Davis Advantage Basic Nursing: Thinking, Doing, and Caring 3rd Edition Treas
Wilkinson Test Bank
Chapter 1 Evolution of Nursing Thought & Action
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. What is the most influential factor that has shaped the nursing
profession? 1)
Physicians need for handmaidens
2)
Societal need for healthcare outside the home
3)
Military demand for nurses in the field 4)
Germ theory influence on sanitation
ANS: 3
Throughout the centuries, stability of the government has been related to the success of the
military to protect or extend its domain. As the survival and well-being of soldiers is
critical, nurses provided healthcare to the sick and injured at the battle site. The physicians
handmaiden was/is a nursing stereotype rather than an influence on nursing. Although
there has been need for healthcare outside the home throughout history, this has more
influence on the development of hospitals than on nursing; this need provided one more
setting for nursing work. Germ theory and sanitation helped to improve healthcare but did
not shape nursing.
PTS: 1 DIF: Moderate REF: dm 910 KEY: Nursing process: N/A Client need: N/A |
Cognitive level: Recall
2. Which of the following is an example of an illness prevention activity? Select
all that apply.
1)
Encouraging the use of a food diary
2)
Joining a cancer support group
3)
Administering immunization for HPV
4)
Teaching a diabetic patient about his diet
ANS: 3
Administering immunization for HPV is an example of illness prevention. Although cancer
is a disease, it is assumed that a person joining a support group would already have the
disease; therefore, this is not disease prevention but treatment. Illness-prevention activities
focus on avoiding a specific disease. A food diary is a health-promotion activity. Teaching
a diabetic patient about diet is a treatment for diabetes; the patient already has diabetes, so
it cannot prevent diabetes.
PTS: 1 DIF: Moderate REF: p. 18; high-level question, not directly stated in text KEY:
Nursing process: N/A | Client need: HPM | Cognitive level: Application
3. Which of the following contributions of Florence Nightingale had an
immediate impact on improving patients health?
1)
Providing a clean environment
2)
Improving nursing education
3)
Changing the delivery of care in hospitals
4)
Establishing nursing as a distinct profession
ANS: 1
Improved sanitation (a clean environment) greatly and immediately reduced the rate of
infection and mortality in hospitals. The other responses are all activities of Florence
Nightingale that improved healthcare or nursing, but the impact is long range, not
immediate.
PTS: 1 DIF: Easy REF: V1, p. 3; student must infer from content | V1, p. 10; student
must infer from content
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
4. All of the following are aspects of the full-spectrum nursing role. Which one
is essential for the nurse to do in order to successfully carry out all the others?
1)
Thinking and reasoning about the clients care
2)
Providing hands-on client care
3)
Carrying out physician orders
4)
Delegating to assistive personnel
ANS: 1
A substantial portion of the nursing role involves using clinical judgment, critical
thinking, and problem solving, which directly affect the care the client will actually
receive. Providing hands-on care is important; however, clinical judgment, critical
thinking, and problem solving are essential to do it successfully. Carrying out physician
orders is a small part of a nurses role; it, too, requires nursing assessment, planning,
intervention, and evaluation. Many simple nursing tasks are being delegated to nursing
assistive personnel; delegation requires careful analysis of patient status and the
appropriateness of support personnel to deliver care. Another way to analyze this
question is that none of the options of providing hands-on care, carrying out physician
orders, and delegating to assistive personnel is required for the nurse to think and reason
about a clients care; so the answer must be 1.
PTS:1DIFifficultREF: p. 11
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis
5. Which statement pertaining to Benners practice model for clinical competence
is true?
1)
Progression through the stages is constant, with most nurses reaching the proficient stage.
2)
Progression through the stages involves continual development of thinking and technical
skills.
3)
The nurse must have experience in many areas before being considered an expert.
4)
The nurses progress through the stages is determined by years of experience and skills.
ANS: 2
Movement through the stages is not constant. Benners model is based on integration of
knowledge, technical skill, and intuition in the development of clinical wisdom. The
model does not mention experience in many areas. The model does not mention years of
experience.
PTS:1DIF:ModerateREF:p. 15
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
6. Which of the following best explains why it is difficult for the profession
to develop a definition of nursing?
1)
There are too many different and conflicting images of nurses.
2)
There are constant changes in healthcare and the activities of nurses.
3)
There is disagreement among the different nursing organizations.
4)
There are different education pathways and levels of practice.
ANS: 2
The conflicting images of nursing make it more important to develop a definition; they
may also make it more difficult, but not to the extent that constant change does.
Healthcare is constantly changing and with it come changes in where, how, and what
nursing care is delivered. Constant changes make it difficult to develop a definition.
Although different nursing organizations have different definitions, they are similar in
most ways. The different education pathways affect entry into practice, not the definition
of nursing.
PTS: 1 DIF: Moderate REF: p. 11; How Is Nursing Defined?
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis
7. Nurses have the potential to be very influential in shaping healthcare
policy. Which of the following factors contributes most to nurses influence?
1)
Nurses are the largest health professional group.
2)
Nurses have a long history of serving the public.
3)
Nurses have achieved some independence from physicians in recent years.
4)
Political involvement has helped refute negative images portrayed in the media.
ANS: 1
Nurses are trusted professionals and the largest health professional group. As such, they
have political power to effect changes. If nursing were a small group, there would be
little potential for power in shaping policies, even if all the other answers were true.
Serving the public, while positive, does not necessarily help nurses to be influential in
establishing health policy. Independence from physicians, although positive, does not
necessarily make nurses influential in establishing healthcare policy. Refuting negative
media, although positive, does not necessarily make nurses influential in establishing
healthcare policy.
PTS: 1 DIF: Moderate REF: p. 21
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis
8. Nursing was described as a distinct occupation in the sacred books of
which faith?
1)
Buddhism
2)
Christianity
3)
Hinduism
4)
Judaism
ANS: 3
The Vedas, the sacred books of the Hindu faith, described Indian healthcare practices and
were the earliest writings of a distinct nursing occupation.
PTS:1DIF:EasyREF:p. 7
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
9. The American Red Cross was established
by 1)
Louisa May Alcott 2)
Clara Barton
3)
Dorothea Dix
4)
Harriet Tubman
ANS: 2
Clara Barton was an American teacher, nurse, and humanitarian who organized the
American Red Cross after the Civil War. Louisa May Alcott was an American novelist
who wrote Little Women in 1868. Dorothea Dix was an American activist who acted on
behalf of the indigent population with mental illness. She was credited for establishing the
first psychiatric institution. Harriet Tubman was an African American abolitionist and
Union spy during the Civil War. After escaping captivity, she set up a network of
antislavery activists, known as the Underground Railroad.
PTS:1DIF:EasyREF:p. 10
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
10. Which of the following is the most important reason to develop a definition
of nursing?
1)
Recruit more informed people into the nursing profession
2)
Evaluate the degree of role satisfaction 3)
Dispel the stereotypical images of nurses and nursing
4)
Differentiate nursing activities from those of other health professionals
ANS: 4
Nursing organization leaders think it is important to develop a definition of nursing to
bring value and understanding to the profession, differentiate nursing activities from
those of other health professionals, and help student nurses understand what is expected
of them. A definition of nursing would not be likely to increase the number of informed
people recruited into nursing. A definition of nursing would do little to improve the
nurses role satisfaction. Although a definition of nursing might contribute to fighting
stereotypes of nursing, other, more powerful influences (e.g., media portrayals) exist to
counteract it.
PTS:1DIF:EasyREF:V1, dm 1113; students must infer from content KEY:
Nursing process: N/A | Client need: N/A | Cognitive level: Recall
11. Which of the following provides evidence-based support for the
contribution that advanced practice nurses (APNs) make within healthcare?
1)
Reduced usage of diagnostics using advanced technology
2)
Decreased number of unnecessary visits to the emergency department 3)
Improved patient compliance with prescribed treatments
4)
Increased usage of complementary alternative therapies
ANS: 3
Studies demonstrate that APNs have improved patient outcomes over those of physicians,
including increased patient understanding and cooperation with treatments and decreased
need for hospitalizations. No well-known, scientific studies support APNs effect on the use
of advanced technology. No well-known, scientific studies support APNs effect on the
frequency of emergency department visits. No well-known, scientific studies support
APNs effect on the use of alternative therapies.
PTS:1DIF:ModerateREF:p. 20
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
12. Which of the following is an example of what traditional medicine
and complementary and alternative medicine therapies have in common?
1)
Both can produce adverse effects in some patients.
2)
Both use prescription medications.
3)
Both are usually reimbursed by insurance programs.
4)
Both are regulated by the FDA.
ANS: 1
Both traditional and complementary therapies can produce adverse effects in some
patients. Many medications are derived from herbs, but the alternative treatments usually
use the herbs, not prescription medication. Insurance programs do not necessarily
reimburse alternative treatments, because many are not supported by sound scientific
research methodology. Alternative medications are not regulated by the FDA.
PTS:1DIF:ModerateREF:p. 20
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
13. Of the following, the biggest disadvantage of having nursing assistive
personnel (NAP) help nurses is that the nurse
1)
Must know what aspects of care can legally and safely be delegated to the NAP
2)
May rely too heavily on information gathered by the NAP when making patient care
decisions
3)
Is removed from many components of direct patient care that have been delegated to the
NAP
4)
Still maintains responsibility for the patient care given by the NAP
ANS: 2
All of the options may be disadvantages to using NAPs, but making decisions based on
anothers information is the greatest drawback because of the potential for negatively
affecting patient care. Treatment decisions based on incorrect information may cause
harm to the patient.
PTS:1DIFifficultREF:p. 2021; students must conclude from content KEY:
Nursing process: N/A | Client need: N/A | Cognitive level: Analysis
14. An older adult has type 1 diabetes. He can perform self-care activities but
needs help with shopping and meal preparation as well as with blood glucose monitoring
and insulin administration. Which type of healthcare facility would be most appropriate
for him?
1)
Acute care facility 2)
Ambulatory care facility 3)
Extended care facility
4)
Assisted living facility
ANS: 4
Assisted living facilities are intended for those who are able to perform self-care
activities but who require assistance with meals, housekeeping, or medications. Acute
care facilities focus on preventing illnesses and treating acute problems. These facilities
include physicians offices, clinics, and diagnostic centers. Ambulatory care facilities
provide outpatient care. Clients live at home or in nonhospital settings and come to the
site for care. Ambulatory care facilities include private health and medical offices, clinics,
surgery centers, and outpatient therapy centers. Extended care facilities typically provide
long-term care, rehabilitation, wound care, and ongoing monitoring of patient conditions.
PTS:1DIF:EasyREF:p. 18; ESG,
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
15. The nurse in the intensive care unit is providing care for only one patient, who
was admitted in septic shock. Based on this information, which care delivery model can
you infer that this nurse is following?
1)
Functional
2)
Primary
3)
Case method
4)
Team ANS:
3
The nurse is following the case method model of nursing care. In this model, one nurse
cares for one patient during a single shift. When the functional nursing model is
employed, care is compartmentalized, and each task is assigned to a staff member with
the appropriate knowledge and skills. In primary nursing, one nurse plans the care for a
group of patients round-the-clock. The primary nurse assesses the patient and develops
the plan of care. When he or she is working, he or she provides care for those patients
that he or she is responsible for. In his or her absence, the associate nurses deliver care.
Although the nurse in this case could possibly be a primary nurse, there are not enough
data to confidently infer that. If the team nursing approach is utilized, a licensed nurse
(RN or LVN) is paired with a nursing assistant. The pair is then assigned to a group of
patients.
PTS:1DIF:ModerateREF:ESG,
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis
16. Which healthcare worker should the nurse consult to counsel a patient
about financial and family stressors affecting healthcare?
1)
Social worker
2)
Occupational therapist
3)
Physicians assistant
4)
Technologist
ANS: 1
The social worker coordinates services and counsels patients about financial, housing,
marital, and family issues affecting healthcare. The occupational therapist helps patients
regain function and independence for activities of daily living. Physicians assistants work
under the physicians direction to diagnose certain diseases and injuries. Technologists
provide a variety of specific functions in hospitals, diagnostic centers, and emergency care.
For example, laboratory technologists aid in the diagnosis and treatment of patients by
examining blood, urine, tissue, and body fluids. Radiology technologists perform x- rays
and other diagnostic testing.
PTS:1DIF:ModerateREF:ESG,
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension
17. Which type of managed care allows patients the greatest choice of
providers, medications, and medical devices?
1)
Health maintenance organization
2)
Integrated delivery network 3)
Preferred provider organization
4)
Employment-based private insurance
ANS: 3
Preferred provider organizations are a form of managed care that allows the patient a
greater choice of providers, medications, and medical devices within the designated list.
Health maintenance organizations allow the patient to choose a primary care provider
within the organization to coordinate his care. This type of program will only reimburse
medical care when the patient has first obtained a referral from the primary provider.
Integrated delivery networks combine providers, healthcare facilities, pharmaceuticals,
and services into one system, and the patient must remain within the system to receive
care. Employment-based private insurance is not a managed care organization.
PTS:1DIF:EasyREF:ESG,
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis
18. A patient who underwent a total abdominal hysterectomy is assisted out of bed
as soon as her vital signs are stable. This intervention is most likely being directed by a
1)
Critical pathway 2)
Nursing care plan
3)
Case manager
4)
Traditional care model
ANS: 1
This patients care is most likely being directed by a critical pathway. A critical pathway
is a multidisciplinary approach to care that sequences interventions over a length of stay
for a given case type, such as total abdominal hysterectomy. Using this model, the patient
can be assisted out of bed as soon as her vital signs are stable. Using the traditional model,
the nurse would have to obtain a physicians order to assist the patient out of bed after
surgery. The nursing care plan guides nursing care but cannot specify when the patient can
get out of bed postoperatively without a physicians order. When case management is used,
care is coordinated by the case manager across the healthcare setting, but the case manager
does not direct each care intervention.
PTS:1DIF:ModerateREF:ESG
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
19. Which member of the healthcare team typically serves as the case
manager? 1)
Occupational therapist
2)
Physician
3)
Physicians assistant
4)
Registered nurse
ANS: 4
Typically, registered nurses serve as case managers for patients with specific diagnoses.
Their role is coordinator of care across the healthcare system. The occupational therapist,
physician, and physicians assistant all serve on the healthcare team and take direction
from the case manager.
PTS: 1 DIF: Easy REF: ESG,
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Recall
20. Which of the following is considered a primary care
service? 1)
Providing wound care
2)
Administering childhood immunizations
3)
Providing drug rehabilitation
4)
Outpatient hernia repair
ANS: 2
Primary care services focus on health promotion and disease prevention; administering
childhood immunizations is one such service. Providing wound care and drug
rehabilitation are examples of tertiary care services. Outpatient hernia repair surgery is an
example of a secondary care service.
PTS:1DIF:ModerateREF:ESG,
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
21. Which of the following nursing activities represent direct care? Choose all
that apply.
1)
Bathing a patient
2)
Administering a medication
3)
Documenting an assessment
4)
Making work assignments for the shift
ANS: 1
B
Direct care involves personal interaction between the nurse and clients (e.g., giving
medications, dressing a wound, or teaching a client about medicines or care). Nurses
deliver indirect care when they work on behalf of an individual, group, family, or
community to improve their health status (e.g., restocking the code blue cart [an
emergency cart], ordering unit supplies, or arranging unit staffing).
PTS:1DIF:EasyREF:p. 17
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:
Comprehension
22. An 80-year-old patient fell and fractured her hip and is in the hospital. Before
the fall, she lived at home with her husband and managed their activities of daily living
very well. The goal is for the patient to recover from the injury and return to her home.
The hospital is ready to discharge her because she has exceeded the recommended length
of stay in a hospital. However, she cannot walk or care for herself yet, and she will require
lengthy physical therapy and further monitoring of her medications and her physical and
mental status. To which type of facility should she be transferred?
1)
Nursing home
2)
Rehabilitation center 3)
Outpatient therapy center
4)
None of these; she should receive home healthcare
ANS: 2
A skilled nursing facility primarily provides skilled nursing care for patients who can be
expected to improve with treatment. For example, a patient who no longer needs
hospitalization may transfer to a skilled nursing facility to get skilled care until she is able
to return home. A nursing home provides custodial care for people, like this patient, who
cannot live on their own but who are not sick enough to require hospitalization. It provides
a room, custodial care, and opportunity for recreation. This patient cannot ambulate or
perform activities of daily living, so outpatient therapy and home care would not be
appropriate.
PTS:1DIF:ModerateREF:p. 18
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:
Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which of the following are examples of a health-promotion activity? Select
all that apply.
1)
Helping a client develop a plan for a low-fat, low-cholesterol diet
2)
Disinfecting an abraded knee after a child falls off a bicycle
3)
Administering a tetanus vaccination after an injury from a car accident
4)
Distributing educational brochures about the benefits of exercise
ANS: 1, 4
Health promotion includes strategies that promote positive lifestyle changes. Disinfecting
an abraded knee is a treatment/intervention for an injury. Administering a vaccination is a
disease-prevention and treatment activity.
PTS: 1 DIF: Moderate REF: p. 18; high-level question, not directly stated in text
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Application
Matching
Match the nursing role listed on the left with the appropriate activity listed on the right.
Each activity has only one correct answer.
1)
Planning the units staffing schedule
2)
Participating on a committee to develop a program to teach schoolchildren proper
handwashing
3)
Teaching the client about a scheduled test
4)
Discussing new medication at a staff meeting
5)
Discussing with the physician the clients reasons for not wanting the recommended
surgery.
1. Direct care provider
2. Client advocate
3. Manager
4. Change agent
1.ANS:3PTS:1DIF:Moderate
REF:p. 13; must recognize examples not provided in content
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application
2.ANS:5PTS:1DIF:Moderate
REF:p. 13; must recognize examples not provided in content
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application
3.ANS:1PTS:1DIF:Moderate
REF:p. 13; must recognize examples not provided in content
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application
4.ANS:2PTS:1DIF:Moderate
REF:p. 13; must recognize examples not provided in content
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application Match
the event with the appropriate year. Each item has only one correct answer. 1)
Nursing programs become affiliated with religious groups
2)
Start of public health nursing with the founding of the Henry Street Settlement
3)
First formal nursing education in United States
4)
First hospital
5)
Establishment of the Army Nursing Service
6)
Disassociation of nursing from religious orders
7)
Florence Nightingale cared for the soldiers of the Crimean War
5. 1st-century AD
6. 15th to 19th century
7. 1854
8. 1861
9. 1873
10. 1893
•
ANS:4PTS:1DIFifficult
REF: dm 611; must recognize examples not provided in content
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
•
ANS:6PTS:1DIFifficult
REF: dm 611; must recognize examples not provided in content
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
•
ANS:7PTS:1DIFifficult
REF: dm 611; must recognize examples not provided in content
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
•
ANS:5PTS:1DIFifficult
REF: dm 611; must recognize examples not provided in content
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
•
ANS:3PTS:1DIFifficult
REF: dm 611; must recognize examples not provided in content
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
•
ANS:2PTS:1DIFifficult
REF: dm 611; must recognize examples not provided in content
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
Match the nursing organization with its function in the nursing profession.
1)
Responsible for setting and maintaining nursing education standards
2)
Developed Code for Nurses and the Standards of Clinical Nursing Practice
3)
Responsible for publishing the journal, Image
4)
Honor society for nursing
5)
Represents nursing and promotes nursing leadership worldwide
11. American Nurses Association (ANA)
12. National Student Nurses Association (NSNA)
13. National League for Nursing (NLN)
14. International Council of Nursing (ICN)
15. Sigma Theta Tau International (STTI)
•
ANS: 2 PTS: 1 DIF: Moderate REF: p. 17
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
•
ANS: 3 PTS: 1 DIF: Moderate REF: p. 17
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
•
ANS: 1 PTS: 1 DIF: Moderate REF: p. 17
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
•
ANS: 5 PTS: 1 DIF: Moderate REF: p. 17
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
•
ANS: 4 PTS: 1 DIF: Moderate REF: p. 17
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
True/False
Indicate whether the statement is true or false.
1. The nurse caring for a patient undergoing minor surgery as an outpatient
provides the same type of care as for a hospitalized patient undergoing the same
procedure.
ANS: T
The nurse caring for a patient receiving care after outpatient surgery provides the same
type of care as with the hospitalized patient. The only difference is that the outpatient
spends fewer than 24 hours in the facility.
PTS:1DIF:EasyREF:p. 18; students must draw conclusion from content
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Recall
Completion
Complete each statement.
is a health program, administered by the state and funded
•
by federal and state governments to provide care for low-income people.
ANS:
Medicaid
Medicaid is a health program run by the state and funded by the federal and state
governments. It is intended to provide preventative and acute healthcare for individuals
without ability to pay for services, particularly pregnant women and children.
PTS:1DIF:ModerateREF:ESG
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
is a federal insurance-type program designed to fund
•
healthcare for people age 65 years and older, the disabled, and those with endstage renal disease from the high cost of healthcare.
ANS: Medicare
Medicare is a federal insurance program created by Title XVIII of Social Security Act of
1965. This Act was designed to protect people age 65 years and older from the high cost
of healthcare. In 1972, the program was expanded to cover disabled workers as well as
people with end-stage renal disease.
