. PTS: 1 DIF: A REF: 627 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 17. The best position for the nurse to position the client in order to auscultate the apical site, if a low-pitched murmur is suspected during prior assessment, is: 1 Sitting up 2 Standing 3 Lying on the left side 4 Dorsal recumbent ANS: 3 Extra heart sounds or heart murmurs are heard more easily with the client lying on the left side (lateral recumbent) with the stethoscope at the apical site. Sitting upright is used for assessing lung expansion and symmetry of the upper extremities. Standing is not the best position for WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material auscultating a heart murmur. The dorsal recumbent position is best used for abdominal assessment. PTS: 1 DIF: A REF: 559 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 18. As part of the examination, the nurse will be assessing the clients balance. The test that should be administered is the: 1 Weber test 2 3 Allen test Romberg test 4 Rinne test ANS: 3 The Romberg test assesses the clients balance. The Weber test assesses for unilateral deafness. The Allen test assesses for patency of the arteries of the hand (usually before arterial puncture). The Rinne test compares bone conduction hearing with air conduction. PTS: 1 DIF: A REF: 636-637 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 19. Part of the neurological exam is evaluating the response of the cranial nerves. To test cranial nerve VIII, the nurse should: 1 Ask the client to read printed material 2 Assess the directions of gaze 3 Assess the clients ability to hear the spoken word 4 Ask the client to say ah ANS: 3 To test cranial nerve VIII (auditory), the nurse should assess the clients ability to hear the spoken word. To test cranial nerve II (optic), the nurse should assess the clients ability to read printed material. To test cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), the nurse should assess the clients directions of gaze. To assess cranial nerve X (vagus), the nurse should ask the client to say ah. WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material PTS: 1 DIF: A REF: 634 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 20. A student nurse is working with a client who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. The student expects to hear: 1 2 3 4 Coarse crackles and bubbling High-pitched musical sounds Dry, grating noises Loud, low-pitched rumbling ANS: 2 Wheezes are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration. Coarse crackles and bubbling are not descriptive of wheezes. Dry, grating noises are heard with a pleural friction rub. Loud, lowpitched rumbling is characteristic of rhonchi. PTS: 1 DIF: A REF: 596 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 21. The nurse instructs the male client that the protocol for testicular self-examination is to: 1 Perform the examination annually after age 35 2 Use both hands to roll the testicles and feel the consistency 3 Perform the examination before bathing or showering 4 Contact the physician if a cordlike structure is felt on the top and back of the testicle ANS: 2 The nurse instructs the male client that the protocol for testicular self-examination is to use both hands to gently roll the testicle, feeling for lumps, thickening, or a change in consistency (hardening). All men 15 years and older should perform the testicular self-exam monthly. The examination should be performed after a warm bath or shower when the scrotal sac is relaxed. A cordlike structure on the top and back of the testicle is a normal finding. It is the epididymis. PTS: 1 DIF: A REF: 623 OBJ: Knowledge TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 22. The nurse uses olfaction in the clients assessment. If a sweet, fruity smell is noticed in the oral cavity, the nurse suspects: 1 2 3 4 Diabetic acidosis Gum disease Stomatitis Malabsorption syndrome ANS: 1 A sweet, fruity smell noticed in the oral cavity is indicative of diabetic acidosis. Halitosis of the oral cavity is indicative of gum disease. Stomatitis is characterized by oral pain, bad breath, inflammation, and oral ulcers in the mouth. Foul-smelling stools in the infant is indicative of malabsorption syndrome. PTS: 1 DIF: A REF: 557 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 23. A client with cardiopulmonary disease receives a physical examination performed by a nurse. Knowing the client history, the nurse is attentive when checking the nails for the presence of: 1 Clubbing 2 Paronychia 3 Beaus lines 4 Splinter hemorrhages ANS: 1 Clubbing of the nails is caused by a chronic lack of oxygen, such as occurs in heart or pulmonary disease. Paronychia is caused by local infection or trauma. Beaus lines are caused by