Chapter 2 Clinical Judgement
1. Which of the following characteristics do the various definitions of
critical thinking have in common? Critical thinking
1)
Requires reasoned thought 2)
Asks the questions why? or how?
3)
Is a hierarchical process 4)
Demands specialized thinking skills
ANS: 1
The definitions listed in the text as well as definitions in Box 2-1 state that critical
thinking requires reasoning or reasoned thinking. Critical thinking is neither linear nor
hierarchical. That means that the steps involved in critical thinking are not necessarily
sequential, where mastery of one step is necessary to proceed to the next. Critical thinking
is a purposeful, dynamic, analytic process that contributes to reasoned decisions and
sound contextual judgments.
PTS:1DIF:ModerateREF: p. 25; high-level question, answer not stated verbatim
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis
2. A few nurses on a unit have proposed to the nurse manager that the process for
documenting care on the unit be changed. They have described a completely new system.
Why is it important for the nurse manager to have a critical attitude? It will help the
manager to
1)
Consider all the possible advantages and disadvantages
2)
Maintain an open mind about the proposed change
3)
Apply the nursing process to the situation
4)
Make a decision based on past experience with documentation
ANS: 2
A critical attitude enables the person to think fairly and keep an open mind.
PTS:1DIF:ModerateREF:dm 26
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
3. The nurse has just been assigned to the clinical care of a newly admitted patient.
To know how to best care for the patient, the nurse uses the nursing process. Which step
would the nurse probably do first?
1)
Assessment
2)
Diagnosis
3)
Plan outcomes
4)
Plan interventions
ANS: 1
Assessment is the first step of the nursing process. The nursing diagnosis is derived from
the data gathered during assessment, outcomes from the diagnosis, and interventions from
the outcomes.
PTS:1DIF:EasyREF: p. 30-31
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
4. Which of the following is an example of theoretical
knowledge? 1)
A nurse uses sterile technique to catheterize a patient.
2)
Room air has an oxygen concentration of 21%. 3)
Glucose monitoring machines should be calibrated daily.
4)
An irregular apical heart rate should be compared with the radial pulse.
ANS: 2
Theoretical knowledge consists of research findings, facts, principles, and theories. The
oxygen concentration of room air is a scientific fact. The others are examples of practical
knowledgewhat to do and how to do it.
PTS:1DIF:ModerateREF:p. 30; high-level question, answer not stated verbatim
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
5. Which of the following is an example of practical knowledge? (Assume all
are true.)
1)
The tricuspid valve is between the right atrium and ventricle of the heart.
2)
The pancreas does not produce enough insulin in type 1 diabetes.
3)
When assessing the abdomen, you should auscultate before palpating. 4)
Research shows pain medication given intravenously acts faster than by other routes.
ANS: 3
Practical knowledge is knowing what to do and how to do it, such as how to do an
assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve),
fact (type 1 diabetes), and research (IV pain medication).
PTS:1DIF:ModerateREF:p. 30; high-level question, answer not stated verbatim
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
6. Which of the following is an example of self-knowledge? The nurse thinks,
I know that I
1)
Should take the clients apical pulse for 1 minute before giving digoxin
2)
Should follow the clients wishes even though it is not what I would want
3)
Have religious beliefs that may make it difficult to take care of some clients
4)
Need to honor the clients request not to discuss his health concern with the family
ANS: 3
Self-knowledge is being aware of your religious and cultural beliefs and values. Taking
the pulse is an example of practical knowledge. Following client wishes and honoring
client requests are examples of ethical knowledge.
PTS:1DIFifficultREF: p. 30; high-level question, answer not stated verbatim | V1, p. 32;
high-level question, answer not stated verbatim
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
7. Which of the following is the most important reason for nurses to be
critical thinkers?
1)
Nurses need to follow policies and procedures.
2)
Nurses work with other healthcare team members.
3)
Nurses care for clients who have multiple health problems.
4)
Nurses have to be flexible and work variable schedules.
ANS: 3
Critical thinking is essential for client care, particularly when the care is complex,
involving numerous health issues. Following policies and procedures does not necessarily
require critical thinking, and working with others or being flexible and working different
schedules do not necessarily require critical thinking.
PTS:1DIF:ModerateREF: p. 26-27; high-level question, answer not stated verbatim
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
8. The nurse administering pain medication every 4 hours is an example of
which aspect of patient care?
1)
Assessment data
2)
Nursing diagnosis
3)
Patient outcome 4)
Nursing intervention
ANS: 4
Interventions are activities that will help the patient achieve a goal, such as administering
pain-relieving medication. An example of assessment data might be, Patient reports pain
is a 5 on a 1 to 10 scale. The nursing diagnosis would be Pain. The nurse might define the
patient outcome in this scenario as, The patient will state the level of pain is less than 4.
PTS:1DIF:ModerateREF:p. 31; high-level question, answer not stated verbatim
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
9. How does nursing diagnosis differ from a medical diagnosis? A
nursing diagnosis is
1)
Terminology for the clients disease or injury
2)
A part of the clients medical diagnosis
3)
The clients presenting signs and symptoms
4)
A clients response to a health problem
ANS: 4
A nursing diagnosis is the clients response to actual or potential health problems.
PTS:1DIF:ModerateREF: p. 31
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall
10. Which statement about the nursing process is
correct? 1)
It was developed from the ANA Standards of Care.
2)
It is a problem-solving method to guide nursing activities.
3)
It is a linear process with separate, distinct steps.
4)
It involves care that only the nurse will give.
ANS: 2
The nursing process is a problem-solving process that guides nursing actions. The ANA
organizes its Standards of Care around the nursing process, but the process was not
developed from the standards. The nursing process is cyclical and involves care the
nurses give or delegate to other members of the healthcare team.
PTS:1DIF:EasyREF: p. 31
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
11. What do critical thinking and the nursing process have in
common? 1)
They are both linear processes used to guide ones thinking.
2)
They are both thinking methods used to solve a problem.
3)
They both use specific steps to solve a problem.
4)
They both use similar steps to solve a problem.
ANS: 2
Critical thinking and the nursing process are ways of thinking that can be used in problem
solving (although critical thinking can be used beyond problem-solving applications).
Neither method of thinking is linear. The nursing process has specific steps; critical
thinking does not.
PTS:1DIFifficultREF: p. 31
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis
12. A nurse admits a patient to the unit after completing a comprehensive
interview and physical examination. To develop a nursing diagnosis, the nurse must now
1)
Analyze the assessment data
2)
Consult standards of care
3)
Decide which interventions are appropriate
4)
Ask the clients perceptions of her health problem
ANS: 1
The basis of the nursing diagnosis is the assessment data. Standards of care are referred to
when establishing nursing interventions. Customizing interventions personalizes nursing
care. Asking the patient about her perceptions is a method to validate whether the nurse has
chosen the correct nursing diagnosis and would probably have been done during the
comprehensive assessment.
PTS: 1 DIF: Moderate REF: p. 31
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application
13. The nurse developed a care plan for a patient to help prevent Impaired Skin
Integrity. She has made sure that nursing assistive personnel change the patients position
every 2 hours. In the evaluation phase of the nursing process, which of the following
would the nurse do first?
1)
Determine whether she has gathered enough assessment data.
2)
Judge whether the interventions achieved the stated outcomes.
3)
Follow up to verify that care for the nursing diagnosis was given.
4)
Decide whether the nursing diagnosis was accurate for the patients condition.
ANS: 2
The evaluation phase judges whether the interventions were effective in achieving the
desired outcomes and helped to alleviate the nursing diagnosis. This must be done before
examining the nursing process steps and revising the care plan.
PTS:1DIF:ModerateREF: p. 31
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis
14. In caring for a patient with comorbidities, the nurse draws upon her
knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest
guidelines for providing skin care and includes them in the plan of care. The nurse
provides skin care according to the procedural guidelines and begins regular monitoring
to evaluate the effectiveness of the interventions. These activities are best described as
1)
Full-spectrum nursing
2)
Critical thinking 3)
Nursing process 4)
Nursing knowledge
ANS: 1
Full-spectrum nursing (1) involves the use of critical thinking, nursing knowledge,
nursing process, and patient situation. Although the other answers are important for
planning and delivering nursing care, they do not reflect all the nurse has demonstrated.
PTS:1DIFifficultREF:dm 32-33; high-level question, answer not stated verbatim
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Analysis
15. The nurse is preparing to admit a patient from the emergency department. The
transferring nurse reports that the patient is obese. The nurse has been overweight at one
time and works very hard now to maintain a healthy weight. She immediately thinks, I
know I tend to feel negatively about obese people; I figure if I can stop eating, they should
be able to. I must remember how very difficult that is and be very careful not to be
judgmental of this patient. This best illustrates
1)
Theoretical knowledge
2)
Self-knowledge
3)
Using reliable resources 4)
Use of the nursing process
ANS: 2
Self-knowledge is self-understandingawareness of ones beliefs, values, biases, and so on.
That best describes the nurses awareness that her bias can affect her patient care.
Theoretical knowledge consists of information, facts, principles, and theories in nursing
and related disciplines; it consists of research findings and rationally constructed
explanations of phenomena. Using reliable resources is a critical thinking skill. The
nursing process is a problem-solving process consisting of the steps of assessing,
diagnosing, planning outcomes, planning interventions, implementing, and evaluating.
The nurse has not yet met this patient, so she could not have begun the nursing process.
PTS:1DIFifficultREF:dm 30; high-level question, answer not stated verbatim
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which aspects of healthcare are affected by a clients culture? Select all
that apply.
1)
How the clients views healthcare
2)
How the client views illness
3)
How the client will pay for healthcare services
4)
The types of treatments the client will accept
5)
When the client will seek healthcare services
6)
The environment where the healthcare services are provided
7)
The ease of accessibility of healthcare services
ANS: 1, 2, 4, 5
Culture affects clients view of health and healthcare. It influences how they will
define illness, when they will seek healthcare, and what treatments are acceptable in their
culture. How services are paid for is related to economic status. Regardless of culture,
anyone can be affected by previous healthcare experiences, the environment in which
healthcare is provided, and accessibility of services.
Chapter 3 Nursing Process
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which of the following is an example of a problem that nurses can
treat independently?
1)
Hemorrhage
2)
Nausea
3)
Fracture
4)
Infection
ANS: 2
A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or
other stressor that nurses can identify, prevent, or treat independently. Nausea is the only
problem that meets that criterion; all others are medical or collaborative problems.
PTS:1DIF:ModerateREF: dm 57
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application
2. Which of the following is an example of a cluster of related
cues? 1)
Complains of nausea and stomach pain after eating
2)
Has a productive cough and states stools are loose
3)
Has a daily bowel movement and eats a high-fiber diet
4)
Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84
ANS: 1
A cue is an unhealthy response; a cluster of cues consists of cues related to each other.
Productive cough and loose stools are abnormal findings but are not obviously or usually
related to each other. Daily bowel movement and high-fiber diet are related but normal
responses. The vital signs are also within normal limits.
PTS:1DIFifficultREF: dm 62
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
3. Which of the following explains why it is important to have the correct
etiology for a nursing diagnosis? The etiology
1)
Is the cause of the problem
2)
Cannot always be observed
3)
Directs nursing care
4)
Is an inference
ANS: 3
The etiology directs nursing interventions. If the incorrect etiology is given, the nursing
care would not be appropriate for the client. The other statements are true but not a
reason for the importance of the etiology being correct.
PTS:1DIFifficultREF:dm 63
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
4. How does a risk nursing diagnosis differ from a possible nursing
diagnosis? 1)
A risk diagnosis is based on data about the patient.
2)
A possible diagnosis is based on partial (or incomplete) data.
3)
Nurses collect the data to support risk diagnoses.
4)
A possible diagnosis becomes an actual diagnosis when symptoms develop.
ANS: 2
A possible nursing diagnosis is based on nursing knowledge, intuition, and experience and
does not have enough data to support it; it is based on incomplete data. A risk diagnosis
describes a problem that may develop in a vulnerable client if nursing care is not initiated
to prevent it; it is made when risk factors are present in the data. Nurses collect data to
support both risk and possible diagnoses; therefore, this statement does not differentiate
them. A risk diagnosis becomes an actual diagnosis when symptoms develop.
PTS:1DIF:ModerateREF:p. 60
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
5. Which of the following describes the difference between a collaborative
problem and a medical diagnosis?
1)
A collaborative problem is treated by the nurse; a physician is responsible for the
treatment of a medical problem.
2)
A collaborative problem is a nursing diagnosis that requires specific orders from a
physician; a medical diagnosis directs all nursing care.
3)
A collaborative problem has the potential to become an actual nursing diagnosis; a
medical diagnosis rarely changes.
4)
A collaborative problem requires intervention by the nurse and physician or other
professional; a medical diagnosis requires intervention by a physician.
ANS: 4
Collaborative problems are physiological complications a client may be at risk for due to
her medical diagnosis, medical treatment, or diagnostic studies. A collaborative problem
requires monitoring by the nurse and intervention by a physician. A medical diagnosis
requires interventions (medications, treatments) by the physician. Medical diagnoses do
not direct all nursing care. Collaborative problems have the potential to become medical,
not nursing, diagnoses.
PTS:1DIF:ModerateREF: dm 5859
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
6. Which of the following is the best approach to validate a clinical
inference? 1)
Have another nurse evaluate it.
2)
Have the physician evaluate it.
3)
Have sufficient supportive data.
4)
Have the clients family confirm it.
ANS: 3
All clinical inferences should be well supported by data. The more reliable data you
gather, the more certain you can be that your inference is accurate. Because inferences
are nursing diagnoses, it would be inappropriate to have a physician evaluate them.
Although another experienced nurse could evaluate the inference, it still needs to be
supported by sound and sufficient data. Even clients can validate clinical inferences in
some situations, but adequate supporting data are still needed. Keep in mind that the
clients data might or might not be sufficient to prove the inference.
PTS: 1 DIF: Easy REF: p. 63
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall
7. What is wrong with the following diagnostic statement? Impaired
Physical Mobility related to laziness and not having appropriate shoes. The
statement is
1)
Judgmental
2)
Too complex
3)
Legally questionable 4)
Without supportive data
ANS: 1
Lazy implies criticism of the client and therefore is judgmental. There need to be several
(certainly more than two) etiological factors for the statement to be complex. There is no
blame implied or harm resulting, so the statement is not legally questionable. There is no
minimum amount of supportive data for a diagnosis and the stated etiology related to the
nursing diagnosis. No supportive data are given in the stem of the question, so you could
not choose lack of data as the best answer because all the options lack data as far as you
can tell from the information given in the question. In addition, it is not necessary to
include supportive data in the diagnostic statement (although some do prefer to use
A.M.B. and include defining characteristics).
PTS:1DIF:ModerateREF:p. 74
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
8. When making a diagnosis using NANDA-I, which of the following
provides support for the diagnostic label you choose?
1)
Etiology
2)
Related factors 3)
Diagnostic label
4)
Defining characteristics
ANS: 4
The defining characteristics are the signs and symptoms that must be present to support
any given nursing diagnosis. The etiology and related factors are the causes or
contributing factors to the problem. The diagnostic label is the name NANDA-I has given
the problem; it is chosen based on the presence of defining characteristics.
PTS:1DIF:EasyREF:p. 68
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall
9. Based only on Maslows hierarchy of needs, which nursing diagnosis should
have the highest priority?
1)
Self-care Deficit 2)
Risk for Aspiration
3)
Impaired Physical Mobility
4)
Disturbed Sensory Perception
ANS: 2
Highest priority is given to problems that are life threatening or that could be destructive
to the client. Safety is most basic in Maslows hierarchy. Even though Risk for Aspiration
is not an actual problem, it poses the most immediate life-threatening risk to the client,
and nursing interventions must be performed to prevent it from becoming an actual
problem.
PTS:1DIF:ModerateREF:dm 6465
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
10. Which of the following describes the most important use of nursing
diagnosis? (All statements are true.)
1)
Differentiates the nurses role from that of the physician
2)
Identifies a body of knowledge unique to nursing
3)
Helps nursing develop a more professional image
4)
Describes the clients needs for nursing care
ANS: 4
Benefits to nurses and nursing are that nursing diagnoses differentiate the nurses role,
they identify a unique body of nursing knowledge, and some think they help nursing to
develop a more professional image. However, the primary goal of nursing is to serve the
good of the patient. Therefore, the most important use of a diagnosis is to specifically
identify the clients needs for quality nursing care.
PTS: 1 DIF: Moderate REF: p. 56
KEY: Nursing process: Diagnosis | Client need: Safe-care environment | Cognitive level:
Analysis
11. Which of the following is a criticism of standardized nursing
diagnoses developed by NANDA-I?
1)
There is little research to support nursing diagnoses labels.
2)
A perfect nursing diagnosis must be written for it to be useful.
3)
They are not included in all states nurse practice acts.
4)
Other professions do not recognize nursing diagnoses.
ANS: 1
Best practice is evidence-based practice; that is, it is developed through sound, scientific
research. Research is currently being conducted, but many of the diagnoses are not
research based. A perfect nursing diagnosis is impossible to write, so that is not an issue.
Having standardized nursing diagnoses recognized in state practice acts or by other
professions has nothing to do with the value of the NANDA-I taxonomy.
PTS:1DIFifficultREF: p. 57
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall
12. Which of the following most accurately describes nursing diagnoses? A
nursing diagnosis
1)
Supports the nurses diagnostic reasoning
2)
Supports the clients medical diagnosis
3)
Identifies a clients response to a health problem
4)
Identifies a clients health problem
ANS: 3
Nursing diagnoses are statements that nurses use to describe a clients physical, mental,
emotional, spiritual, and social response to disease, injury, or other stressor. Diagnostic
reasoning is used to identify the appropriate nursing diagnosis; it is not meant to support
the diagnosis. A health problem is a condition that requires intervention to promote
wellness or prevent illness; it is sometimes, but not always, a nursing diagnosis. Nursing
diagnoses are not medical diagnoses.
PTS:1DIF:ModerateREF: p. 57
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
13. The diagnostic label, or patient problem, is used primarily to
suggest 1)
Client goals 2)
Cue clusters 3)
Interventions
4)
Etiology
ANS: 1
As a general rule, the problem suggests goals for client outcomes. The etiology suggests
interventions. Cue clusters support whether the correct nursing diagnosis has been
identified.
PTS: 1 DIF: Moderate REF: p. 73
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall
14. Which nursing diagnosis is written in the correct format when using
the NANDA-I taxonomy?
1)
Bowel Obstruction related to recent abdominal surgery A.M.B. nausea, vomiting, and
abdominal pain
2)
Inability to Ingest Food related to imbalanced nutrition: less than body requirements
A.M.B. inadequate food intake, weight less than 20% under ideal body weight
3)
Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacral area
4)
Caregiver Role Strain related to alienation from family and friends A.M.B 24-hour care
responsibilities
ANS: 3
The components of NANDA-I nursing diagnosis might include the following four parts:
diagnostic label, defining characteristics, related factors, and risk factors. Impaired Skin
Integrity . . . has the problem statement, etiology, and symptoms. For Bowel Obstruction .
. . the problem is a medical diagnosis. The cause-and-effect order of Inability to Ingest
Food . . . is incorrect; it starts with the etiology. The etiology and symptoms (A.M.B.) of
Caregiver Role Strain . . . are reversed (alienation from family and friends are the
symptoms that support the diagnosis).
PTS: 1 DIF: Difficult REF: dm 7071
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application
15. What is wrong with the format of this diagnostic statement:
Possible Risk for Constipation related to irregular defecation habits A.M.B. statement
that When Im busy, I cant always take the time to go to the bathroom.
1)
Possible nursing diagnoses do not have signs and symptoms.
2)
A nursing diagnosis is either a possible risk or a risk, not both.
3)
Constipation is a medical diagnosis.
4)
The etiology is actually a defining characteristic.
ANS: 2
If there are risk factors, it is not a possible diagnosis, it is a risk diagnosis. It is possible to
have a possible risk for diagnosis. The patient with possible diagnoses may have
symptoms, just not enough to support the diagnosis. Constipation is a nursing diagnosis,
and the etiology is a defining characteristic for a risk diagnosis because it contributes to the
problem. In risk diagnoses, the etiology consists of the risk factors.
PTS: 1 DIF: Moderate REF: dm 60
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
16. Which nursing diagnosis is written in the correct
format? 1)
Imbalanced Nutrition: Less than Body Requirements related to body weight less than
20% under ideal weight
2)
Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm
3)
Impaired Swallowing related to absent gag reflex
4)
Excess Fluid Volume related to 3 lb weight gain in 24 hours
ANS: 3
The etiology should describe what is causing or contributing to the problem. The
etiologies for Ineffective Airway Clearance, Impaired Airway Swallowing, and Excess
Fluid Volume describe signs or symptoms rather than causal factors.
PTS: 1 DIF: Difficult REF: V1, p. 64 | dm 70-73
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
17. The patient shows the necessary defining characteristics, and the nurse
has diagnosed Decisional Conflict related to unclear personal values and beliefs.
What essential action should the nurse take to help ensure the accuracy of this
diagnosis? 1)
Ask a more experienced nurse to confirm it.