systemic illness such as severe infection or by injury to the nail. Splinter hemorrhages are caused by minor trauma, subacute bacterial endocarditis, or trichinosis (infection by the roundworm). PTS: 1 DIF: A REF: 575 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 24. During the physical examination, the client tells the nurse that he has been told he has myopia. The nurse expects to find that the client: 1 2 3 4 Is nearsighted Has decreased peripheral vision Has diminished night vision Experiences more glare, flashes, and floaters ANS: 1 Myopia is nearsightedness. Peripheral vision is not reduced with myopia. The client with myopia is able to see close objects, but not distant objects. Peripheral vision may be decreased in openangle glaucoma. Diminished night vision may occur with cataracts, not myopia. Problems with glare, flashes, and floaters may indicate eye disease and the client should be referred to a physician. PTS: 1 DIF: A REF: 577 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 25. The school-aged child is taken to the school nurse after experiencing a nosebleed during a softball game. The appropriate intervention is for the nurse to: 1 Have the child lean backward 2 Apply pressure to the anterior nose 3 Apply a warm cloth to the area Have the child close his mouth and blow his nose 4 ANS: 2 The nurse should have the child who is experiencing a nosebleed sit up and lean forward to avoid aspiration of blood, apply pressure to the anterior nose with the thumb and forefinger as the child breathes through the mouth, and apply ice or a cold cloth to the bridge of the nose if pressure fails to stop bleeding. The child should not lean backward as this may cause the child to aspirate blood. A cold cloth will slow bleeding and help blood to coagulate, not a warm cloth. The child should breathe through the mouth. Blowing his nose may only continue bleeding as it may disturb any clot formation PTS: 1 DIF: A REF: 586 OBJ: Comprehension TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 26. An older adult client is visiting the physicians office for a check-up. The client asks the nurse how often the influenza and pneumonia vaccines should be obtained. The nurse responds to the client that these vaccinations should be done: 1 2 Every 6 months Annually 3 Every 5 years 4 Every 7 years ANS: 2 Older adults should be counseled to receive annual influenza and pneumonia vaccinations. It is not necessary to receive these vaccinations every 6 months. The influenza and pneumonia vaccines should be obtained annually in the older adult because of their greater susceptibility to respiratory tract infection. It is recommended that older adults receive the influenza and pneumonia vaccines annually because they have a greater susceptibility to respiratory tract infection. PTS: 1 DIF: A REF: Chapter 34, 649 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 27. A pregnant client is seen by the nurse in the antenatal clinic. On inspection, the nurse expects that this clients breasts will have: 1 Softer tissue 2 Flatter nipples 3 Darkened areola 4 Diminished superficial veins ANS: 3 Normal changes of the breasts during pregnancy include the areola becoming darker and the diameter increasing. Breast tissue becomes softer during menopause, not pregnancy. Nipples become flatter in older adulthood. Superficial veins become more prominent during pregnancy. PTS: 1 DIF: A REF: 612 OBJ: Comprehension TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 28. At a medical clinic, a client with vascular insufficiency is seen frequently. The nurse will give the client additional instruction about her condition if the client: 1 2 3 4 Walks regularly Wears knee-length stockings Elevates the feet when sitting Alternates periods of sitting and standing ANS: 2 The client with risk or evidence of vascular insufficiency should not wear tight clothing over the lower body or legs, such as knee-length stockings. Walking regularly is recommended for the client with vascular insufficiency. The client with vascular insufficiency should elevate his or her feet when sitting. The client with vascular insufficiency should avoid sitting or standing for long periods. PTS: 1 DIF: A REF: 605 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 29. During the physical examination, the nurse should assess the clients glands by using the: 1 Dorsum of the hand 2 Pads of the fingers 3 Palmar surface of the hand Fingertip grasp of the tissue 4 ANS: 2 To assess the clients glands, the nurse should use the pads of the fingers and palpate gently. The dorsum of the hand may be used to detect skin temperature, not to assess the clients glands. The palmar surface of the hand is not used to assess the clients glands. The nurse should not use