2)
Have a social worker interview the patient.
3)
Ask the patient to confirm the diagnosis.
4)
Read about Decisional Conflict in the NANDA-I handbook.
ANS: 3
After identifying problems and etiologies (which this nurse has done), the nurse should
verify them with the patient to help ensure that her conclusions are accurate. If the patient
does not agree that he has Decisional Conflict, the nurse might interview him more to
clarify the meaning of the data. Certainly the nurse could ask another nurses opinion, but
that is not essential. It would make no sense to have a social worker interview the patient
unless the situation remains unclear even after confirming with the client. If the nurse did
have adequate theoretical knowledge of Decisional Conflict for this patient, she should
have been informed by reading the NANDA-I handbook before making the diagnosis. If
the patient does not confirm the diagnosis, and the nurse concludes the diagnosis is in
error, she might then reread the NANDA-I guide.
PTS: 1 DIF: Moderate REF: V1, p. 56 | p. 63
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application
18. The clients weight is appropriate for his height. His laboratory values and
other assessments reflect normal nutritional status. However, he has told the nurse, I
probably eat a little too much red meat. And what is this I hear about needing omega 3
oils in my diet? I dont like to take supplements, and I think I could really improve my
nutrition.
Which of the following nursing diagnoses should the nurse use?
1)
Balanced Nutrition
2)
Possible Imbalanced Nutrition: Less Than Body Requirements
3)
Risk for Imbalanced Nutrition: Less Than Body Requirements
4)
Readiness for Enhanced Nutrition
ANS: 4
You will use a wellness diagnosis when a persons present level of wellness is effective and
when the person wants to move to a higher level of wellnessin this case, a higher level of
nutrition. The format for a wellness diagnosis is Readiness for Enhanced . . . Use a
possible diagnosis when you have enough data to suspect a problem but need more data to
support a diagnosis. Use a risk diagnosis when there are risk factors for a problem.
PTS: 1 DIF: Moderate REF: p. 72
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application
19. The patient verbalizes an overwhelming lack of energy. He says, I still feel
exhausted even after I sleep. I feel guilty when I cant keep up with my usual daily
activities or sleep during the day. Ive been a little depressed lately, too. The patient seems
to have difficulty concentrating but has no apparent physical problems. Which of the
following diagnoses best describes his health status?
1)
Fatigue related to depression
2)
Fatigue related to difficulty concentrating
3)
Guilt related to lack of energy
4)
Chronic confusion related to lack of energy
ANS: 1
The diagnosis that best describes the overall health status is Fatigue. The only cue that
might cause Fatigue is depression. You cannot use depression as the problem because it
is a medical diagnosis, and it is not a NANDA-I label. The other cues (difficulty
concentrating, inability to perform ADLs, and guilt) are symptoms of Fatigue, not
etiologies. These diagnoses would lead the nurse to focus on dealing with guilt and
confusion, so the source of the Fatigue would not be addressed.
PTS: 1 DIF: Difficult REF: dm 70-73
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application
20. Which of the following nursing diagnoses is written in correct format?
Assume the facts are correct in all of them.
1)
Readiness for Enhanced Nutrition
2)
Pain related to stating, On a scale of 1 to 5, its a 5.
3)
Impaired Mobility related to pain A.M.B. hip fracture
4)
Risk for Infection related to compromised immunity A.M.B. fever
ANS: 1
Wellness diagnoses (e.g., Readiness for Enhanced . . .) are usually one-part statements. A
pain ranking of 5 is a symptom of pain, not an etiology, so it should be preceded by
A.M.B. or as manifested by. Hip fracture is a medical diagnosis that is causing an
etiology of pain; therefore, it should be preceded by secondary to. Risk diagnoses do not
have symptoms, so it is not correct to put anything after A.M.B.
PTS: 1 DIF: Moderate REF: dm 70-73
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which of the following are cues? Select all that
apply. 1)
Taking a brisk walk five times a week
2)
Using laxatives to have a bowel movement
3)
Needing more sleep than usual
4)
Decreasing the amount of fat in the diet
5)
Weighing less than indicated by developmental norms
ANS: 2, 3, 5
Cues are a deviation from norms, such as changes in usual health behavior, indications of
delayed growth and development, changes in behaviors, or nonproductive or
dysfunctional behavior.
PTS:1DIF:ModerateREF:p. 61-62
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application
2. Using Maslows hierarchy of needs, rank the following nursing diagnoses in
order of importance, beginning with the highest-priority diagnosis.
1)
Anxiety
2)
Risk for infection
3)
Disturbed body image
4)
Sleep deprivation
ANS: 4, 2, 1, 3
In Maslows hierarchy, physiologic needs and safety are the highest priority. Sleep is a
basic physiologic need. Infection can threaten physical health. In this question, infection
is not present; therefore, there is just a risk for it. Sleep Deprivation is an immediate
problem that affects general physical, mental, and emotional health. Neither Anxiety nor
Disturbed Body image is a physiologic or safety need. Anxiety is a more immediate need
than Disturbed Body Image, so it probably deserves a higher ranking. Remind students
that the ranking would depend on the severity of each problem, which is not known by
the labels alone.
Chapter 4 Evidence-Based Practice: Theory & Research
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which commonly accepted practice came out of the Framingham study? Use
of 1)
Mammography in breast cancer screening
2)
Colonoscopy in colon cancer screening
3)
Pap testing in cervical cancer screening
4)
Digital rectal examination in prostate cancer screening
ANS: 1
One commonly accepted practice that came out of the Framingham study is the link
between mammography and breast cancer. Before the Framingham study, mammography
was considered an unreliable tool in breast cancer screening.
PTS:1DIF:EasyREF:p. 137
KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall
2. Which theorist developed the nursing theory known as the science of
human caring?
1)
Florence Nightingale
2)
Patricia Benner 3)
Jean Watson 4)
Nola Pender
ANS: 3
Dr. Jean Watson developed the nursing theory known as the science of human caring.
Her theory describes caring from a nursing perspective. Florence Nightingale developed
the theory that stated that a clean environment would improve the health of patients. By
changing the care environment, she dramatically reduced the death rate of soldiers. Dr.
Patricia Benners theory described the progression of a beginning nurse who learns to be
an expert nurse. Nola Penders theory on health promotion became the basis for most
health-promotion teaching done by nurses.
PTS: 1 DIF: Easy REF: p. 137
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
3. A patient complains of pain after undergoing surgery. The nurse forms a
mental image of pain based on her own experiences with pain. This mental image is
known as a(n)
1)
Phenomenon
2)
Concept
3)
Assumption
4)
Definition
ANS: 2
A concept is a mental image of a phenomenon, an aspect of reality that you can observe
and experience. In the scenario above, the nurse forms a mental image of pain because of
her past experiences with pain. Phenomena are the subject matter of a discipline. They
mark the boundaries of a discipline. An assumption is an idea that is taken for granted. In
a theory, the assumption is the idea that the researcher presumes to be true and does not
intend to test with research. A definition is a statement of meaning of a term or concept
that sets forth the concepts characteristics or indicators.
PTS: 1 DIF: Moderate REF: p. 138
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application
4. Hildegard Peplau was a nursing theorist whose major contribution to nursing
was 1)
Transcultural nursing
2)
Health promotion
3)
Nurse-patient relationship
4)
Holistic comfort
ANS: 3
Hildegard Peplau was a psychiatric nurse who showed that developing a relationship with
psychiatric patients made their treatment more effective. From her work, she developed the
theory of interpersonal relations, which focuses on the nurse-patient relationship. This
theory is in use every day in nursing.
PTS: 1 DIF: Easy REF: p. 142
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
5. The nurse and other hospital personnel strive to keep the patient care area
clean. This most directly illustrates the ideas of which nursing theorist?
1)
Virginia Henderson
2)
Imogene Rigdon
3)
Katherine Kolcaba
4)
Florence Nightingale
ANS: 4
Florence Nightingale was instrumental in identifying the importance of a clean patient care
environment. During the Crimean War, Nightingale dramatically reduced the death rate of
soldiers by changing the healthcare environment. Virginia Henderson identified 14 basic
needs that are addressed by nursing care. Imogene Rigdon developed a theory about
bereavement of older women after noticing that older women handle grief differently than
do men and younger women. Katherine Kolcaba developed a theory of holistic comfort in
nursing.
PTS: 1 DIF: Moderate REF: p. 141
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
6. A patient who emigrated from India is admitted to the medical step-down unit
with a bowel obstruction. A nasogastric (NG) tube is inserted to decompress her stomach.
She asks the nurse if her daughter can bring in garlic to administer through her NG tube.
The nurse tells the patient that she will ask the physician when she makes rounds. This
nurse is utilizing the theory developed by which nurse theorist?
1)
Betty Neuman
2)
Dorothea Orem
3)
Callista Roy 4)
Madeline Leininger
ANS: 4
The nurse is utilizing the theory developed by Madeline Leininger. Leiningers theory
focuses on the values of cultural diversity. According to her theory, the nurse must make
cultural accommodations for the health benefit of the patient.
PTS:1DIF:ModerateREF:p. 142-143
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
7. According to Maslows hierarchy of needs, which patient need should the
nurse address first?
1)
Protecting the patient against falls
2)
Protecting the patient from an abusive spouse
3)
Promoting rest in the critically ill patient
4)
Promoting self-esteem after a body image change
ANS: 3
According to Maslows hierarchy of needs, basic physiological needs should be met first.
They include the need for rest, food, air, water, temperature regulation, elimination, sex,
and physical activity. Therefore, the nurse should address the critically ill patients need
for rest first.
PTS:1DIF:ModerateREF: p. 144
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
8. A nurse researcher is designing a research project. After identifying and
stating the problem, the nurse researcher clarifies the purpose of the study. Which step in
the research process should she complete next?
1)
Perform a literature review. 2)
Develop a conceptual framework.
3)
Formulate the hypothesis.
4)
Define the study variables.
ANS: 1
After identifying and stating the problem, the nurse researcher should clarify the purpose
of the study. Next, the researcher should perform a literature search to find out what is
already known about the problem. After the literature search, the researcher should choose
a conceptual framework to guide the research, formulate the hypothesis or research
question, and define the study variables.
PTS:1DIF:ModerateREF:p. 151-152
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Comprehension
9. The mother of a child participating in a research study that uses high-dose
steroids wishes to withdraw her child from the study. Despite reassurance that adverse
reactions to steroids in children are uncommon, the mother still wishes to withdraw. By
withdrawing from the study, the mother is exercising which right? The right
1)
Not to be harmed
2)
To self-determination
3)
To full disclosure
4)
Of confidentiality
ANS: 2
The mother is exercising the right to self-determination. This refers to the right of the
participant (or parent in the case of a minor) to withdraw from a research study at any
time and for any reason. The right to not be harmed outlines the safety protocols of the
study. All research participants also have the right to full disclosure. This guarantees the
participants answers to questions, such as the purpose of the research study, the risks and
benefits, and what happens if the patient feels worse as a result of the study. Moreover,
participants also have the right to confidentiality. Typically that right is preserved by
giving participants an identification code rather than associating them by name.
PTS:1DIF:ModerateREF:p. 151
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
10. After suffering an acute myocardial infarction, a patient attends cardiac
rehabilitation. This will help to gradually build his exercise tolerance. According to
Maslows hierarchy of needs, cardiac rehabilitation most directly addresses which need?
1)
Safety and security
2)
Physiological
3)
Self-actualization
4)
Self-esteem
ANS: 2
Cardiac rehabilitation most directly addresses the patients physiological need for physical
activity as well as for health and healing. Indirectly, of course, better physical condition
might enable the patient to perform activities that would lead to higher self-esteem and
even self-actualization.
PTS:1DIF:ModerateREF: p. 144
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Application
11. In his later work, Maslow identified growth needs that must be met
before reaching self-actualization. These needs include
1)
Cognitive and aesthetic needs
2)
Love and belonging needs
3)
Safety and security needs
4)
Physiological and self-esteem needs
ANS: 1
In his later work, Maslow identified two growth needs that must be met before reaching
self-actualization. They include cognitive (to know, understand, and explore) and
aesthetic (for symmetry, order, and beauty) needs. The needs Maslow identified in his
earlier work were physiological, safety and security, love and belonging, esteem, and
self-actualization.
PTS:1DIF:EasyREF: p. 144-145
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
12. The PICO question reads, Is TENS effective in the management of chronic
low- back pain in adults? Which part of this question comes from the I in PICO?
1)
Adults
2)
Management
3)
Pain
4) TENS
ANS: 4
TENS is the intervention (I) in the PICO system. Adults comes from patient (P).
Management comes from the outcome (O). There is no comparison intervention (C) in
this PICO question.
PTS:1DIFifficultREF:p. 152
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application
13. While reading a journal article, the nurse asks herself these questions: What is
this about overall? Is it true in whole or in part? Does it matter to my practice? What is
this nurse doing?
1)
Reading the article analytically
2)
Performing a literature review
3)
Formulating a searchable question
4)
Determining the soundness of the article
ANS: 1
Analytical reading involves questioning the article to be sure you understand it and to
determine whether it is applicable to your practice. Such reading asks these questions:
What is this about as a whole? Is it true in whole or in part? Does it matter to my
practice? A literature review is performed by searching indexes and databases and reading
more than one article. Formulating a searchable question involves creating a PICO-type
statement to guide a search of the literature. The nurse would determine whether the
article is a research report by looking for the individual parts of the article to see if they
were present in the form of research (e.g., title, problem, hypothesis, purpose, methods,
data, data analysis, conclusions).
PTS:1DIF:ModerateREF:p. 153
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application
Completion
Complete each statement.
•
1. Nursing research is based on the method.
ANS: scientific
Nursing research is based on the scientific method. It is the process in which the
researcher, through use of senses, systematically collects observable, verifiable data to
describe, explain, or predict events.
PTS:1DIF:EasyREF:p. 149
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
•
The unit council in the intensive care unit is designing a
research study to see if they are meeting the spiritual needs of their
patients. The study will involve patient interviews after discharge. After
the interview process, the staff will examine patient statements for
research. ANS:
recurring themes. The unit council is conducting
qualitative
The unit council is conducting qualitative research, which focuses on the lived
experiences of people.
PTS:1DIF:ModerateREF:p. 149
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
•
A 56-year-old patient diagnosed with an acute myocardial
infarction (heart attack) makes inappropriate sexual comments to the
licensed practical nurse (LPN). The LPN is visibly upset. The registered
nurse (RN) assigned to the patient informs the patient that his behavior is
unacceptable and will not be tolerated. Is the RN demonstrating holistic or
mechanistic nursing?
ANS: mechanistic
The nurse is demonstrating the mechanistic nursing approach, which focuses on getting
the task done.
PTS:1DIF:ModerateREF:p. 136
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
•
A 23-year-old athlete decides to donate bone marrow for a
child who requires a bone marrow transplant to fight leukemia.
According to Maslows later work, this athlete is fulfilling his need for
.
ANS: self-transcendence
Self-transcendence is the drive to connect to something beyond oneself and to help others
recognize their potential. Donating bone marrow to someone to improve his or her life
fulfills the need for self-transcendence.
PTS:1DIFifficultREF: p. 145
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application
True/False
Indicate whether the statement is true or false.
1. Institutional review boards were created to protect the rights of
research participants.
ANS: T
Every healthcare facility and university that receives federal funding must have an
institutional review board to protect the rights of research participants.
Chapter 5 Life Span: Infancy Through Middle Adulthood
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is providing prenatal counseling for a couple who is trying to
become pregnant. The priority for the nurse is to include which of the following pieces
of information?
1)
Stages of growth and development of the fetus
2)
Recommended schedule of visits to her healthcare provider
3)
Recommended average weight gain during pregnancy
4)
Healthy eating habits before and during pregnancy
ANS: 4
Maternal nutrition is vital to the healthy growth of the fetus. Poor maternal nutrition leads
to an undergrown placenta. A small, poorly functioning placenta and smaller than normal
umbilical cord are the causes for small-for-gestational age (otherwise known as small- fordates) babies. The other options are all things the prospective mother needs to know, but
they would not have an immediate impact on fetal health.
PTS: 1 DIF: Moderate REF: p. 166
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Analysis
2. Which of the following would indicate a 4-year-old child has successfully
gone through Eriksons Stage 3 (Initiative Versus Guilt)? The child
1)
Refrains from hitting a friend 2)
Plays cooperatively with friends
3)
Is able to develop friendships
4)
Is able to express his feelings
ANS: 1
Stage 3 is Initiative Versus Guilt, in which the child becomes responsible for his
behavior, develops self-discipline, and is able to manage his impulses. Cooperation and
expressing feelings are tasks for Stage 2. Children develop friendships during the
preschool age.
PTS: 1 DIF: Moderate REF: dm 163-164
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
3. The nurse is preparing to assess a toddler. To make the assessment go
smoothly, before examining the child the nurse should first
1)
Talk to the mother before talking to the child
2)
Ask the child about his favorite toy
3)
Get the childs height and weight
4)
Ask the mother to undress the child
ANS: 2
Toddlers have a fear of strangers, so it would be important to establish rapport before
examining the child. Although talking to the mother before the child prior to a physical
assessment does not lead to distrust, the action simply does not contribute to building a
rapport with the child. Undressing the child before a trusting relationship is established
often creates anxiety in the child, leading to uncooperativeness, fear, or withdrawal.
Obtaining the childs height and weight would not help the child feel secure.
PTS: 1 DIF: Moderate REF: p. 175
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
4. According to Erikson, a behavior demonstrating an important psychosocial
task for a toddler would be for the child to
1)
Act defiantly by refusing to hold her mothers hand while crossing the street
2)
Recognize that it is wrong to take a toy away from someone else
3)
Be able to understand the concept of time in hours
4)
Express to his parents and playmates that he does not like something
ANS: 1
The primary task during Eriksons stage 2, Autonomy Versus Shame and Doubt, is
establishing an identity as separate from the parent/caregiver. A child between 18 months
and 3 years typically tests the boundaries as part of exercising his will to control his
environment. No is a declaration of independence and a bid for increased autonomy. Acts
of independence and autonomy (e.g., refusing to hold her mothers hand) are normal during
this developmental stage. The toddler should be able to tolerate time away from her
parents, delay gratification, and have elimination control. The other tasks are accomplished
during the preschool stage.
PTS: 1 DIF: Moderate REF: p. 163
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
5. A mother comes to the clinic with her infant for a newborn checkup at 1 week of
age. The mother tells the nurse, My baby looks yellow to me. The nurses best response is
which of the following?
1)
What type of detergent are you using to wash the baby clothes?
2)
Is there a possibility you had hepatitis during your pregnancy?
3)
The color is from the breakdown of maternal red blood cells.
4)
There is a cream you can use to reduce the yellowing.
ANS: 3
Jaundice results from the breakdown of the maternal red blood cells that are in the babys
system after birth, which elevates the bilirubin in the serum. If detergent caused a reaction,
the reaction would commonly present as a rash. Although hepatitis B virus may pass
through the placenta to the fetus, the infant does not typically show signs at 1 week of life.
If treatment becomes necessary, the infant would receive phototherapy; there is no cream
to reduce the yellow appearance related to newborn jaundice.
PTS: 1 DIF: Moderate REF: p. 170
KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level: Application
6. A father brings his toddler to the clinic for well-child care. Which of
the following would be most important for the nurse to assess?
1)
How successful the child is with potty training
2)
How the child acts when you enter the room
3)
Whether the child is using eating utensils
4)
Whether the home is child-proofed
ANS: 4
Although all of these areas address important developmental tasks during the toddler
period, safety is the highest priority at this age because the child has increased dexterity,
mobility, and determination and is becoming more independent. Potty training is typically
accomplished between 18 months and 3 years of age but is not a safety concern. It would
be normal for a child at this age to be afraid of strangers. The child should be using
utensils for most foods, but again it is not a safety concern.
PTS: 1 DIF: Moderate REF: dm 174-175
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Analysis
7. Which comment made by a woman in her early 50s would be a cue indicating
the need for further assessment for a problem?
1)
My skin is so dry I need to use lotion every day after I bathe.
2)
I have episodes when I feel really hot even when others are not.
3)
Its getting harder to lift those big bags of dog food.
4)
I have to write myself notes because Im getting so forgetful.
ANS: 4
Memory in middle adulthood should remain intact. There is a normal decrease in skin
moisture and muscle tone in middle adulthood. The perimenopausal period occurs during
this time, hallmarked by hot flashes and night sweats.
PTS: 1 DIF: Moderate REF: dm 189-191
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
8. The nurse has instructed a group of parents on common adolescent
behavior. Which comment by the parent would indicate the most urgent need for
further discussion?
1)
I guess my daughter wont be asking my opinion very much.
2)
Im really going to watch my daughters eating habits.
3)
We are really going to have to think about rules we want to enforce after he gets his
drivers license.
4)
We dont keep alcohol in the house, so thats at least one thing we dont need to worry
about.
ANS: 4
Concerns about alcohol intake during adolescence is highest priority, regardless of
whether or not it is stored in the home. Alcohol-related injury and death are a risk that
should be avoided in every circumstance. Not having alcohol in the house does not
guarantee the teenager wont consume it with his friends. During the teen years, the
relationships among peers strengthen and strongly influence adolescent behavior.
Although the parents typically still maintain influence on the core values in the home,
teens seek peers opinions for matters about social life or concerns of everyday living. As
teens are developmentally concerned with appearance and social relationships, there can
be an overemphasis on body image, leading to obesity, as well as eating disorders. Motor
vehicle accidents are the leading cause of death for teenagers, typically due to
distractibility, inattention, impulsiveness, and inexperience in various driving situations.
PTS: 1 DIF: Moderate REF: p. 183
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis
9. Which of the following would be the priority for most adolescents?
Being 1)
A good student
2)
Sexually active
3)
Picked to be on the soccer team
4)
Able to function independently
ANS: 3
The developmental task during adolescence is to establish personal identity. Socially,
preteens and teens are driven by a need to belong to a group. School-age children need to
receive positive reinforcement for accomplishments and desired behavior, such as being
good students. Although a small number of preadolescents are sexually active, it is not the
major focus for this age. Functioning independently is a task for the young adult.
PTS: 1 DIF: Moderate REF: p. 182
KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis
10. During adolescence, it would be most important to encourage the teen to
eat plenty of
1)
Grains
2)
Dairy products
3)
Vegetables
4)
Fruit
ANS: 2
Both males and females experience a growth spurt during adolescence. Although the
childs diet should include adequate amounts of all the food groups, peak bone mass is
attained during this stage, so the child needs to consume adequate calcium, vitamin D,
iron, and protein. These nutrients are found in dairy products.
PTS: 1 DIF: Easy REF: dm 181-182
KEY: Nursing process: Implementation | Client need: HPM | Cognitive level: Application
11. According to Erikson, which of the following must a middle-aged adult do to
be prepared for the final stages of life?
1)
Accept the fact that she is getting older.
2)
Reconcile that death is a part of life.
3)
Feel she has made a contribution to society.
4)
Have had a meaningful and intimate relationship.
ANS: 3
Generativity Versus Stagnation is the stage Erikson describes for the middle adult. During
this stage, a mature adult either continues to gain skills, be productive, and pass on his or
her knowledge to the next generation or stagnates. During the middle years, many adults
are realistic and insightful about age-related physical and emotional changes. Others
experience difficulty coping with passing youth and advancing age. Accepting death as a
part of the continuum of life is a task for the older adult. Developing meaningful
relationships is a task most influential for the young adult.
PTS: 1 DIF: Moderate REF: p. 190
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall
12. The nurse teaches a mother of a preschool-age child about expected
development. Which comment by the parent indicates that she understands the
information?
1)
She understands the monsters in books are not real.
2)
When I mention that her birthday is in a week, she understands.
3)
I am saving to buy her the roller skates shes been asking for.
4)
I cant expect her to understand when a friend doesnt agree with her.
ANS: 3
Preschoolers hand-eye coordination develops markedly during this period. They can hop
on one foot, skip, and begin to learn to skate. The imagination of a preschool-age child is
typically active, whereby they have fears of mythical figures, such as monsters. They have
a limited ability to understand the concept of time or to tell time. A preschooler has the
ability to consider simple viewpoints of other people.
PTS: 1 DIF: Moderate REF: p. 176
KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application
13. A mother has brought her 8-month-old daughter to the healthcare clinic for
a well-child appointment and any needed immunizations. To assess the childs physical
development with age-appropriate norms, which of the following questions should the
nurse ask?
1)
Is your child able to walk while holding onto furniture?
2)
Is your child able to crawl on her hands and knees?
3)
Is your child able to pick up food with her fingers?
4)
Is your child able to sit up without support?
ANS: 4
At 7 months, most children can sit up by themselves. Cruising usually occurs around 8 to
12 months. At about 7 to 10 months, a child begins to crawl. Infants develop a pincer
grasp around 10 months.
PTS: 1 DIF: Moderate REF: p. 171
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
14. A mother comes to the healthcare clinic for a regular health examination for
her 5-year-old son prior to kindergarten admission. Which comment by the mother would
indicate the need for follow-up questions to the mother?
1)
Hes not a good boy like my other son.
2)
Ive had to treat him for lice a couple of times.
3)
He has an imaginary friend he calls Buddy.
4)
Hes so funny when he imitates his dad doing things.
ANS: 1
Negative comments or comparisons with another child can be an indicator of or potential
for child abuse. The nurse needs to determine whether this is an actual problem. Head lice
are a common health problem for children of this age because of close physical contact
with play. The mother seems to have a healthy attitude about the infestations and to be
knowledgeable in the treatment. Imaginary play, magical thinking, and belief in mythical
figures are normal at age 5. A child this age will normally imitate the same-sex parent.
PTS: 1 DIF: Difficult REF: p. 177
p. 82
KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis
15. Which behavior by the mother is most likely to help the infant to develop
trust? 1)
Talking to the infant 2)
Breastfeeding instead of bottle-feeding
3)
Promptly responding to the infants crying
4)
Having the infant sleep in the same room with the parent
ANS: 3
Because the infant is totally dependent on the parents, quickly responding to his cries
promotes attachment and trust. Although all options may promote attachment, they are not
absolutely necessary for bonding to occur. Mother-infant attachment is complex and
involves all sensesnot simply hearing the mother talk to him. There are physical and
emotional benefits to breastfeeding, but it is not necessary for mother-infant attachment.
Sleeping in the same room may help the parent respond more quickly to the infants needs
but is not the basis for attachment.
PTS: 1 DIF: Moderate REF: p. 171
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension
16. The nurse is talking to a class of children, ages 9 to 11 years. For this age
group, it would be most important for the nurse to discuss
1)
Safe sex practices
2)
Healthy food choices
3)
Use of seat belts and safety equipment
4)
The importance of getting enough sleep
ANS: 3
All are important topics to discuss with this age, but children of this age are very active,
and injuries are common. Motor vehicle accidents are the most common cause of injury.
They are just starting puberty, so sexual activity is still not usual. The discussion of
appropriate food choices and getting enough sleep should be done throughout the childs
developmental stages; it is not peculiar to ages 10 to 12 years. The preteen years are
particularly important for adequate sleep and rest primarily because of the physical
changes, active social lives, and increasingly complex demands on their lives.
PTS: 1 DIF: Moderate REF: p. 181
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
17. A 38-year-old client comes into the clinic for a health examination. Knowing
the psychosocial development tasks and common health problems for this age group, it
would be most important for the nurse to ask
1)
If the client has episodes of feeling depressed
2)
Whether the client practices safe sex
3)
About the clients exercise habits
4)
About the health history of the clients parents
ANS: 1
Striving to be self-sufficient and successful and to establish a career and family are the
tasks for this age. These tasks are demanding and can be emotionally difficult and
potentially cause depression. Untreated depression is a leading cause of death among
young adults. Sexually transmitted infections are a risk for this age group but are not as
severe a threat as depression. Exercise is important to overall health but is not a source of
stress. There are genetic health problems that can impact the client.
Chapter 6 Life Span: Older Adults
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which of the following is the most common major challenge for older
adults? 1)
Dealing with the needs of their children
2)
Chronic health problems leading to the loss of independence
3)
Loss of the ability to reminisce about the past
4)
The decline of intellectual abilities
ANS: 2
Older adults have many losses to deal with, including the development of chronic health
concerns and loss of independence. During the older adult years, children often provide
care for their aging parents. Loss of short-term memory is more common than recollection
of events involving long-term memory. Older adults have vivid memories of past events.
Intellectual abilities do not become impaired with age; short-term memory and reaction
time decline.
PTS: 1 DIF: Moderate REF: p.205
KEY: Nursing process: N/A | Client need: PHSI/PSI | Cognitive level: Comprehension
2. Which of the following would be the most important health assessment focus
for older adulthood?
1)
Cancer screening with the annual health examinations
2)
Seeking information about consistent use of seat belts
3)
Screening for eating disorders
4)
A bone scan (DEXA test) for osteoporosis
ANS: 1
Chronic diseases, including cancer, are major health problems for older adults. In fact,
cancer is the second leading cause of deaths for older adults. Older adults should also
have an annual physical exam; they should receive cancer screening at that time. Habits
for seat belt use should have already been established; although it may be important to
reinforce seat belt use, the most important assessment is cancer screening. Eating
disorders are more common in adolescence and young adulthood. Although loss of bone
density is fairly common in older adults and can be pathological, it does not assume the
status as cancer with regard to mortality for older adults.
PTS: 1 DIF: Difficult REF: dm 211-212
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension
3. To which age group do most hospitalized patients
belong? 1)
Infants
2)
Young adults
3)
Middle adults
4)
Older adults
ANS: 4
Half of all hospitalized patients are older adults.
PTS: 1 DIF: Easy REF: p. 202
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall
4. Which of the following reflects an understanding of the characteristics of
older adults?
1)
Fewer than 5% of all older adults live in nursing homes.
2)
Average life expectancy at birth has declined slightly over the past 10 years.
3)
In general, males tend to live longer than do females.
4)
Black men have the lowest life expectancy, but the gap decreases as a person ages.
ANS: 1
Only 3.3% of people 65 and over live in nursing homes; this rises to 15% for those over
85 years. In the United States, life expectancy at birth has risen dramatically in the past
century: In 1900, average life expectancy was 49.2 years; in 2005, average life
expectancy was 77.8 years. At age 65, white women led life expectancy with 20 years,
followed closely by black women at 18.7 and white men at 17.2 years, whereas black
men at age 65 had the lowest life expectancy at 15.2. The disparity in death rates for
people of different races is less for older adults than younger ones.
PTS: 1 DIF: Moderate REF: p. 206
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension
5 A 75-year-old white female patient says, Ive heard that women live to an older
age than men do. My husband and I are the same age, so I am afraid I will have to spend
some years without him. That really worries me. Which response is based on correct
information?
1)
That is a realistic concern, as women do have a longer life expectancy than men. But
many things can happen to change that.
2)
You need not worry, because both you and your husband are white. That statistic is true
only for black men and women.
3)
It is true that women have a longer life expectancy at birth. However, life expectancy
measured at age 65 is almost the same for both sexes. You are both well past 65.
4)
That is true only in certain geographical areas, such as those with a high population of
newly retired persons.
ANS: 3
For infants born in 2005, the average total life expectancy for females is 80.4 years.
Life expectancy measured at age 65 was nearly the same for men and women in 1900;
however, women had a lead of about 3 years over men in 2005, narrowing the gap as men
age. So the longer men live, the longer they will live. The statistics are true for white
people as well as black people. The answer saying, That is a realistic concern . . . is only
partially true. Women do have a longer life expectancy at birth, but that tends to almost
disappear after men reach age 65, and it continues to lessen as they continue to age. Inmigration and out-migration have nothing to do with gender differences in life
expectancy, although they do affect the population distribution within a state, for
example.
PTS: 1 DIF: Difficult REF: p. 202
KEY: Nursing process: Implementation | Client need: HPM | Cognitive level: Application
6 An 86-year-old patient had prostate surgery 2 days ago. Which nursing action
best meets his developmental needs?
1)
Perform a spiritual assessment and make referrals as needed.
2)
Provide a complete bed bath and other hygiene needs.
3)
Encourage the patient to perform self-care as much as possible.
4)
Administer pain medications to keep the patient comfortable.
ANS: 3
An important nursing goals for all older adults should be to maintain the persons ability to
function independently for as long as possible. Encouraging self-care will help to achieve
that goal. A spiritual assessment is appropriate but is not a need of older adults any more
than of other age groups. Providing hygiene needs does not promote independence.
Administering analgesics is appropriate but does not encourage functional independence.
PTS: 1 DIF: Moderate REF: Cp. 212
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application
7. A client tells the nurse, I cant see well enough to read anymore. I have
new glasses, but its still hard. What should the nurse advise her to do first?
1)
Go back to the eye doctor and have him check your glasses.
2)
Buy some audio books and listen to those.
3)
Adapt to reading less and find a new leisure activity.
4)
Install a bright but glare-free light near where you read.
ANS: 4
With aging, there is decreased pupil accommodation, decreased tear production, and
thickening of the lens of the eye. All of these contribute to impaired near vision
(presbyopia). Decrease in pupil accommodation allows less light into the eye, so in order
to read, the person needs a good light. However, there is also increased sensitivity to glare,
so the light should have a glare-free bulb. The patient should try this first, since she
already has new glasses. If this doesnt help, then perhaps she should have the glasses
rechecked. If her vision cannot be improved, then she could think about buying audio
books and other ways to adapt to her difficulty reading.
PTS: 1 DIF: Moderate REF: Cp. 214
KEY: Nursing process: Implementation | Client need: HPM | Cognitive level: Application
8. A couple is planning to move to a housing development that has been built to
provide elder-friendly dwellings and environments for independent living. The houses are
smaller and on a single level. Their purchase includes home maintenance and repair, snow
and trash removal, a pool, and a walking track. Only people 60 years and older qualify to
buy a house in this community. Medical and nursing care are not a part of the purchase.
How would their living situation be described?
1)
Naturally occurring retirement community
2)
Retirement community
3)
Continuing care retirement community 4)
Assisted living facilities
ANS: 2
The scenario describes a retirement community. A naturally occurring retirement
community is one in which the person ages in place, living in the same home as always
and in a neighborhood where the neighbors have aged together and have provided support
for each other through the years. A continuing care retirement community is residential
living (e.g., cottages, cluster homes, apartments) into which a person must move. The
person pays an entrance fee and monthly fees. In return, the contract provides for
assistance with activities of daily living, coordinated social activities, health monitoring,
and so on. There is usually a health clinic on site. Assisted living facilities (ALFs) are
congregate residential settings that provide or coordinate personal services, 24-hour
supervision and assistance (scheduled and unscheduled), activities, and health- related
services. State regulations and level of services preclude residents from staying in an ALF
when their needs become greater than the resources and services provided.
PTS: 1 DIF: Moderate REF: p. 205
KEY: Nursing process: Implementation | Client need: HPM | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. A client is concerned about the age-related changes of her mother, who is 80
years old. Which statement(s) made by the client would likely represent a normal change
of aging?
1)
My mother seems to get cold very easily.
2)
My mother complains of her mouth being dry.
3)
Mother goes around the house turning on all the lights.
4)
Mother complains of leaking urine when she coughs.
ANS: 1, 2, 3
Incontinence is not a normal part of aging and should be explored further. The thinning of
the layers of the skin causes older adults to feel colda normal part of aging. With aging, the
brown fat layer, which contributes to generating and maintaining body temperature,
becomes thinner as well. This is not the same type of fat as adipose, which is a white fat
layer. Additionally, older adults who are sedentary often feel cooler. The elderly normally
experience a decrease in saliva production, so although this is also a symptom of
dehydration, dry mouth is a normal change of aging. Visual acuity decreases with age, but
this, too, is a normal part of aging.
PTS: 1 DIF: Moderate REF: dm 208-209, 214
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
2. A client lives alone. He is very weak, stays in bed most of the time, and becomes
fatigued after taking only two or three steps with a walker. His personal hygiene is poor.
He moves very slowly when doing even small tasks, such as eating a meal. Which of the
following are appropriate interventions for this patient? Choose all that apply; assume all
are possible.
1)
Arrange for a home aide to assist with activities of daily living.
2)
Refer the client to a senior center for an adapted physical activity (APA) program.
3)
Assess the patient for symptoms of depression and memory loss.
4)
Arrange for nutritious meals to be delivered to the patients home.
ANS: 1, 3, 4
This client has the characteristics of frailty: low physical activity, muscle weakness,
fatigue, and slowed performance. Clearly, the client is not able to perform ADLs
adequately; therefore, a home aide is needed. Adapted physical activity programs are
designed for adults in better physical health, not for frail elders. The client would be
unlikely to benefit from an APA and probably could not even participate in such a group
activity. Depression and impaired mental abilities tend to accompany frailty, so it is
important to assess those for this client. Nutrition is essential to slow the progression of
frailty, so having meals delivered is both appropriate and important.
PTS: 1 DIF: Difficult REF: dm 214-216
KEY: Nursing process: Interventions | Client need: PHSI/PSI | Cognitive level:
Application
3. When interpreting a population pyramid, which of the following do you need
to know?
1)
The youngest age group makes up the base of the pyramid.
2)
Men are on the left side of the pyramid and women on the right.
3)
The length of a bar indicates how many people are in that age category.
4)
Adolescents are the youngest group on the pyramid.
ANS: 1, 2
Age distribution of a population is often illustrated in a pyramid, with the youngest age
group (04) at the base and the oldest age group (85+) at the peak, and men on the left of
the figure and women on the right. The shape of a population pyramid changes to
rectangle in developed countries with fewer births and increased life expectancy. The
length of a bar does not indicate the absolute number of people in a category; it indicates
the proportion of the total population represented by that category.
PTS: 1 DIF: Difficult REF: dm 203-204
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension
4. How can the nurse facilitate communication with an older
adult? 1)
Assess for hearing deficit at the beginning of the interaction.
2)
Speak in a more loudly than normal, and at a slightly higher pitch.
3)
Pay special attention to cues from body language.
4)
Speak slowly, allowing time for the patient to word his answers.
ANS: 1, 3, 4
The nurse should check for sensory deficits at the beginning of the interaction so he can
allow for lip reading, as needed. Because older adults sometimes have difficulty
expressing themselves, body language (e.g., wringing hands, fidgeting) is especially
important. Because older adults process information slowly, the nurse should speak
slowly, allowing them to formulate their answers. Speaking slowly does not mean the
nurse should speak loudly or at a higher pitch. Many older adults have high-pitch hearing
loss.
PTS: 1 DIF: Moderate REF: p. 214
KEY: Nursing process: Implementation | Client need: HPM | Cognitive level:
Comprehension
5. Which older adult is experiencing normal aging changes of the urinary
system? 1)
A man who has difficulty voiding, especially when starting his stream
2)
A woman who wakes up to void once during the night
3)
A man who has difficulty getting a hard erection
4)
A man who says he has burning when he urinates
ANS: 2, 3
Because of changes in bladder capacity and changes in blood flow to the kidneys, many
older adults wake at least once during the night to void. Sexual response changes are also
normal; it is common for older adult men to have less firm erections. A man who has
difficulty starting his urine stream and voiding likely has an enlarged prostate, which is
physiologically not normal. Burning on urination is indicative of a bladder infection and is
not normal.
Chapter 7 Experiencing Health and Illness
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. In an effort to promote health, the home health nurse opens the clients bedroom
windows to let in fresh air and sunlight, washes her hands often, and teaches the patient
and family about the importance of hygiene and cleanliness. This most closely illustrates
the ideas of which of the following people?
1)
Jean Watson 2)
Jurgen Moltmann
3)
Florence Nightingale
4)
Robert Louis Stevenson
ANS: 3
Florence Nightingale believed that health was prevention of disease through the use of
fresh air, pure water, efficient drainage, cleanliness, and light. Jean Watson believes that
health has three elements: a high level of overall physical, mental, and social functioning;
a general adaptive-maintenance level of daily functioning; and the absence of illness (or
the presence of efforts that lead to its absence). Jurgen Moltmann believes that true health
is the strength to live, the strength to suffer, and the strength to die. He also stated that
health is not a condition of the body; it is the power of the soul to cope with the varying
condition of that body. Robert Louis Stevenson wrote that health is not a matter of holding
good cards; it is playing a poor hand well.
PTS: 1 DIF: Easy REF: p. 222
KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall
2. Which of the following is known to be a healthy strategy for coping with
stress? 1)
Performing meaningful work
2)
Consuming simple carbohydrates
3)
Drinking three glasses of red wine each day
4)
Weight training
ANS: 1
Many individuals find that meaningful work is a healthy way to cope with stressors.
Consuming simple carbohydrates is not a healthy way to cope with stress. Drinking more
than one glass of red wine each day is considered unhealthy. Weight training has been
shown to increase bone density and reduce the risk of osteoporosis and heart disease but
not necessarily to reduce stress.
PTS:1DIF:ModerateREF:p. 225
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application
3. Which family would most likely be helpful in encouraging the client
to experience a high level of wellness? A family who
1)
Controls feelings to avoid conflict
2)
Teaches negotiation skills and independence
3)
Encourages risk taking and adventure
4)
Views themselves as helpless victims
ANS: 2
Families who promote independence and teach good negotiation skills enable family
members to experience a high level of wellness by thinking for themselves. In contrast,
families who tend to squelch personal feelings to avoid conflict may not allow a high
level of wellness. Families who emphasize caution in new situations are more beneficial
than those who encourage risk-taking. Families who view themselves as capable and
successful are more advantageous than those who view themselves as helpless victims.
PTS:1DIF:EasyREF:p. 225
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
4. The client is a 76-year-old man who is experiencing chronic illness. He has a
genetic-linked anemia. He says he does not eat a balanced diet, as he prefers sweets to
meat and vegetables. Which of the following dimensions of health can the nurse most
likely influence by teaching and counseling him?
1)
Age-related changes
2)
Genetic anemia
3)
Eating habits
4)
Gender-related issues
ANS: 3
The nurse is most likely to influence the patients eating habits because those are the
dimension over which he has the most control and, therefore, has the most potential for
changing. Although people consider biological factors when they describe themselves as
well or ill, they are not entirely within our control. Biological factors include age and
developmental stage, genetic makeup, and sex.