a fingertip grasp of the tissue when assessing a clients glands. PTS: 1 DIF: A REF: 589 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 30. The nurse is evaluating the client for conduction deafness in the right ear. In using Webers test, the nurse appropriately places the tuning fork and confirms this type of deafness when: 1 2 3 4 Sound is not heard in either ear Sound is heard best by the client in the left ear Sound is heard best by the client in the right ear Sound is reduced and heard longer through air conduction ANS: 3 In conduction deafness, sound is heard best in the impaired ear. Sound that is not heard in either ear is not indicative of conduction deafness. Sound would not be heard best by the client in the left ear if there was conduction deafness in the right ear. This option is describing the Rinnes test, not the Webers test. In conduction deafness, bone-conducted sound can be heard longer. In sensorineural loss, sound is reduced and heard longer through air. PTS: 1 DIF: A REF: 584 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 31. The presence of arterial insufficiency is suspected during an inspection of the lower extremities when the nurse observes: 1 Increased hair growth 2 Cooler skin temperatures 3 Marked edema 4 Brown pigmentation ANS: 2 In the presence of arterial insufficiency, the client has signs resulting from an absence of blood flow, such as pain, pallor, and decreased or absent pulses in the lower extremities. The lower extremities become dusky red when the extremity is lowered. They feel cool to touch because blood flow is blocked to the extremity. Decreased hair growth or the absence of hair growth over the legs may indicate arterial insufficiency. Marked edema is seen in venous insufficiency, not arterial insufficiency. Brown pigmentation around the ankles is seen in venous insufficiency. Skin changes in arterial insufficiency include thin, shiny skin, decreased hair growth, and thickened nails. PTS: 1 DIF: A REF: 608 OBJ: Comprehension TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 32. The sounds heard over the trachea during the auscultation of the thorax, are expected to be: 1 2 Soft, low-pitched, and breezy Loud, high-pitched, and hollow 3 Moist, crackling, and bubbling 4 High-pitched and musical ANS: 2 Sounds heard during auscultation over the trachea should be loud, high-pitched and hollow. Soft, low-pitched, and breezy sounds are heard over the lungs periphery. Moist, crackling, and bubbling sounds are adventitious sounds known as crackles and are caused by sudden reinflation of groups of alveoli and disruptive passage of air. They are most commonly heard in dependent lobes: right and left lung bases. High-pitched and musical sounds are wheezes. Wheezes can be heard over all lung fields. PTS: 1 DIF: A REF: 596 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 33. The nurse tests the function of the clients cranial nerves during the neurological component of the physical examination. In testing cranial nerve III, the nurse verifies the clients ability to: 1 Smile and frown 2 Read printed material 3 Identify sweet and sour tastes 4 React to light with changes in pupil size ANS: 4 In testing cranial nerve III (oculomotor), the nurse determines the clients ability to react to light with changes in pupil size. Testing accommodation will also assess cranial nerve III. In testing cranial nerve VII (facial), the nurse determines the clients ability to smile and frown. In testing cranial nerve II (optic), the nurse determines the clients ability to read printed material. In testing cranial nerve IX (glossopharyngeal), the nurse determines the clients ability to identify sweet and sour tastes. PTS: 1 DIF: A REF: 634 OBJ: Knowledge TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 34. Which of the following statements made by a nurse reflects the best understanding of the health value of conducting a blood pressure (BP) screening at a senior citizens centers health fair? 1 This is a high risk group, so assessing BP allows us to identify clients at risk and send them for treatment. 2 Older adults enjoy health fairs, so its a good place to screen substantial numbers of clients for hypertension. 3 Hypertension doesnt present symptoms early on, so screening elder adults is a wonderful preventive measure. 4 Blood pressure problems are common among this group, so its a good way to monitor the effectiveness of their medications. ANS: 1 Health screenings focus on a specific physical problem. For example, blood pressure screenings detect the risk for high blood pressure. If this screening determines that a client has a risk for disease, the nurse refers the client for a more complete physical examination. While the other options are not incorrect, they do not show the most thorough understanding of the value of health screenings. PTS: 1 DIF: C REF: 553 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 35. Which of the following statements made by the RN preparing to conduct a clients initial health history shows the best understanding of the therapeutic objective of the interview? 