PTS:1DIF:EasyREF:p. 224
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application
5. What type of loss is most common among patients who are hospitalized
for complex health conditions?
1)
Privacy
2)
Dignity
3)
Functional
4)
Identity
ANS: 2
Hospitalized patients commonly experience the loss of dignity. Wearing a hospital gown,
having their body exposed, invasive procedures, loss of control over body functionsall of
these contribute to loss of dignity, and all are very common among hospitalized patients.
Healthcare providers have a duty to protect privacy and confidentiality of patients, even
though it is certainly threatened by some situations during hospitalization. Some patients
lose functioning and identity during hospitalization, but they are not common occurrences.
PTS:1DIF:ModerateREF:p. 227
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension
6. A 62-year-old patient is admitted to the hospital with hypertension.
Which question by the nurse is most important when performing the initial
assessment interview?
1)
What medications do you take at home?
2)
Do you have any environmental, food, or drug allergies?
3)
Do you have an advance directive? 4)
What is the greatest concern you are dealing with today?
ANS: 4
It is most important for the nurse to ask the patient about his greatest concern. His
concern can then be incorporated into the plan of care, making sure that his needs are
met. Asking about medications, allergies, and an advance directive is also important but
does not take priority over asking about the patients greatest concern.
PTS:1DIF:ModerateREF:p. 231
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis
7. When developing goals, which guideline should the nurse keep in mind?
Goals should be
1)
Realistic so that progress is recognized by the patient
2)
Developed solely by the healthcare team
3)
Developed without family input, to maintain confidentiality
4)
Valued by the multidisciplinary care providers
ANS: 1
Goals should be realistic so that progress is recognized by the patient. They should be
valued by both the patient and family. The nurse should develop goals with input from
the patient and his family.
PTS:1DIF:ModerateREF:p. 231
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension
8. Which one of the following important nursing actions is a hospitalized patient
likely to experience on an emotional level and remember long after this hospitalization
has ended?
1)
Administering her medications according to schedule
2)
Allowing flexible visitation by her family and friends
3)
Explaining treatment options in terms she can understand
4)
Providing a healing presence by listening and being attentive
ANS: 4
The nurse can contribute meaningfully to the patients hospitalization by providing a
healing presence. The nurse can do this by listening to the patient and being attentive.
Administering medications according to schedule, allowing flexible visitation, and
explaining treatment options are important contributions that the nurse can make, but they
will not be most meaningful to the patient. Patients may be impressed, even amazed, by
the healthcare technology used to diagnose and treat their illnesses. However, often what
they remember, perhaps through the rest of their lives, is the people who connected with
them in a personal way.
PTS:1DIF:ModerateREF:p. 232
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension
9. Which statement best describes the health/illness
continuum? 1)
Health is the absence of disease; illness is the presence of disease.
2)
Health and illness are along a continuum that cannot be divided.
3)
Health is remission of disease; illness is exacerbation of disease.
4)
Health is not having illness; illness is not having health.
ANS: 2
The health/illness continuum is best described as a graduated spectrum that cannot be
divided.
PTS:1DIF:ModerateREF:p. 223
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension
10. Which of the following helps the body release growth hormone (growth
hormone assists in tissue regeneration, synthesis of bone, and formation of red blood
cells)?
1)
A healthy diet
2)
Physical activity
3)
Restful sleep
4)
Comfortable room temperature
ANS: 3
During sleep, our bodies release the majority of our growth hormone, which assists in
tissue regeneration, synthesis of bone, and formation of red blood cells. Consuming
healthy foods helps prevent disease. Physical activity reduces the risk of chronic disease
and promotes longevity. Keeping the body at a comfortable temperature helps maintain
health but not release of growth hormone.
PTS:1DIF:ModerateREF:p. 224
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
11. A client has been hospitalized for 6 weeks. All of the following interventions
are good ones, but which intervention is specifically focused on helping the patient cope
with the emotional responses to prolonged hospitalization?
1)
Providing skin care every shift to prevent skin breakdown
2)
Encouraging the patient to get up in a chair to eat meals
3)
Assisting the patient to ambulate in the hallway for several minutes each day
4)
Designating a corner of the patients room to display personal mementos
ANS: 4
The patients environment can help nourish wellness. Helping the patient designate a corner
of the room to display personal mementos can be healing and help the patient cope with
the prolonged hospitalization. The other interventions might be helpful to the patient but
are not as helpful in specifically dealing with hospitalization as is designating a portion of
the room that is uniquely hers.
PTS:1DIF:ModerateREF:p. 226
KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application
12. Which of the following is particularly valuable in helping a patient with
a terminal illness maintain a sense of self?
1)
Family relationships
2)
Spirituality
3)
Nutrition
4)
Sleep and rest
ANS: 2
When a patient is faced with a terminal illness, spirituality can help the patient maintain
his sense of self. Family relationships can provide a loving, supportive source of comfort
and reassurance but can sometimes cause the patient pain and a feeling of loneliness when
faced with a terminal illness. Nutrition, sleep, and rest are healing but usually not as
helpful to a patient with terminal illness as is spirituality.
PTS:1DIFifficultREF:p. 226
KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall
13. A client with a history of schizophrenia is diagnosed with a urinary
tract infection. What is probably the most significant barrier this patient faces?
1)
Chronic urinary incontinence 2)
Stigma associated with mental illness
3)
Risk for recurring infections
4)
Auditory hallucinations (hearing things)
ANS: 2
Mental illness is associated with a stigma that is usually a barrier, and even considered a
debilitating handicap. Chronic urinary incontinence is not commonly associated with
urinary tract infection, and nothing in the scenario suggests that the patient is incontinent.
The patient is at risk for recurring urinary tract infections, but this is not considered a
debilitating handicap. Auditory hallucinations are associated with schizophrenia but have
not been described as the most debilitating handicap.
PTS:1DIF:ModerateREF:p. 226
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application
14. A 76-year-old patient is admitted with an acute myocardial infarction (heart
attack). The doctor tells the patient that an angioplasty is necessary. The patient agrees
and signs the informed consent. This patient is experiencing which stage of illness
behavior?
1)
Sick-role behavior 2)
Seeking professional care
3)
Experiencing symptoms 4)
Dependence on others
ANS: 4
This patient is experiencing the dependence-on-others stage of illness behavior; he has
accepted the diagnosis and treatment of the healthcare provider. The patient entered the
experiencing illness stage when he began having chest pain at home. He entered the sickrole behavior phase when he admitted to family that he was experiencing chest pain.
When he decided to go to the emergency department for healthcare intervention, he
entered the seeking-professional-care stage of illness.
PTS:1DIF:ModerateREF:dm 228-229
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis
15. Many health providers define illness as pathology; however, people experience,
rather than define, illness. Which of the following is how most people experience illness?
1)
Feeling lousy, a true sense of not being all right
2)
A change in the way they feel or a disruption in their typical life
3)
Something to be dreaded and avoided if at all possible
4)
An experience that offers the potential for learning and spiritual growth
ANS: 2
People typically describe their illness in terms of how it makes them feel or the effect it
has on day-to-day life. Feeling lousy is inappropriate as many people do not feel lousy
when they are ill. For example, hypertension is an illness that may have no symptoms.
Similarly, patients may have chronic disease that is well managed and therefore does not
make them feel ill. Something to be dreaded and avoided . . . is also not accurate. If a
person has an external locus of control, he may view illness as a consequence of actions
taken. From this viewpoint, he may have little control over whether he can avoid illness.
Finally, although some people do grow and learn in the face of illness, most people do not
hold such a positive view about illnessand the question asks how
people experience illness.
PTS:1DIF:ModerateREF:p. 222
KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall
16. Dunn believes that an individuals state of health should be evaluated in
the context of the persons environment. This approach illustrates that
1)
An unhealthy physical environment, characterized by poor living conditions, always has
a negative effect on an individuals health
2)
Adequate income, food, and shelter create a healthful environment and always improve
physical health status
3)
Physical environment, family, and social support may help or hinder the health status of
an individual
4)
The environment that should always be assessed is the clients immediate surroundings;
extended boundaries do not apply in an ill state
ANS: 3
The home environment, community, family, friends, and support system all influence
health status. The balance among these variables has a net positive or negative effect on a
clients health status. The effect of poor living conditions may be offset by the presence of
loving family and friends. Poverty does not always have a negative effect on health.
Similarly, the presence of food, shelter, and clothing does not always convey protective
health, as loneliness and hopelessness may counteract these positive influences. When
examining the clients environment, extended boundaries must be considered, especially
when providing community-based care.
PTS:1DIFifficultREF:p. 223
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
17. Some people readily become ill when under stress. Others are able to deal with
tremendous stress and remain physically and mentally healthy. This disparity is affected
by a persons level of hardiness. How can you apply this knowledge to your nursing care?
1)
You cannot use this information at all. People are innately hardy or not. This is
something that you must merely recognize.
2)
You should encourage all people to develop some level of hardiness in order to get
through difficult physical and emotional times.
3)
You should assess for your own level of hardiness: If you are hardy, you will be a better
nurse; if you are not, you can learn more about hardiness.
4)
You can assess for hardiness in patients; you can encourage hardy patients to learn about
their illness as a means for them to be more comfortable.
ANS: 4
Hardiness is a personality trait that helps many cope with stress and illness. As a
personality trait, it is unlikely that you can teach or otherwise encourage this trait.
Awareness of your own level of hardiness will help you understand your response to
stress, but hardiness does not necessarily make you a better nurse.
PTS:1DIFifficultREF:p. 229
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
18. When preparing a room to receive a newly admitted patient, which of
the following should the nursing assistive personnel (NAP) do?
1)
Mop the floor with an approved disinfecting solution.
2)
Fold the top bed linens back to open the bed.
3)
Hook up the suction machine and check to see that it is working.
4)
Position the bed in its lowest position.
ANS: 2
The NAP should create an open bed. The housekeeping department is almost always
responsible for cleaning the room between patients. The nurse is responsible for hooking
up and checking special equipment such as suction. The nurse would need to tell the NAP
whether the patient is to be admitted ambulatory, by wheelchair, or by stretcher to know
whether to position the bed high or low.
PTS:1DIF:ModerateREF:p. 233
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
19. When transferring a patient from a hospital to a long-term care facility, which
of the following is most helpful in facilitating the patients planning and emotional
adjustment?
1)
Notify the patient and family as much in advance of the transfer as possible.
2)
Send a complete copy of the patients medical records to the new facility.
3)
Carefully coordinate the transfer with the long-term facility to keep it smooth.
4)
Help arrange for transportation and accompany the patient to the transport vehicle.
ANS: 1
Notifying the patient and family well in advance of the transfer allows them time to adjust
emotionally and to make any necessary plans. A copy of the records is usually sent, and
the nurse does coordinate the transfer with the receiving facility; however, that does very
little to assist with the patients emotional status or planning. Someone from the hospital
may accompany the patient to the car; or if the transfer is by ambulance, perhaps not.
Either way, that will not help the patient and family to do the necessary planning for the
transfer.
PTS: 1 DIF: Moderate REF: p. 233
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
20. A 36-year-old mother of three small children has had nausea, vomiting, and
extreme fatigue for the past 2 days. She calls her mother and tells her she is ill and asks if
her mother can care for the children. Which stage of illness behavior is she experiencing?
Choose all that apply.
1)
Sick-role behavior 2)
Dependence on others
3)
Seeking professional care
4)
Experiencing symptoms ANS:
1
The 36-year-old mother is assuming sick-role behavior because she is identifying herself
as ill. She is also in the stage of experiencing symptoms; she is experiencing symptoms
and realizes that illness is starting, even though she has not yet entered the stages of
dependence and seeking professional care. By telling her mother of the illness, she is
relieved of her normal dutiescaring for her children. Dependence on others occurs when
the client accepts a diagnosis and treatment from the healthcare provider. Seeking
professional care occurs after the sick-role behavior stage. During this stage, the client
makes the decision that she is ill and that professional healthcare is needed.
Chapter 8 Stress & Adaptation
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1.When released in response to alarm, which of the following substances promotes
a sense of well-being?
1)
Aldosterone
2)
Thyroid-stimulating hormone 3)
Endorphins
4)
Adrenocorticotropic hormone
ANS:3
Endorphins act like opiates to produce a sense of well-being; they are released by the
hypothalamus and posterior pituitary gland in response to alarm. Aldosterone promotes
fluid retention by increasing the reabsorption of water by renal tubules. Thyroidstimulating hormone increases the efficiency of cellular metabolism and fat conversion to
energy for cell and muscle needs. Adrenocorticotropic hormone stimulates the adrenal
cortex to produce and secrete glucocorticoids and mineralocorticoids.
PTS:1DIF:ModerateREF:p. 253
KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
2.After sustaining injuries in a motor vehicle accident, a patient experiences a
decrease in blood pressure and an increase in heart rate and respiratory rate despite
surgical intervention and fluid resuscitation. Which stage of the general adaptation
syndrome is the patient most likely experiencing?
1)
Alarm
2)
Resistance
3)
Exhaustion
4)
Recovery
ANS:3
Physiological responses in the exhaustion stage include low blood pressure and high
respiratory and heart rates. During the alarm stage, heart rate and blood pressure both
increase. In the resistance stage, the body tries to maintain homeostasis; blood pressure
and heart rate normalize. If adaptation is successful, recovery takes place.
PTS:1DIFifficultREF:p. 254
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
3.You are caring for a patient who suddenly experiences a cardiac arrest. As you
respond to this emergency, which substance will your body secrete in large amounts to
help prepare you to react in this situation?
1)
Epinephrine
2)
Corticotrophin-releasing hormone
3)
Aldosterone
4)
Antidiuretic hormone
ANS:1
During the shock phase of the general adaptation syndrome, large amounts of epinephrine
prepare the body to react in an emergency situation. In response to the epinephrine release,
the endocrine system releases corticotrophin-releasing hormone, aldosterone, and
antidiuretic hormone.
PTS: 1 DIF: Moderate REF: p. 252
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Application
4.What is the function of antidiuretic hormone when released in the alarm stage
of the general adaptation syndrome?
1)
Promotes fluid retention by increasing the reabsorption of water by kidney tubules
2)
Increases efficiency of cellular metabolism and fat conversion to energy for cells and
muscle
3)
Increases the use of fats and proteins for energy and conserves glucose for use by the
brain
4)
Promotes fluid excretion by causing the kidneys to reabsorb more sodium
ANS:1
Antidiuretic hormone promotes fluid retention by increasing the reabsorption of water by
kidney tubules. Thyroid-stimulating hormone increases efficiency of cellular metabolism
and fat conversion to energy for cells and muscle. Cortisol increases the use of fats and
proteins for energy and conserves glucose for use by the brain. Aldosterone promotes fluid
retention by causing the kidneys to reabsorb more sodium.
PTS:1DIF:ModerateREF:p. 252
KEY:Nursing process: N/A |Client need: PHSI | Cognitive level: Recall
5.A patient sustains a laceration of the thigh in an industrial accident. Which step
in the inflammatory process will the patient experience first?
1)
Cellular inflammation
2)
Exudate formation 3)
Tissue regeneration
4)
Vascular response
ANS:4
Immediately after the injury, the vascular response occurs. Blood vessels at the site
constrict to control bleeding. After the injured cells release histamine, the vessels dilate,
causing increased blood flow to the area. During the next phase, known as the cellular
response phase, white blood cells migrate to the site of injury. In the exudate-formation
phase, the fluid and white blood cells move from circulation to the site of injury, forming
an exudate. Tissue regeneration occurs in the healing phase.
PTS:1DIF:ModerateREF:p. 254
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
6.A patient complains of a vague, uneasy feeling of dread, and his heart rate is
elevated. Which of the following nursing diagnoses is most appropriate for this patient?
1)
Anger
2)
Fear
3)
Anxiety
4)
Hopelessness
ANS:3
NANDA-International defines Anxiety as a vague, uneasy feeling of discomfort or dread
accompanied by an autonomic response. This patient is most likely feeling anxious.
Anger is not a nursing diagnosis. Fear, which is also a nursing diagnosis, is an emotion or
feeling of apprehension from an identified danger, threat, or pain. Hopelessness is a
nursing diagnosis defined as a state in which the patient sees few or no available
alternatives and cannot mobilize energy on his own behalf.
PTS:1DIF:ModerateREF:p. 256
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
7.A patient who has been hospitalized for weeks becomes angry and tells the
nurse who is caring for him, I hate this place; nobody knows how to take care of me or
Id be home by now. Which response by the nurse is best in this situation?
1)
You seem angry; whats going on that makes you hate this place?
2)
Im sorry that we arent caring for you according to your expectations.
3)
You were very sick; dont be angry; youre lucky to be alive.
4)
You shouldnt be angry with us; were trying to help you.
ANS:1
You seem angry; whats going on . . . encourages the patient to express his feelings and
may provide you with more information. The nurse should not take responsibility for the
patients anger by apologizing (Im sorry . . .). Advising the patient dont be angry or you
shouldnt be angry diminishes the patients right to be angry.
PTS:1DIF:ModerateREF:p. 266
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis
8.You are caring for a patient with numerous physiological complaints. A family
member tells you that the patient is pretending to have the symptoms of a stomach ulcer
to avoid going to work. Which somatoform disorder is this patient most likely
experiencing?
1)
Hypochondriasis
2)
Somatization
3)
Somatoform pain disorder
4)
Malingering
ANS:4
Malingering is a conscious effort to escape unpleasant situations by pretending to have
symptoms of a disorder. With hypochondriasis, the patient is preoccupied with the idea
that he is or will become seriously ill. In somatization, anxiety and emotional turmoil are
expressed in physical symptoms. With somatoform pain disorder, emotional pain
manifests physically.
PTS:1DIF:ModerateREF:p. 259
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
9.After a patient has an argument with her husband, she becomes verbally abusive
to the nurse who is caring for her. Which coping mechanism is this patient exhibiting?
1)
Reaction formation
2)
Displacement
3)
Denial
4)
Conversion
ANS:2
This patient is using displacement. She is transferring the emotions she feels toward her
husband to the nurse. When a patient uses the coping mechanism of reaction formation,
the patient is aware of her feelings but acts in an opposite manner to what she is really
feeling. With the coping mechanism of denial, the patient transforms reality by refusing
to acknowledge thoughts, feeling, desires, or impulses. With conversion, emotional
conflict is changed into physical symptoms that have no physical basis.
PTS:1DIF:ModerateREF:p. 257
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
10.A patient who has been diagnosed with breast cancer decides on a treatment plan
and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis,
this patient is most likely experiencing which phase of crisis?
1)
Precrisis
2)
Impact
3)
Crisis
4)
Adaptive
ANS:4
When a patient begins to think rationally and problem-solve, she is most likely
experiencing the adaptive phase of crisis. During the precrisis phase, the patient finds
success using her previous coping strategies. Anxiety and confusion increase during the
impact phase if usual coping strategies are ineffective. The patient may use new coping
strategies, such as withdrawal, during the crisis phase.
PTS: 1 DIF: Moderate REF: dm 259-260
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
11.A nurse identifies the nursing diagnosis Diarrhea related to stress for a patient.
Which nursing intervention should be included in the nursing care plan to help the patient
relieve the cause of the diarrhea?
1)
Monitor and record the frequency of stools on the graphic record.
2)
Administer prescribed antidiarrheal medications as needed.
3)
Encourage the patient to verbalize about stressors and anxiety.
4)
Provide oral fluids on a regular schedule.
ANS:3
The nurse should encourage the patient to verbalize about stressors and anxiety to help
relieve stress, which is the cause of the patients diarrhea. Monitoring stool frequency is
an assessment, not a nursing intervention. The other interventions may be necessary to
treat diarrhea, but they do not alleviate the cause of the diarrhea.
PTS: 1 DIF: Moderate REF: p. 259
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis
12.When counseling a patient about behaviors to reduce stress, which of
the following goals should the nurse put on the care plan?
1)
The patient will limit his intake of fat to no more than 15% of the daily calories
consumed.
2)
The patient will eat three meals per day at approximately the same time each day.
3)
The patient will limit his intake of sugar and salt, as well as sweet and salty foods.
4)
The patient will consume no more than three alcoholic beverages a day.
ANS:3
The nurse should advise the client to limit the intake of sugar and salt; limit the intake of
fat to no more than 30% (not 15%) of daily calories; eat smaller, more frequent meals
(not three meals a day); and consume no more than two alcoholic beverages per day but
not necessarily every day.
PTS:1DIF:ModerateREF:p. 265
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
13.At the end of a guided imagery session, which physical assessment finding
would suggest that the relaxation technique was successful?
1)
Decreased blood pressure
2)
Decreased peripheral skin temperature
3)
Increased heart rate
4)
Increased respiratory rate
ANS:1
Reassessment findings that suggest relaxation has been effective include decreased blood
pressures, increased peripheral skin temperature, decreased heart rate, and decreased
respiratory rate.
PTS:1DIF:ModerateREF:dm 266-267
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension
14.The nurse is caring for a patient with unresolved anger. For which
associated complication should the nurse assess?
1)
Depression
2)
Hypochondriasis
3)
Somatization
4)
Malingering
ANS:1
Depression is sometimes associated with unresolved anger and may result from stress. A
person with hypochondriasis is preoccupied with feelings that he will become seriously ill.