1 Its all about finding out what the problems are and discovering the best way to fix them. 2 Clients are more comfortable when you take the time to get to know them and their problems. 3 I use it as an opportunity to show the client that his care is very important to the hospitals staff. It is the most appropriate way to initiate the therapeutic nature of the nurse-client relationship. 4 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: 1 The main objective of interacting with clients is to find out what their concerns are and to help them find solutions. While the other options are not incorrect, they do not express the primary objective of information gathering directed towards client care. PTS: 1 DIF: C REF: 553 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 36. A client reports pain in his left ankle since twisting it yesterday. Which of the following assessment findings best supports the clients claims of ankle pain? 1 The client grimaces when walking to the examination room. 2 The clients left ankle is swollen with noted bruising. The client reports a pain rating of 7 on a scale of 1 to 10. 3 4 The clients heart rate increases after walking to the examination room. ANS: 2 A subsequent physical assessment can reveal information that refutes, confirms, or supplements the history. Think critically about the information the client provides, apply knowledge from previous clinical care, and methodically conduct the examination to create a clear picture of the clients status. The objective signs of swelling and bruising best support the possible spraining of the ankle and the resulting claim of pain. The increase in heart rate is subjective but can be a result of various factors, pain being only one. The remaining options reflect objective data. PTS: 1 DIF: C REF: 553 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Psychosocial Integrity/Coping Mechanisms/Stress Management 37. While bathing an elderly client who has limited abilities for self-care, the nurse notices several patches of dry skin on the clients heels, elbows, and coccyx. The nurse cleans and dries all the areas well and applies a moisturizing lotion. The most appropriate immediate follow-up by the nurse to ensure appropriate nursing care for this clients skin is to: 1 Revise the clients care plan to show the need for the application of moisturizing lotion 2 Assume personal responsibility to apply the moisturizing lotion daily to the clients skin WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 3 Encourage the client to tell whomever bathes her to apply the moisturizing lotion to her areas of dry skin 4 Inform the staff that the clients skin is showing signs of breakdown and moisturizing lotion needs to be applied daily ANS: 1 The nurse revises the written care plan so that other nurses and nursing assistive personnel know the type of skin care to provide. The other options are less likely to convey the information effectively. PTS: 1 DIF: C REF: 553 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 38. Which of the following statements best reflects an understanding of the most effective means of showing nursing accountability for client care? 1 I always try to tailor client education to my clients care needs. 2 A clients care plan is never stagnate; it always needs updating. 3 Selecting the most appropriate interventions is the key to quality care. 4 By re-assessing the client regularly, I can tell if the interventions are working. ANS: 4 Nurses demonstrate accountability for their nursing care through evaluating the results of nursing interventions. Nurses make accurate, detailed, objective measurements through physical assessment. These measurements determine whether the expected outcomes of care are met. The remaining options are correct but not as directly related to nursing accountability for effective client care. PTS: 1 DIF: C REF: 554 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 39. The nurse encourages the client to relax and take a deep, slow breath in order to prepare for a palpating assessment of the abdomen. The primary reason for this is to: WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Encourage the client to be emotionally comfortable and relaxed 2 Distract the client from the actual possible discomfort the pressure may cause Facilitate the effectiveness of the palpating technique to detect abdominal masses 3 4 Allow the client an