In somatization, anxiety and emotional turmoil are expressed in physical symptoms, loss
of physical function, pain that changes location often, and depression. Malingering is a
conscious effort to avoid unpleasant situations. Hypochondriasis, somatization, and
malingering are not associated with unresolved anger.
PTS:1DIF:EasyREF:p. 256
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension
15.Before entering the room of a patient who is angry and yelling, the nurse
removes her stethoscope from around her neck. The best rationale for doing so is that the
stethoscope
1)
Could be used by the patient to hurt her
2)
Might cause the patient not to trust her
3)
Would distract her from focusing on the patient
4)
Will function as another stressor for the patient
ANS:1
When dealing with an angry patient, the nurse must be alert to her own safety needs. A
stethoscope, dangling jewelry, or anything else the patient might use as to harm the nurse
should be removed before entering the patients room. It is unlikely that a stethoscope
would cause the patient not to trust the nurse, nor function as a stressor because
stethoscopes are common in the healthcare setting; nearly every caregiver carries a
stethoscope. For the same reason, it would not likely distract the nurse. Nurses carry
stethoscopes so routinely that they likely dont even notice their presence.
PTS:1DIF:ModerateREF:p. 266
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis
16.A patient is in crisis. After assessing the situation, what should the nurse do
first? 1)
Determine the imminent cause of the crisis.
2)
Intervene to relieve the patients anxiety.
3)
Decide on the type of help the patient needs.
4)
Ensure the safety of both the nurse and patient.
ANS:4
The first goal of crisis intervention is to assess the situation. Then ensure safety of self
and patient, defuse the situation, decrease the persons anxiety, determine the problem
(cause of the crisis), and decide on the type of help needed. Safety is always foremost.
PTS:1DIF:ModerateREF:p. 269
KEY:Nursing process: Implementation | Client need: SECE | Cognitive level:
Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1.During the alarm stage of the general adaptation syndrome, which
metabolic change(s) occur(s)? Choose all that apply.
1)
Rate of metabolism decreases.
2)
Liver converts more glycogen to glucose.
3)
Use of amino acids decreases.
4)
Amino acids and fats are more available for energy.
ANS:2, 4
The metabolic changes that occur during the alarm stage of the general adaptation
syndrome include the following: The rate of metabolism increases, the liver converts
more glycogen to glucose, and there is increased use of amino acids and mobilization of
fats for energy.
PTS:1DIF:ModerateREF:dm 252-253
KEY: Nursing process: N/A | Client need: Physiological integrity | Cognitive level:
Comprehension
2.Two days after a patient undergoes abdominal surgery, his surgical incision is
red and slightly edematous; it is oozing a small amount of serosanguineous (pink-tinged
serous) fluid. On the basis of these data, what can you conclude? Choose all that apply. 1)
The wound is most likely infected.
2)
This is a vascular response to inflammation.
3)
Damaged cells are being regenerated.
4)
Exudate formation is occurring.
ANS:2, 4
During the vascular response phase of the inflammatory process, blood vessels constrict
to control bleeding. Fluid from the capillaries moves into tissues, causing edema. The
fluid and white blood cells that move to the site of injury are called exudates; this includes
the serosanguineous exudate that commonly appears at surgical incisions. When a wound
becomes infected, yellow, foul-smelling drainage may form at the site; there is no mention
of pus in the scenario. Regeneration occurs when identical or similar cells replace
damaged cells; although this may be occurring, you cannot prove it with the data given
here.
Chapter 9 Psychosocial Health & Illness
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which of the following is considered a strength of the nursing
profession? 1)
Biomedical focus
2)
Psychosocial focus
3)
Biopsychosocial focus
4)
Physical focus
ANS: 3
A strength of the nursing profession is the ability to go beyond the biomedical,
psychosocial, or physical focus to care for the entire person. This approach focuses on the
overall biopsychosocial well-being of the patient.
PTS:1DIF:EasyREF:p. 273
KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall
2. A homeless patient is admitted with an infected leg wound. According
to Maslows hierarchy of needs, which nursing intervention meets one of his basic
physiological needs?
1)
Providing the patient with a dinner tray
2)
Administering antibiotics as prescribed
3)
Irrigating a wound with normal saline solution
4)
Encouraging the patient to express his feelings
ANS: 1
According to Abraham Maslow and his hierarchy of needs, basic physiological needs,
such as food, should be addressed first. After the patients basic needs are met, the nurse
can provide wound care, administer antibiotics as prescribed (safety needs), and
encourage the patient to express his feelings (love and belonging or self-actualization,
depending on what feelings he expresses).
PTS:1DIF:ModerateREF:p. 274
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
3. Which of the following can the nurse assess using Erik Eriksons
theory? 1)
Moral development
2)
Developmental tasks
3)
Social identity
4)
Self-esteem
ANS: 2
Using Eriksons theory, the nurse can assess for successful completion of developmental
tasks. The theory does not help the nurse assess social identity or self-esteem. However,
these factors are components of developmental tasks that Eriksons theory explores. Moral
development was addressed in the Kohlbergs theory.
PTS:1DIF:EasyREF:p. 274
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension
4. Which statement best describes self-concept? An
individuals 1)
Understanding of how others perceive him
2)
Evaluation of himself
3)
Overall view of himself
4)
Perspective of his role in society
ANS: 3
Self-concept is an individuals overall view of himself. The overall view includes his
evaluation of himself and how he thinks others evaluate him.
PTS:1DIF:EasyREF:p. 274
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
5. A 13-year-old patient is admitted to the hospital. There is no medical restriction
on visitation. To help maintain the patients social identity while hospitalized, it is most
important for the nurse to encourage visits by
1)
Peers
2)
Grandparents
3)
Siblings
4)
Parents
ANS: 1
Peers are more important than family in maintaining social identity in this age group.
PTS:1DIF:ModerateREF:p. 275
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall
6. Which response by the patient demonstrates an internal locus of
control? 1)
My blood sugar wouldnt be out of control if my wife prepared better foods.
2)
I knew I shouldnt have come to this hospital; Id be better if I hadnt.
3)
God must be getting even with me for my past behavior.
4)
Im just glad to be alive; the accident couldve been a lot worse.
ANS: 4
People who demonstrate an internal locus of control take responsibility for their life
experiences and their responses to them. This allows them to interpret unexpected events
in a positive light, as the response the accident couldve been a lot worse illustrates. The
other options demonstrate an external locus of control; control of the situation is
attributed to external factors.
PTS:1DIF:ModerateREF:p. 275
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
7. The nurse is caring for a group of patients on the medical-surgical unit. Which
patient is most likely to experience the most difficulty in adapting to a change in body
image? The patient
1)
Who suffered a traumatic amputation of the left leg in an industrial accident
2)
With hypothyroidism who has coarse, dry, thinning hair and weight gain
3)
Who is obese and who underwent gastric bypass surgery
4)
With peripheral vascular disease who required a wound graft
ANS: 1
Theoretically, the patient who suffered a traumatic amputation in an industrial accident
will most likely have more difficulty adjusting to his change in body image because the
change occurred abruptly. The patients described in the other options will naturally have
some difficulty adjusting to their body image change, but it should not be as great
because the physical changes are more gradual, which allows for adaptation over time.
PTS:1DIF:ModerateREF:dm 275-276
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
8. Which individual is most likely to have a positive body
image? 1)
Child who has been deaf since birth
2)
Child who was born with cystic fibrosis
3)
Adolescent of average appearance who had an appendectomy
4)
Adult born with a spinal defect and associated paralysis of the lower body
ANS: 3
The adolescent with average appearance who had an appendectomy is likely to have a
positive body image because the adolescent suffered an acute, reversible illness. Those
born with physical handicaps are less likely to have a positive body image because many
times the handicap leaves them socially isolated. This is, of course, not to imply that no
one born with a physical handicap has a positive body image; and, of course, a particular
adolescents body image might suffer after an appendectomy. However, the question asks
which is most likely based on theoretical knowledge of body image.
PTS:1DIF:ModerateREF:dm 275-276
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis
9. A 35-year-old patient diagnosed with testicular cancer is undergoing
chemotherapy, which leaves him unable to help care for his young children. As a result,
his wife misses work whenever the children are ill. She has become increasingly
distressed over her situation. Her experience best demonstrates which of the following?
1)
Role strain
2)
Interpersonal role conflict
3)
Role performance
4)
Inter-role conflict
ANS: 4
The patients wife is most likely experiencing inter-role conflict, in which her role as a
mother and worker are making competing demands on her. Role strain is a mismatch
between role expectations and role performance. Interpersonal role conflict results when
another persons idea about how a role should be performed differs from that of the person
who is performing the role. Role performance is defined as the actions a person takes and
the behaviors he demonstrates in performing a role.
PTS:1DIFifficultREF:p. 276
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
10. Which statement best describes selfesteem? 1)
View of oneself as a unique human being
2)
Ones mental image of ones physical self
3)
Ones overall view of oneself
4)
How well one likes oneself
ANS: 4
Personal identity is ones view of oneself as a unique human being. Body image is
described as ones mental image of ones physical self. Self-concept is defined as ones
overall view of oneself. Self-esteem is a favorable impression of oneself or self-respect.
PTS:1DIF:ModerateREF:dm 276-277
KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall
11. A patient undergoing fertility treatments for the past 9 months learns
that despite in vitro fertilization she still is not pregnant. This patient is at risk for
experiencing a crisis in which component of self-concept?
1)
Body image
2)
Self-esteem
3)
Personal identity
4)
Role performance
ANS: 2
Setbacks such as not becoming pregnant after months of fertility treatment can cause the
patient to question her self-worth. This might provoke a crisis in self-esteem. The patient
is not at risk for experiencing a crisis in body image, personal identity, or role
performance.
PTS:1DIFifficultREF:dm 276-277
KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application
12. A 17-year-old patient sustained facial fractures and a 6-inch laceration on the
left side of her face in a motor vehicle accident. The patient tells the nurse that she does
not want anyone to see her looking this way. Which statement by the nurse is most
appropriate?
1)
Tell me what you mean by looking this way.
2)
OK, Ill restrict your visitors until your face heals.
3)
Your friends and family love you no matter what.
4)
Youre young; your face will heal quickly.
ANS: 1
Tell me what you mean . . . encourages the patient to clarify her statement so that the nurse
knows exactly what the patient means. The nurse cannot assume that the patient is talking
about her facial wounds. Ill restrict your visitors . . . assumes that the patient is speaking
about her facial wounds when she might not be. The other options are examples of false
reassurance and do not address the patients concerns.
PTS: 1 DIF: Moderate REF: dm 288-289; ESG, Nursing Interventions, V2, p. 116;
ESG, Supplemental Materials, Psychosocial Nursing Interventions
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
13. A patient has recently had a change in a family relationship that is greatly
affecting his health. Which nursing diagnosis could you probably make for this patient?
1)
Parental Role Conflict
2)
Interrupted Family Processes
3)
Compromised Family Coping
4)
Ineffective Individual Coping
ANS: 2
Interrupted Family Processes is defined as a change in a family relationship significantly
affecting a patients health. Parental Role Conflict occurs when significant role confusion
by a parent results in response to crises. Compromised Family Coping occurs when
support from a usual family member is compromised or disabled, causing a significant
health challenge. Ineffective Individual Coping occurs when the patient is unable to
comprehend and effectively judge stressors.
PTS:1DIFifficultREF:p. 281
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
14. The nurse is updating a care plan for a patient who has a nursing diagnosis
of Anxiety. Which patient behavior might suggest that the problem is resolving?
1)
Pacing in the hallway at intervals
2)
Using relaxation techniques
3)
Speaking rapidly when spoken to
4)
Avoiding eye contact
ANS: 2
Using relaxation techniques might suggest that the patients anxiety is resolving. Pacing,
speaking rapidly, and avoiding eye contact suggest that anxiety is still a problem for the
patient. The patients use of relaxation techniques indicates problem solving by the
patient.
PTS: 1 DIF: Easy REF: dm 288-289
KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Comprehension
15. Which nursing diagnosis is categorized as a psychosocial, rather than a
self- concept, diagnosis?
1)
Ineffective Individual Coping 2)
Situational Low Self-Esteem
3)
Disturbed Personal Identity
4)
Disturbed Body Image
ANS: 1
Ineffective Individual Coping is considered a psychosocial nursing diagnosis. It implies
poor life choices, inability to use available resources, and other interactional and
relationship symptoms. The term psychosocial encompasses both
psychological and social factors. The other diagnoses represent primarily individual,
psychological factors. They are examples of self-concept nursing diagnoses.
PTS:1DIF:ModerateREF:p. 281
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Recall
16. Which statement by the nurse is best when communicating with a patient
with clinical depression?
1)
Its a beautiful day today; youll feel better if you look out the window.
2)
Youre having a bad day; Im sure youll feel better soon.
3)
Life seems overwhelming at times; would you like to discuss how youre feeling?
4)
You are very lucky to have such a supportive family.
ANS: 3
When caring for a patient with depression, the nurse should encourage the patient to
discuss his feelings. Its a beautiful day . . . and Youre having a bad day . . . offer false
reassurance. It would not be therapeutic to say, You are very lucky . . .; that is offering a
judgment.
PTS:1DIF:ModerateREF:p. 293
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
17. A patient who lost his job last month has now been told that his wife wants a
divorce. He says, I know I dont have much to offer a woman. She wants more than what I
am, and now Im not even bringing home any money. Which nursing diagnosis is most
appropriate?
1)
Chronic Low Self-Esteem
2)
Situational Low Self-Esteem
3)
Disturbed Personal Identity
4)
Disturbed Body Image
ANS: 2
Situational Low Self-Esteem occurs when a person exhibits self-disapproval and negative
self-evaluations as a specific reaction to loss or change (in this case, of a job and a
marriage). There are no data to indicate long-standing (Chronic) Low Self-Esteem. This
client has no defining characteristics for Disturbed Personal Identity, which is an inability
to determine boundaries between self and others, nor of Disturbed Body Image. He does
mention his appearance but does not focus on it in particular; it is only part of his overall
dissatisfaction with himself.
PTS:1DIF:ModerateREF:p. 284
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
18. The nurse is updating the care plan of a patient who must undergo a right
mastectomy for breast cancer. Which nursing diagnosis should the nurse anticipate in
expectation of the body changes associated with the upcoming surgery?
1)
Deficient Knowledge
2)
Impaired Adjustment
3)
Hopelessness
4)
Grieving
ANS: 4
Grieving may occur as a result of body changes associated with mastectomy. Deficient
Knowledge, Impaired Adjustment, and Hopelessness are not associated with the expected
body changes associated with the upcoming surgery, although they could certainly occur.
PTS:1DIF:ModerateREF:p. 285
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
19. A patient admitted with depression has a nursing diagnosis of Chronic
Low Self-Esteem. Which NOC outcome is essential for this nursing diagnosis?
1)
Decision Making
2)
Distorted Thought Content 3)
Role Performance
4)
Depression Level
ANS: 4
Depression Level is the appropriate NOC outcome for the patient admitted with
depression who has the nursing diagnosis Chronic Low Self-Esteem. Decision Making is
associated with the nursing diagnosis Situational Low Self-Esteem, Role Performance
with Ineffective Role Performance, and Distorted Thought Content with Disturbed
Personal Identity. Although the other options might contribute to the patients low selfesteem, the nurse must write one goal (outcome) that, if achieved, would demonstrate
resolution of the nursing diagnosis. Decision Making is the only outcome that does that.
PTS: 1 DIF: Moderate REF: p. 293; ESG,
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
20. The nursing diagnosis Disturbed Personal Identity is identified for a newly
admitted patient. Which of the following is an example of an individualized goal for that
patient?
1)
Distorted Thought Control
2)
Anxiety Level
3)
Self-Mutilation Restraint
4)
No Self-Injury, Consistently Demonstrated
ANS: 4
No Self-Injury, Consistently Demonstrated is an example of using NOC indicators and
outcomes to write an individualized goal. The other options are examples of NOC
outcomes; they are not written as goals.
PTS:1DIF:ModerateREF:p. 293
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
21. A 73-year-old patient was admitted with a perforated bowel. Following
surgical repair, he developed complications and required an extensive stay in the hospital.
How can the medical-surgical nurse best promote self-esteem in this patient?
1)
Assist the patient to ambulate in the hallway once daily.
2)
Encourage the patient to participate in self-care.
3)
Introduce herself to the patient if he does not know her.
4)
Listen attentively when the patient speaks.
ANS: 2
Encouraging the patient to his accomplish own self-care, such as bathing and brushing his
teeth, encourages independence and promotes self-esteem. Assisting the patient to
ambulate in the hallway prevents complications of immobility. Introducing yourself and
listening attentively to the patient prevents depersonalization.
PTS:1DIFifficultREF:p. 285
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
22. The nurse is developing a plan of care for a mother of three small children
who has been admitted with a serious acute illness, which is likely to continue long term.
The nurse writes the following intervention: Facilitate communication between patient
and significant other regarding the sharing of responsibilities to accommodate changes
brought on by illness. The purpose of this intervention is to help
1)
Promote self-esteem
2)
Promote positive body image 3)
Facilitate role enhancement
4)
Prevent depersonalization
ANS: 3
Facilitating communication between the patient and significant other regarding sharing of
responsibilities to accommodate changes brought on by the illness can help facilitate role
enhancement in the patient. The intervention is not designed to promote self-esteem or
positive body image or to prevent depersonalization.
PTS:1DIF:ModerateREF:p. 286
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
23. A patient comes to the emergency department complaining of headache,
palpitations, nausea, and dizziness. After determining that the patient is anxious, the
nurse notes tachycardia and trembling. Which level of anxiety is this patient exhibiting?
1)
Mild anxiety
2)
Moderate anxiety
3)
Severe anxiety
4)
Panic anxiety
ANS: 3
The patient experiencing severe anxiety may experience physical symptoms including
headache, palpitations, tachycardia, insomnia, dizziness, nausea, trembling,
hyperventilation, urinary frequency, and diarrhea. Symptoms associated with mild anxiety
include muscle tension, restlessness, irritability, and a sense of unease. The patient
experiencing moderate anxiety might experience a rise in heart rate and respiratory rate,
increased perspiration, gastric discomfort, and increased muscle tension. The patient
suffering from panic anxiety might believe he has a life-threatening illness. Physical
symptoms include dilated pupils, labored breathing, severe trembling, sleeplessness,
palpitations, diaphoresis, pallor, and uncoordinated muscle movements.
PTS:1DIF:ModerateREF:p. 278
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
24. The nurse is assessing a patient admitted with a newly diagnosed bleeding
duodenal ulcer. He is exhibiting physiological signs of anxiety and seems to have
difficulty concentrating. During the interview, the patient tells the nurse that he is often
short of breath and says, I lie awake nights worrying about everything. He has been
unable to work or care for his family for the past 6 months. What is the nurses priority
after documenting this information in the nurses notes?
1)
Provide emotional support for the patient using reflective listening technique.
2)
Do nothing; people with duodenal ulcers typically cannot work.
3)
Question the patients family about the information received from the patient.
4)
Notify the primary care provider and ask for a referral to a mental health professional.
ANS: 4
The nurse should involve a mental health professional immediately, because the patient is
exhibiting signs of a disabling anxiety disorder. Although it is important for the nurse to
provide emotional support for the patient, a mental health professional is needed for this
patient. Doing nothing is neglectful. Questioning the patients family about the information
violates the patients right to privacy, unless the nurse obtains the patients permission to do
so.
PTS: 1 DIF: Difficult REF: p. 291; requires synthesis, answer not given verbatim.
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis
25. An adult patient is diagnosed with lung cancer, and surgery to remove the
right lung is recommended. The patient is uncertain about whether he should consent to
the surgery because of the risks involved. Which nursing diagnosis is most appropriate
for this patient?
1)
Decisional Conflict
2)
Death Anxiety
3)
Powerlessness
4)
Ineffective Denial
ANS: 1
Decisional Conflict is the most appropriate nursing diagnosis for this patient because he is
uncertain about whether he should take the surgical risk. Death Anxiety is apprehension,
worry, or fear related to death or dying; there is nothing to suggest that this patient is
suffering from Death Anxiety at this time. Powerlessness is a perceived lack of control
over a current situation; this patient is trying to exert some control over his care.
Ineffective Denial is appropriate when the patient consciously or unconsciously rejects
knowledge; there is nothing in this scenario to suggest that the patient is rejecting
knowledge.
PTS:1DIF:ModerateREF:p. 288
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
26. Which nursing intervention specifically helps reduce a patients
anxiety? 1)
Teaching the importance of adequate nutrition and hydration
2)
Giving clear fact pertaining to the patients circumstances
3)
Promoting small-group activities to improve self-esteem
4)
Monitoring the patient for the risk of suicide
ANS: 2
Using clear and factual knowledge that is tailored to the patients circumstances helps
reduce anxiety. Teaching the importance of adequate hydration, promoting small-group
activities to improve self-esteem, and monitoring the patient for suicide risk are
interventions designed to help the patient with depression.
PTS:1DIF:EasyREF:p. 289
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall
27. The nurse caring for a patient admitted with severe depression identifies a
nursing diagnosis of Hopelessness on the care plan. Which outcome is appropriate for
this diagnosis?
1)
Displays stabilization and control of mood
2)
Sleeps 6 to 8 hours per night with report of feeling rested
3)
Does not engage in risky, self-injurious behavior
4)
Eats a well-balanced diet to prevent weight change
ANS: 1
An outcome for the nursing diagnosis Hopelessness is displays stabilization and control of
mood. Sleeps 6 to 8 hours per night and reports feeling rested and eats a well-balanced
diet to prevent weight change are example of outcomes for the diagnosis Depressed
Mood. Does not engage in risky, self-injurious behavior is an outcome for the nursing
diagnosis Risk for Suicide.
PTS: 1 DIF: Moderate REF: p. 293
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
28. The nurse is assessing a patient for depression. Which of the following sets
of behavioral symptoms may indicate depression?
1)
Preoccupation with loss, self-blame, and ambivalence
2)
Anger, helplessness, guilt, and sadness
3)
Anorexia, insomnia, headache, and constipation
4)
Tearfulness, withdrawal, and present substance abuse
ANS: 4
Tearfulness, regression, restlessness, agitation, withdrawal, past or present substance
abuse, and a past history of suicide attempts are all behavioral symptoms of depression.
Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, and sadness are
affective findings associated with depression. Cognitive findings in depression include
preoccupation with loss, self-blame, ambivalence, and blaming others. Physiological
findings of depression include anorexia, overeating, insomnia, hypersomnia, headache,
backache, chest pain, and constipation.
PTS:1DIF:ModerateREF:p. 289
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension
29. A frail, elderly patient admitted with dehydration to a medical-surgical unit is
exhibiting confusion, distractibility, memory loss, and irritability. What is most important
for the nurse do?
1)
Recognize these symptoms as signs of normal, physiologic aging.
2)
Obtain a urine specimen before notifying the primary care provider.
3)
Be sure she is placed in a room occupied with another patient.
4)
Interview the patient to screen for clinical depression.
ANS: 4
Depression is often masked in older adults and expressed as physical and personality
changes. Memory loss and confusion are also common symptoms of depression in older
adults. Any one of the symptoms might occur as a result of physical illness, but the
combination should prompt the nurse to suspect depression and interview and screen for
it before exploring physiological causes for the symptom (as with a urine specimen).
Placing the patient with another patient would be indicated for social isolation, which can
be associated with depression; however, the nurse needs to screen for depression before
looking for causes.
PTS:1DIF:ModerateREF:dm 291, 295
KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application
30. An elderly patient admitted from a skilled nursing residence to a medicalsurgical unit is exhibiting confusion, distractibility, memory loss, and irritability. She has a
medical diagnosis of dehydration. Which of the following should lead the nurse to suspect
that dementia, rather than depression or dehydration, is the source of the symptoms? The
history and nursing observations indicate that the patient
1)
Rambles, speaks incoherently, and answers questions inappropriately
2)
Speaks slowly with delayed response to questions but responds appropriately 3)
Awakens early in the day yet sleeps almost constantly during the day
4)
Sometimes has difficulty concentrating on details of the present situation
ANS: 1
In dementia, a patients language is disoriented, rambling, and incoherent and the patient
responds to questions inappropriately or with near misses. Speaking slowly and being
slow to respond to verbal stimuli are signs of depression, and in depression, the patient
usually answers questions appropriately. Awakening early and sleeping constantly during
the day are signs of depression; in dementia, sleep is fragmented and the person awakens
often during the night. Difficulty concentrating on details is a thinking pattern seen more
in depression; in dementia, there is difficulty finding words, difficulty calculating, and
decreased judgment.
PTS: 1 DIF: Difficult REF: p. 291
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which assessment finding(s) might suggest that the patient has low selfesteem and requires more in-depth assessment? Choose all that apply.
1)
Infrequent eye contact
2)
Straight posture
3)
Overly critical of others
4)
Careful grooming
ANS: 1, 3
Assessment findings that suggest low self-esteem include avoiding eye contact and being
overly critical of others. You would not need to follow up if the person displayed straight
posture and careful grooming.
PTS: 1 DIF: Easy REF: dm 276-277; 282-284
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
2. Which intervention(s) by the nurse might help the patient maintain a sense of
personhood during hospitalization? Assume that all are culturally appropriate. Choose all
that apply.
1)
Addressing the patient by his first name
2)
Making eye contact if it is comfortable for the patient
3)
Always offering an explanation before beginning a procedure
4)
Speaking to others about the patient so that the patient can hear you
ANS: 2, 3
The nurse can help the patient maintain a sense of personhood by addressing him by his
preferred name, which might be his first name or might be his surname with title. Using
eye contact, always offering an explanation before beginning a procedure, and not talking
about the patient to others in the room are additional ways for the nurse to offer care that
respects patient rights.
Chapter 10. Family Health
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A 12-year-old patients mother recently married a man who has a 13-yearold daughter. The nurse recognizes that the patient belongs to which type of family?
1)
Extended
2)
Traditional
3)
Blended
4)
Nuclear
ANS: 3
The patient belongs to a blended family; in which two single parents marry and raise their
children together. An extended family may contain grandparents, aunts, uncles, cousins,
and other biological relatives. A traditional, or nuclear, family contains a husband, wife,
and their children.
PTS:1DIF:EasyREF:p. 301
KEY: Nursing process: N/A | Client need: PSPI | Cognitive level: Application
2. A 65-year-old patient is admitted to the hospital with heart failure. The patients
best friend accompanies her on admission. They have been sharing a home since they
each were widowed 3 years ago. Both women have grown children who live out of state.
Using the family nursing approach, how can the nurse best intervene?
1)
Involve the friend and children in the patients care, discharge planning, and home care.
2)
Encourage the friend to wait until discharge to provide care for the patient at home.
3)
Explain to the friend that for confidentiality reasons she cannot be involved in the
patients care.
4)
Encourage liberal visiting hours by the friend and the patients children.
ANS: 1
The nurse can best intervene by involving the friend and the patients children in the
patients care, discharge planning, and home care. The friend may or may not be able to
care for the patient at home. But if planning to provide home care, the patients friend
should be informed of the patients needs while in the hospital and have an opportunity to
participate prior to discharge. The nurse can involve the friend with the patients consent
without infringing on the patients privacy. Her name needs to be listed on the patient
privacy (HIPAA) form. The nurse should also encourage liberal visiting hours by the
friend and the patients children if it is beneficial for the patients recovery; however,
comprehensive involvement in care is more inclusive than simply liberalizing visiting
hours and therefore is the best answer.
PTS:1DIF:ModerateREF:dm 301-302
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
3. A patient and his wife are 2 years from retirement when he is diagnosed with
lung cancer. Although with delayed childbearing, developmental stages can vary among
families, which typical stage of family development is this couple likely experiencing?
1)
Family launching young adults
2)
Postparental family
3)
Family with frail elderly
4)
Family with teenagers and young adults
ANS: 2
This couple is most likely experiencing the postparental stage of family development.
During this stage, the parents prepare for retirement and adjust to their children moving
into phases of adulthood. In the stage of family launching young adults, the parents
maintain support of young adults as they leave the security of family and the parents
rediscover marriage. During the stage of family with teenagers and young adults, open
communication is maintained among family members, ethical and moral values are
reinforced, and there is a balance established between rules and independence among
teens.
PTS: 1 DIF: Moderate REF: p. 303
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
4. A 13-year-old girl is admitted to the adolescent unit with acute leukemia.
The patient has a support system that includes her brother, sister, mother, father, and
grandmother as well as members of her local community. Which component of her
support system is considered a suprasystem?
1)
The community
2)
The parents
3)
Her mother
4)
Her sister
ANS: 1
Her surrounding community is considered a suprasystem because it is larger than the
family system. Subsystems within the family include the parents, mother, siblings, sister,
brother, father, and grandmother; they are smaller components that fit within the family
system.
PTS:1DIF:ModerateREF:p. 302
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis
5. The nurse is developing a teaching plan for an older adult patient with Alzheimer
disease and her family. Which point should the nurse include in the teaching plan before
discharge?
1)
Importance of quitting smoking 2)
Availability of community resources
3)
Adherence to a low-fat diet
4)
Importance of physical exercise
ANS: 2
When teaching the family of an older adult, the nurse should include information about
community resources that are available, especially when caring for chronically ill,
disabled, or elderly family members. Middle-age adults typically begin experiencing
signs and symptoms associated with long-standing, unhealthy behaviors. Therefore,
consuming a low-fat diet and limiting the intake of alcohol and tobacco are likely
appropriate topics to include in the teaching plan for a middle-aged adult. Physical
exercise and activity promote the quality of life. Careful planning is necessary to ensure
safety and well-being for the family member with memory loss, confusion, and
disorientation.
PTS:1DIF:ModerateREF:p. 306
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
6. Which factor is related to the increased risk of acquiring polio in the
United States after the disease was thought to be eradicated?
1)
Lack of health insurance
2)
Bioterrorism
3)
Reduced compliance with vaccinations
4)
Drug resistance
ANS: 3
Reduced compliance with community immunization in the United States increases the
risk for diseases, such as polio, that were thought to be eradicated. For vaccines to be
effective, the population needs to receive them. Bioterrorism involves the introduction of
a highly infectious microbe for which there is no protection to the population. Polio is not
such a threat because immunization is available. Vaccinations are available through
governmental programs for those who do not have health insurance. Drug resistance has
led to the reemergence of tuberculosis, which was previously cured with antibiotics.
PTS:1DIF:EasyREF:p. 306
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:
Comprehension
7. Which question helps the nurse to assess family
structure? 1)
Where does your family live?
2)
How are family decisions made?
3)
With which religious affiliation is your family associated?
4)
What is your ethnic background?
ANS: 2
Asking how family decisions are made helps the nurse to assess family structure. Asking
about religious affiliation, ethnic background, and where the family lives provides
identifying data but does not reveal lines of authority and relationships among family
members.
PTS:1DIF:ModerateREF:p. 308
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
8. Which family member is most likely to be
disabled? 1)
60-year-old African American male
2)
65-year-old Asian male
3)
70-year-old Caucasian female
4)
75-year-old Native American female
ANS: 4
Slightly more females (15.6%) than males (14.4%) reported a disability. In 2006, the
prevalence of disability was lowest for persons ages 16 to 20 (6.9%) and highest for those
75 years and older (52.6%). Disability differs by ethnic group. Asians reported 6.3%,
Caucasians 12.7%, African Americans 17.5%, Native Americans 21.7%, and persons of
other ethnic backgrounds reported 11.9% disability. Therefore, the prevalence of disability
would be highest in a female Native American who is 75 years or older.
PTS:1DIFifficultREF:p. 307
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which family function(s) is/are outlined in the structural-functional
family theory? Select all that apply.
1)
Meeting the emotional needs of family members
2)
Reinforcing ethical and moral values 3)
Promoting joint decision making among parents and children
4)
Being productive members of society
ANS: 1, 4
Family functions outlined in the structural-functional family theory include being
productive members of society, caring for elderly members, meeting physical and
emotional needs of family members, and socialization of children. This model is more
focused on the outcomes of family function than the process by which action occurs.
Maintaining support for young adults as they leave the security of the family, reinforcing
ethical and moral values, and promoting joint decision making among parents and
children are examples of tasks outlined in family development theories.
PTS:1DIF:ModerateREF:p. 302
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
2. Which of the following suggest that a family health problem may exist? Select
all that apply. Family members
1)
Respect each others need for privacy 2)
Enact decisions made by the most powerful member
3)
Do not consider a conflict resolved until everyone agrees
4)
Set boundaries between family members
ANS: 2, 3
Respect for privacy and clear boundaries between family members are characteristics of a
healthy family. Boundaries define the responsibilities of adults that are clear and separate
from responsibilities of growing children. In healthy families, there is typically egalitarian
distribution of power. In healthy families, it is not always necessary for all members to
agree; instead, they have the ability to compromise and members feel free to disagree.
PTS: 1 DIF: Moderate REF: p. 310
KEY: Nursing process: Analysis/nursing diagnosis | Client need: PSI | Cognitive level:
Analysis
3. A family assessment should include the following areas. Choose all that
apply. 1)
Coping patterns
2)
Health beliefs
3)
Medical history
4)
Physical exam
ANS: 1, 2
Conducting a family assessment includes identifying the following: data; family
composition; family history and developmental stage; environmental data; family
structure; family function; health beliefs, values, and behaviors; family stressors and
coping; and abuse and violence within the family. The medical history and physical exam
of individuals are only relevant to the family assessment if it affects other family members.
Chapter 11 Culture and Ethnicity
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. North American healthcare culture typically reflects which
culture? 1)
Asian
2)
European American
3)
Latino
4)
African American
ANS: 2
Although the demographics are changing in this recent decade with increasing Hispanic
and Asian inhabitants, North American healthcare culture typically reflects the dominant
(European American) culture because most healthcare providers belong to that culture.
PTS: 1 DIF: Easy REF: p. 317
KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall
2. A 26-year-old man of Mexican heritage is admitted for observation after
sustaining injuries in a motor vehicle accident. When assessing this patient, the nurse
must consider that he may possess which view of pain?
1)
A belief in taboos against narcotic use to relieve pain
2)
Expectation of immediate treatment for relief of pain
3)
Endurance of pain longer and report it less frequently than some patients do
4)
Use of herbal teas, heat application, and prayers to manage his pain
ANS: 3
In general, patients of Mexican heritage may endure pain longer and report it less
frequently than some. Patients of Japanese heritage may have taboos against narcotic use
to relieve pain. Patients of Puerto Rican heritage may use herbal teas, heat application,
and prayers to manage pain. Remember that all of these are archetypes and are not
necessarily true for all members of a cultural group.
PTS:1DIFifficultREF:p. 329
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
3. The nurse is caring for a 42-year-old Chinese American patient who underwent
emergency coronary artery bypass graft surgery. He is self-employed and has no health
insurance. Each day members of his family spend hours at his bedside. Which is the most
important factor for the nurse to focus on when planning the patients discharge?
1)
Ethnic background
2)
Family support
3)
Employment status
4)
Healthcare coverage
ANS: 2
The nurse should focus on the patients strengths and resources for health restoration and
self-care. In this case, that is the patients family. His family can be a great support for
him when he is discharged (e.g., preparing healthy meals, helping him manage exercise
and treatment regimens). Although the patients ethnic background is very important to
his care, discharge planning should revolve around his available resources. Insurance
should not be the focus at this time, although at some point the nurse has probably
obtained data about these topics.
PTS:1DIF:ModerateREF:dm 320, 326
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
4. A patient who came from Central America is admitted with diabetes mellitus.
The nurse is collecting biographical information. Which information provided by the
patient represents his ethnicity?
1)
Latino
2)
Catholic
3)
White
4)
Teacher
ANS: 1
Ethnicity refers to groups whose members share a common cultural heritage. This patient
came from a Spanish-speaking country in Central America; therefore, his ethnicity is
considered Latino. Catholic is his religion, white is his race, and teacher is his occupation.
PTS:1DIF:ModerateREF:p. 318
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
5. A patient who moved to the United States from Italy comes to the clinic for
medical care. The patient has been in this country for several years and has adopted some
elements of her new country. Yet she still retains some customs from her homeland. This
patient is experiencing
1)
Assimilation
2)
Socialization
3)
Acculturation
4)
Immigration
ANS: 3
This patient is experiencing acculturation; she has accepted both her own and the new
culture and has incorporated elements of both into her life. Socialization is the process of
learning to become a member of a society or group. Cultural assimilation occurs when the
new member gradually learns and takes on, to a great extent, the dominant cultures
values, beliefs, and behaviors. Immigration is the act of moving to a new country.
PTS:1DIF:ModerateREF:p. 319
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Analysis
6. Which of the following is considered a practice (as opposed to a belief or
value)? 1)
Always drinking water after exercise
2)
Thinking often about cleanliness
3)
Emphasis on success
4)
Maintaining youth
ANS: 1
A practice is a set of behaviors that one follows, such as always drinking water after
exercise. Preoccupation with cleanliness, emphasis on success, and maintaining youth are
examples of values that are dominant in United States culture.
PTS:1DIF:EasyREF:p. 320
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Comprehension
7. The nurse is caring for a patient who emigrated from Puerto Rico. She can
best care for this patient by learning about the
1)
Practices of the patients ethnic group 2)
Patients individual cultural beliefs
3)
Values of her own culture
4)
Spanish-speaking community
ANS: 2
The nurse cares for this patient by becoming familiar with the patients individual cultural
and ethnic beliefs and values. It is helpful to become familiar with the patients ethnic
group and the Spanish-speaking community; however, the nurse should not assume that
the individual holds the same values, beliefs, and practices as his ethnic group or
community. The nurse should explore her own culture but not assume that the patient
holds those same beliefs and practices.
PTS: 1 DIF: Moderate REF: p. 320
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
8. The nurse is teaching a clinic patient about hypertension. Which statement by
the patient suggests that he is present oriented?
1)
I know I need to lose weight; Ill have to begin an exercise program right away.
2)
If I change my diet and begin exercising, maybe I can control my blood pressure without
medications.
3)
I know I need to give up foods that contain a lot of salt, but with teenagers in the house it
is very difficult.
4)
I will reduce the amount of calories, salt, and fat that I eat; I certainly do not want to have a
stroke.
ANS: 3
Knowing an action is needed but giving reasons for not beginning it just now shows a
focus on the present. The patient knows that he should reduce his sodium intake, but his
present situation is preventing him from doing so. Therefore, he is disregarding the impact
consuming sodium might have on his future. The other responses are future oriented
because they indicate that the patient is planning lifestyle changes that will affect his
future.
PTS:1DIFifficultREF:dm 321, 326
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
9. A patient of Japanese heritage avoids asking for narcotics for pain relief. The
nurse writes a nursing diagnosis of Pain related to reluctance to take medication
secondary to cultural beliefs. If the cultural archetype is true for this particular patient,
this probably means that the patient views pain as
1)
A punishment for immoral behavior
2)
A part of life
3)
Best treated with herbal teas and prayer
4)
A virtue and a matter of family honor
ANS: 4
Patients of Japanese heritage may view pain as a virtue and a matter of family honor. They
may be more accepting of pain medications if the nurse reassures them that pain control
enhances healing. Patients of Mexican heritage may view pain as punishment for immoral
behavior. Those of Navajo Indian heritage commonly view pain as a part of life, whereas
those of Puerto Rican heritage may feel that pain is best treated with herbal teas and
prayer. Keep in mind that these are all archetypes and do not necessarily apply to all
members of a cultural group.
PTS:1DIF:ModerateREF:dm 320-321, 326
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Comprehension
10. The nurse is developing a plan of care for a patient of Aleut descent
who sustained a hip fracture. Which intervention by the nurse recognizes the
patients indigenous healthcare system and should be included in the plan of care?
1)
Asking the family to bring in medals and amulets
2)
Scheduling a visit from the shaman
3)
Providing the patient with her favorite herbal tea
4)
Requesting that the physician consult the patients acupuncturist
ANS: 2
For the patient of Aleut descent, contacting the shaman and scheduling a visit with the
patient might be helpful in recovery. Patients of Hispanic descent might benefit from
herbal tea and medals and amulets brought in by the family. However, it is important to
check with the physician before administering any herbal preparations that might
interfere with prescribed medications. Asians and Pacific Islanders might benefit from a
visit by the acupuncturist.
PTS:1DIFifficultREF:dm 323, 325
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
11. A client incorporates alternative healthcare into her regular health practices.
For which alternative therapy should the patient visit a formally trained practitioner?
1)
Use of herbs and roots
2)
Application of oils and poultices
3)
Burning of dried plants
4)
Acupuncture
ANS: 4
Acupuncture requires a formally trained practitioner. Use of herbs and roots, the
application of oils and poultices, and the burning of dried plants do not require formally
trained practitioners. Patients should be advised to inform their traditional primary
healthcare provider when using various herbal remedies, as they can interfere with other
prescribed medication and cause untoward side effects.
PTS:1DIF:ModerateREF:dm 325-326
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
12. An elderly patient tells the charge nurse that she wants another nurse to take
care of her. When the charge nurse questions the patient, she states I dont want a man
taking care of me. Which cultural barrier is this patient exhibiting?
1)
Ethnocentrism
2)
Racism
3)
Sexism
4)
Chauvinism
ANS: 3
This patient is exhibiting sexism; she is objecting to the nurse merely because of his sex.
Although we tend to think of sexism in a negative light, this woman may merely be
reflecting a cultural attitude. The patient is in no position to actually discriminate against
the nurse, in terms of employment, and so on. Therefore, her preferences should be
respected. Ethnocentrism occurs when a person is positively biased toward their own
culture. Racism is a form of prejudice and discrimination based on race. Chauvinism
occurs when a person assumes that he is superior.
PTS:1DIF:EasyREF:p. 328
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
13. A patient who had surgery 8 hours ago has not voided. The nurse notifies the
physician for an order to insert an indwelling urinary catheter. Which of the following
statements should the nurse use to describe the procedure to the patient?
1)
I need to put a Foley in you because you havent voided since your surgical procedure.