opportunity to cope with any bad feelings regarding the examination ANS: 3 Before palpation, help the client relax and be comfortable because muscle tension during palpation impairs effective assessment. To promote relaxation, have the client take slow, deep breaths and place the arms along the side of the body. While the other options may be reasonable, they are not the primary reason for encouraging the client to relax. PTS: 1 DIF: C REF: 554 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 40. The nurse is about to palpate the clients abdomen to determine the margins of the liver. The primary reason for using the bimanual palpation method is to: 1 Minimize client discomfort 2 Minimize lower hand desensitivity 3 Assist in manipulation of the organ 4 Facilitate quick assessment of the abdomen ANS: 2 When using bimanual palpation, relax one hand (sensing hand) and place it lightly over the clients skin. Use the other hand (active hand) to apply pressure to the sensing hand. The lower hand does not exert pressure directly and thus remains sensitive to detect organ characteristics. This technique does assist in the effective, efficient assessment of the abdomen, but its primary purpose is directed towards hand sensitivity. PTS: 1 DIF: C REF: 555 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material 41. Which of the following statements made by a nursing student regarding assessment technique requires immediate follow-up by the clinical instructor? 1 I always rub my hands together before touching the client. 2 I found that both of the clients carotid arteries beat simultaneously. 3 It will take a lot of practice for me to be master the art of percussion. 4 I always warm the stethoscopes diaphragm before listening for bowel sounds. ANS: 2 Do not palpate a vital artery with pressure that obstructs blood flow nor assess both such arteries at the same time since this could result in a dangerous lack of blood flow to the brain. The remaining options are not inaccurate and so do not require immediate follow-up. PTS: 1 DIF: C REF: 602 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 42. The primary reason for encouraging a client to urinate before beginning a physical examination is: 1 It avoids stimulation of the bladder during palpation or percussion of the abdomen 2 It minimizes the possibility of urinary incontinence caused by embarrassment or awkward positioning A full bladder can hinder the examination of the clients abdominal, genitalia, and rectal areas 3 4 Voiding before the examination will encourage the client to relax, thus facilitating the assessment ANS: 3 An empty bladder and bowel facilitate examination of the abdomen, genitalia, and rectum. The remaining options may be plausible reasons, but they are not the primary one. PTS: 1 DIF: C REF: 558 OBJ: Analysis TOP: Nursing Process: Assessment WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 43. The nurse recognizes that which of the following clients should be thoroughly assessed for their ability to be safely placed in the supine position? 1 An 18-year-old who suffered a fractured elbow playing football 2 A 20-year-old hospitalized with abdominal pain to rule out an appendicitis 3 A 74-year-old client who requires 3 L of continuous oxygen via nasal cannula 4 A 37-year-old reporting complaints of vaginal bleeding between menstrual periods ANS: 3 Clients who are experiencing any degree of respiratory distress will not find this position comfortable and should not be placed in this position because it will make breathing even more difficult. If the client becomes short of breath easily, raise the head of the bed. The other clients may not prefer this position, but there is no medical reason for avoiding it. PTS: 1 DIF: C REF: 558-589 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Reduction of Risk Potential/Techniques of Physical Assessment 44. A male nursing student is assigned to change the abdominal dressing of a 74-year-old female. The clinical nursing instructor asks that a female nurse assist him with the procedure. The primary reason for this decision is: 1 It diverts the clients attention during the assessment and procedure 2 It provides a third party to ensure proper conduct of all involved 3 It facilitates a comfortable, efficient environment for the client It assists with the wound assessment and changing of the abdominal dressing 4 ANS: 2 WWW.THENURSINGMASTERY.COM WWW.THENURSINGMASTERY.COM Downloaded by Kyle Palmer (sosolid120@gmail.com) lOMoARcPSD|9647167 Stuvia.com - The Marketplace to Buy and Sell your Study Material Stuvia.com - The Marketplace to Buy and Sell your Study Material When the client and nurse are of opposite gender, it helps to have a third person of the clients gender in the room. The pres