2)
I need to insert a tube into your bladder to drain the urine because you havent urinated
since surgery.
3)
I need to catheterize you because you havent urinated since having your surgery.
4)
I need to place a catheter in your bladder because you havent voided since surgery.
ANS: 2
I need to insert a tube into your bladder . . . best describes the procedure for the patient
because the explanation is in terms most patients will understand. The other options
contain medical jargon that could confuse the patient.
PTS:1DIF:ModerateREF:p. 328
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
14. A Hispanic patient is frustrated because the healthcare team does not understand
the importance of hot and cold therapies. Which nursing diagnosis is most appropriate for
this patient?
1)
Powerlessness
2)
Impaired Verbal Communication
3)
Spiritual Distress
4)
Risk for Noncompliance
ANS: 1
Powerlessness is the best nursing diagnosis for the patient who is unable to make
healthcare personnel understand the importance of his cultural beliefs. Impaired Verbal
Communication can be used for patients who do not speak or understand the healthcare
personnels language. Spiritual Distress might occur because a treatment is not in
agreement with the patients religious beliefs. Risk for Noncompliance can be identified
when a patient fails to follow a health-promoting or therapeutic plan the healthcare
provider believes they agreed to.
PTS:1DIF:ModerateREF:p. 330
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
15. A patient of Scandinavian heritage is admitted for observation after sustaining
injuries in a motor vehicle accident. The nurse expects that he may endure pain stoically,
without grimacing or vocalizing. The nurses thinking is an example of a/an
1)
Archetype
2)
Bias
3)
Prejudice
4)
Stereotype
ANS: 1
An archetype is an example of a person or thingsomething that is recurrentand it has its
basis in facts. Therefore, it becomes a symbol for remembering some of the culture
specifics and is usually not negative. A bias is the tendency to see only one side of an issue,
a lack of impartiality. Prejudice refers to negative attitudes toward other people that are
based on faulty and rigid stereotypes about race, gender, sexual orientation, and so on. A
cultural stereotype is the unsubstantiated belief that all people of a certain racial or ethnic
group are alike in certain respects. Similar to biases, a stereotype may be positive or
negative.
PTS:1DIF:ModerateREF:dm 320-321
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
16. A patient reports experiencing gas, abdominal bloating, and diarrhea after
consuming milk or cheese. Lactose intolerance might immediately be suspected if the
patient is of which heritage?
1)
African American
2)
Mexican American
3)
European American
4)
Arab American
ANS: 1
Lactose intolerance, caused by a deficiency of the enzyme lactase, is more commonly
seen in African Americans than in the other cultural groups listed. Of course, one would
assume lactose as the cause of the patients symptoms, but it would be important to rule it
out.
PTS:1DIF:ModerateREF:ESG,\
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which statement(s) about culture is/are true? Choose all that
apply. 1)
Culture exists on both material and nonmaterial levels.
2)
Culture mainly influences food choices and special holidays. 3)
Cultural customs change over time at different rates.
4)
Culture is learned through life experiences shared by other cultural members.
ANS: 1, 3, 4
Culture is learned through life experiences that are shared by other members of the
culture, such as family members, those sharing similar religious beliefs, and people of
similar cultural heritage in the same community. Culture exists at many levels that are
both material and nonmaterial. Cultural customs, beliefs, attitudes, and practices are not
static but change over time at different rates, depending on current events, other
significant people, and social influences. Culture is all encompassing and affects
everything its members think and do; it is not limited to food and holidays. Although
those are visible manifestations of a culture, dietary practices and cultural calendars are
not the essence of true and meaningful culture.
PTS:1DIF:EasyREF:dm 317-318
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Comprehension
2. The nurse is caring for a patient of Japanese heritage who refuses pain
medication despite the nurses explaining its importance in the healing process. Which
intervention(s) by the nurse is/are appropriate for this patient? Select all that apply.
1)
Assess the patients pain levels at less frequent intervals.
2)
Document in the patients record that the patient does not want to take opioids.
3)
Utilize nonpharmacological measures to help control the patients pain.
4)
Notify the primary care provider of the patients noncompliance.
ANS: 2, 3
Patients of Japanese heritage commonly avoid opioid use; however, they sometimes
reconsider after healthcare personnel explain that they improve the healing process. When
the patient continues to refuse pain medications despite explanation, the nurse should
respect the patients wishes and utilize nonpharmacological measures to control pain. The
nurse should document that the patient wishes to avoid opioid use in the nurses notes. The
nurse should continue to assess pain levels in this patient at the same frequency as before.
She should recognize and respect his cultural beliefs and not label him as noncompliant.
Note that the same intervention would be appropriate for any patient in this situation, not
just a Japanese patient.
Chapter 12 Spirituality
True/False
Indicate whether the statement is true or false.
1. Religion provides people with instruction and guidance about what to believe
and what values are essential.
ANS: T
Religion provides instruction and guidance on beliefs, values, and codes of conduct. In
contrast, spirituality is a journey that integrates life experiences and understanding.
PTS:1DIF:EasyREF:p. 339
KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall
2. Spirituality occurs over time and involves the accumulation of life
experiences and understanding.
ANS: T
Spirituality is like a journey; it occurs over time and involves the accumulation of
experiences and understanding, whereas religion provides general instruction and
guidance on beliefs, values, and codes of conduct.
PTS:1DIF:EasyREF:dm 339-340
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which statement best describes
theology? 1)
Discussions and theories related to God and His relation to the world
2)
Doctrines about the human soul and its relation to eternal life
3)
A life-long journey involving accumulation of experience and understanding
4)
Codes of conduct that integrate beliefs and values
ANS: 1
Theology is best described as discussions and theories related to God and His relation to
the world. Eschatology includes doctrines about the human soul and its relation to death,
judgment, and eternal life. Spirituality is considered a lifelong journey. Religion provides
codes of conduct that integrate beliefs and values.
PTS:1DIF:ModerateREF:p. 339
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
2. Which of the following is considered a religious denomination within
the tradition of Christianity?
1)
Buddhism
2)
Jehovahs Witnesses
3)
Sikhism
4)
Islam
ANS: 2
Jehovahs Witnesses is a religious denomination within Christianity. Buddhism, Sikhism,
and Islam are all religious traditions outside of Christianity.
PTS:1DIF:EasyREF:dm 342-343; ESG,
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
3. Which factor is held in common by many of the world
religions? 1)
Strict health code, including dietary laws
2)
Belief that one must submit to a god or gods
3)
Rules prohibiting alcohol consumption 4)
Sacred writings that reveal the nature of the Supreme Being
ANS: 4
Many of the world religions have sacred writings that are authoritative and reveal the
nature of the Supreme Being. Mormons follow a strict health code, which advises
healthful living. Islam means submission; therefore people of Islamic faith submit to
Allah. Some religions, such as Mormon, Christian Science, Bahai, and Sikhism, prohibit
alcohol consumption, but many other religions permit it.
PTS:1DIF:EasyREF:p. 339
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall
4. A female patient tells the charge nurse that she does not want a male nurse
caring for her. Which intervention by the charge nurse is best?
1)
Explain that hospital policy does not allow nursing assignments based on the gender of
the nurse.
2)
Explore with the patient her beliefs and determine which might have caused her to make
this statement.
3)
Assure the patient that each nurse is capable of providing professional nursing care,
regardless of their gender.
4)
Comply with the patients request and assign a female nurse to care for the patient.
ANS: 2
The charge nurse can best serve the patient and her staff by exploring the patients beliefs
that might prevent her from being cared for by a male. There are many reasons the woman
may prefer a female nurse: she may be very modest, or she may be prejudiced against
male nurses, for example. Hospital policy might state that, to prevent discrimination
issues, nursing assignments should not be made based on the gender of the patient or
nurse. However, even if this is so, before explaining this to the patient, the charge nurse
should explore the patients beliefs and make special arrangements with hospital
administration to uphold the patients beliefs, if possible. Telling the patient that each nurse
is capable of providing care is not sensitive to the patient and her beliefs.
Simply complying with the patients wishes without further investigation may alienate the
nursing staff.
PTS: 1 DIF: Moderate REF: dm 341-343, dm 351-352
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
5. A patient of Orthodox Jewish faith is admitted to the hospital with heart failure
on Yom Kippur. The physician prescribes digoxin 0.25 mg to be given orally for this
patient. Based on the patients religious affiliation, which of the following actions should
the nurse take?
1)
Administer the medication as prescribed.
2)
Hold the medication until after Yom Kippur.
3)
Explain the importance of taking the medication despite the holiday.
4)
Ask the physician to change the route of administration.
ANS: 4
Orthodox Jews require an alternative to the oral route of drug administration on Yom
Kippur to comply with their religious beliefs. Therefore, the nurse should ask the physician
to change the route of administration. Administering the medication as prescribed breaks
the patients religious tradition on the holiest day of the Jewish calendar. Holding the
medication until after Yom Kippur delays treatment and may cause harm to the patient;
furthermore, it is not within the scope of nursing practice to hold medications that have
been prescribed by a physician. The nurse should explain the importance of the medication
in any case; but the nurse should not try to convince the patient to break away from his
religious tradition when an alternative route of administration is available.
PTS:1DIF:ModerateREF:p. 341
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
6. The nurse is admitting a Roman Catholic adult patient who is critically ill.
Based on her knowledge of the patients religion, for which religious rite should she
expect to notify the hospital chaplain?
1)
Anointing of the Sick
2)
Baptism
3)
Eucharist
4)
Sacrament of Reconciliation
ANS: 1
In Catholicism, those who are seriously ill might want to receive the sacrament of
Anointing the Sick. The Sacrament of Reconciliation, which is performed by a priest, is
used to gain forgiveness for past sins. The Eucharist, or communion, can be prepared and
administered to a hospitalized patient, but it is not typically administered to someone who
is critically ill. Baptism may be offered when infants or children of Christian parents are
critically ill.
PTS:1DIF:EasyREF:p. 342
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension
7. Because of religious beliefs, which of the following patients will most
likely refuse a blood transfusion? One who is affiliated with
1)
Islam
2)
Bahai
3)
Hinduism
4)
Jehovahs Witness
ANS: 4
Those of Jehovahs Witness faith believe that taking blood into ones body is morally
wrong. Therefore, they will not consent to transfusions of whole blood or its components.
Those of Islam, Bahai, and Hindu faith will, as a rule, consent to blood transfusion.
PTS:1DIF:EasyREF:p. 342
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
8. Which special consideration may the nurse need to make when caring for
a female Rastafarian patient?
1)
Allow the patient to wear her own clothing.
2)
Provide a diet that is caffeine-free.
3)
Allow the patient to wear jewelry with religious symbols.
4)
Provide free-flowing water for bathing.
ANS: 1
Wearing secondhand clothes is taboo in the Rastafarian faith; therefore, the nurse should
allow the patient to wear her own bedclothes instead of a hospital gown. Rastafarians
typically consume tea, but some do not drink milk or coffee. Muslim women may wear a
locket containing religious writing around the neck in a small leather bag. These are worn
for protection and strength and should not be removed. Hindus prefer washing with freeflowing water for bathing, which should be provided when possible.
PTS: 1 DIF: Moderate REF: ESG,
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
9. What is the most effective action by the nurse when delivering spiritual care to
a patient of the same religion as the nurse?
1)
Understanding that the patient shares the same beliefs
2)
Striving to meet the patients spiritual needs independently
3)
Explaining her own religious beliefs to the patient
4)
Developing a greater awareness of her own spirituality
ANS: 4
The nurse can best deliver spiritual care by developing a greater awareness of her own
spirituality. This allows the nurse to be a better listener and provide better care for the
patient. The nurse should avoid assuming that a patient who shares the same religious
affiliation has the same beliefs. Moreover, the nurse should avoid trying to meet the
patients spiritual needs independently. A team approach to spirituality provides more
comprehensive care. Also, unless asked, the nurse should avoid explaining her own
religious beliefs, which might offend the patient.
PTS: 1 DIF: Moderate REF: p. 345
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension
10. A Muslim client has asked the nurse to pray with her. Which item should
the nurse anticipate that the patient may request before praying?
1)
Bathing water
2)
Rosary beads
3)
Mala beads
4)
Prayer cloth
ANS: 1
Muslims may want water to wash the mouth, nostrils, and hands before praying. Roman
Catholics may want to hold their rosary beads while praying. Some Buddhists and Hindus
meditate with a set of beads, called a mala. Others may use a prayer cloth or other religious
items.
PTS:1DIF:ModerateREF:dm 342-343, 350-351; ESG,
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension
11. When performing a spiritual assessment, who is the preferred source
of information?
1)
Durable power of attorney
2)
Next of kin
3)
Patient
4)
Patients clergyman
ANS: 3
The patient is the preferred source of information. In the event of an emergency
admission or when a patient cannot give information, the nurse can consult the next of
kin or the durable power of attorney for information about the patients spirituality.
Contacting the clergyman without the patients permission is a breach of patient
confidentiality.
PTS:1DIF:ModerateREF:dm 346-347; high-level question, not answered verbatim in
text.
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis
12. Which type of medicine do those of Hindu faith typically
practice? 1)
Ayurvedic medicine
2)
Western medicine
3)
Chiropractic medicine
4)
Qigong
ANS: 1
Those of Hindu faith typically practice Ayurvedic medicine, which encompasses all
aspects of life, including diet, sleep, elimination, and hygiene. Some believe in the
medicinal properties of hot and cold foods, which have nothing to do with temperature or
degree of spiciness. People who practice Hinduism do not typically practice Western
medicine, chiropractic medicine, or Qigong. Qigong, a form of Chinese martial arts, is
used to achieve healing through focus on the bodys energy centers.
PTS:1DIF:ModerateREF:p. 343
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension
13. A patient tells the nurse, I feel that God has abandoned me. I am so angry that I
cant even pray. The patient refuses to see his clergyman when he calls. Which is the most
appropriate nursing diagnosis for this patient?
1)
Spiritual Distress
2)
Risk for Spiritual Distress
3)
Impaired Religiosity
4)
Moral Distress
ANS: 1
This patient exhibits three defining characteristics for Spiritual Distress (feeling
abandoned by God, inability to pray, refusing to see a religious leader). Therefore, the
actual problem of Spiritual Distress exists, not the potential problem of Risk for Spiritual
Distress. Impaired Religiosity is difficulty in exercising or impaired ability to exercise
reliance on beliefs or to participate in rituals of a faith tradition (e.g., going to church).
This patient is not unable to see the clergyman but chooses not to. Moral Distress occurs
when a person makes a moral decision but is prevented from carrying out the chosen
action.
PTS:1DIF:ModerateREF:p. 348
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
14. The nurse is asking the patient reflective, clarifying questions to help the
patient make a list of what is important and not important in life and the time commitment
for each. Which standardized (NIC) nursing intervention does this action implement?
1)
Spiritual Support
2)
Self-Esteem Enhancement
3)
Values Clarification
4)
Hope Inspiration
ANS: 3
One of the steps of most values-clarification processes is to list values (what is important
and not important in ones life) and the time commitment for each. The nurse facilitates
this by asking reflective, clarifying questions of the patient. Values clarification does not
necessarily directly enhance self-esteem, inspire hope, or provide spiritual support,
although it can indirectly contribute to development of spiritual identity.
PTS: 1 DIF: Moderate REF: ESG, Standardized Language, Table Standardized
Language: Using Selected NIC Interventions and Activities to Support Spirituality
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
15. The nurse is a Christian. She is caring for a Jewish patient who has asked her
to offer a prayer at the bedside. The nurse feels comfortable doing so. Which of the
following actions by the nurse is appropriate?
1)
Offer a prayer for healing using the nurses usual words and format.
2)
Begin the prayer with Jehovah God as she always does while avoiding the name of Jesus.
3)
Avoid saying any name for the Supreme Being while praying and quote an Old
Testament Bible scripture as the prayer.
4)
Say, What name would you like for me to use to address the Supreme Being when I am
praying for you?
ANS: 4
Ask how the patient prefers to address the Divine. Some people prefer the use of parental
language in their prayers; for example, Father God or Divine Mother. Some use the names
Jehovah, Yahweh, or Allah. Hindus may address one or more of multiple gods, each of
whom has several names. So seek direction from the patient in these matters: Most people
are honored to be able to explain their beliefs and practices to someone who is open to the
experience. The nurse should not assume that using the names Jesus and Jehovah God
would be supportive to the patient, although they might not offend in any way. The nurse
does not need to avoid addressing God by a name, but the most supportive way to do so is
to find out the name the patient wishes to use. Furthermore, the nurse should not assume
that the patient would find a New Testament Bible verse to be helpful spiritually.
PTS:1DIF:ModerateREF:p. 350
KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. A patient has a nursing diagnosis of Noncompliance with medication regimen
related to a belief that God will heal her and that it would show a lack of faith to take the
medications. The nurse and a clergyman have spent some time discussing spiritual and
treatment issues with the patient. Which of the following would indicate that progress is
being made toward achieving compliance with healthcare therapy? (Choose all that
apply.) The patient says
1)
I will try to pray more often for stronger faith that God will heal me.
2)
Let me think about it until tomorrow; I may see my way to taking those pills then.
3)
You know, Ive known some very holy people who were not cured by God.
4)
There is no confusion in my mind as to the right thing for me to do.
ANS: 2, 3
Agreeing to consider treatment (think about it) and recognizing that sometimes faithful
people are not cured both suggest that the patient is at least considering that it is all right
for her to question her beliefs. Praying for stronger faith in Gods healing suggests that she
is holding strong in her belief that she will be healed if she only has enough faith. Having
no confusion about the right thing to do would be evidence of problem resolution, provided
the right thing to do is to take the medication. However, you need more information to
know if that is what the patient means. It could just as easily mean that she is more sure
than ever that she should not take the medication.
Chapter 13 Experiencing Loss
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A 73-year-old patient who suffered a stroke is being transferred from the acute
care hospital to a nursing home for ongoing care because she is unable to care for herself
at home. Which type of loss is this patient most likely experiencing?
1)
Environmental loss
2)
Internal loss 3)
Perceived loss
4)
Psychological loss
ANS: 1
This patient is most likely experiencing an environmental loss because she is unable to
return to her familiar home setting. Instead, she is being transferred to the new
environment of a nursing home. Internal, perceived, and psychological losses are internal
and can only be identified by the person experiencing them.
PTS:1DIF:EasyREF:p. 358
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
2. According to William Worden, which task in the grieving process takes
longest to achieve?
1)
Accepting that the loved one is gone
2)
Experiencing the pain from the loss
3)
Adjusting to the environment without the deceased
4)
Investing emotional energy
ANS: 1
Worden described the tasks a grieving person must achieve. They progress from an initial
numbness or denial through experiencing and working through pain and grief and
eventually moving on with life. Shock with disbelief is not a Worden task.
PTS:1DIF:EasyREF:p. 359
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Recall
3. What emotional response is typical during the Randos confrontation phase of
the grieving process?
1)
Anger and bargaining
2)
Shock with disbelief
3)
Denial
4)
Emotional upset
ANS: 4
During the confrontation phase, the person faces the loss and experiences emotional upset.
In the avoidance phase, the person experiences shock, disbelief, denial, anger, and
bargaining. During the accommodation phase, the person begins to live with the loss, feel
better, and resume routine activities.
PTS:1DIF:ModerateREF:p. 359
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall
4. An elderly man lost his wife a year ago to cardiovascular disease. During
a healthcare visit, he tells the nurse he has begun adjusting to life without his wife.
According to John Bowlby, which stage of grief does this comment most likely indicate?
1)
Shock and numbness
2)
Yearning and searching
3)
Disorganization and despair 4)
Reorganization
ANS: 4
According to Bowlby, a person adjusts to life without the deceased during the
reorganization phase. During the shock and numbness phase, the person experiences
disorientation and a feeling of helplessness. The person wants to be reconnected with the
deceased during the yearning and searching phase. The person feels pain and the
emotions of grief during the disorganization and despair phase.
PTS:1DIF:ModerateREF:p. 359
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
5. Which patient is at most risk for experiencing difficult
grieving? 1)
The middle-aged woman whose grandmother died of advanced Parkinsons disease 2)
The young adult with three small children whose wife died suddenly in an accident
3)
The middle-aged person whose spouse suffered a slow, painful death
4)
The older adult whose spouse died of complications of chronic renal disease
ANS: 2
Although it is impossible to predict with certainty and the grieving process is highly
individual and personal, in general those who suffer a sudden loss typically have more
difficult grieving than those who have had the time to prepare for the death. Family and
friends of persons with chronic illnesses (e.g., cancer) have usually had time to
emotionally prepare for the death, initiate the funeral and burial arrangements, and begin
the grieving process before the death occurs.
PTS: 1 DIF: Moderate REF: p. 360
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
6. During a health history, a patient whose wife died unexpectedly 6 months ago in a
motor vehicle accident admits that he drinks at least six bourbon and waters every night
before going to bed. Which type of grief does this best illustrate?
1)
Delayed
2)
Chronic
3)
Disenfranchised
4)
Masked
ANS: 4
Masked grief occurs when the person is grieving, but it may look as though something else
is occurring; in this case, the person is abusing alcohol. Delayed grief occurs when grief is
put off until a later time. Chronic grief begins as normal grief but continues long term with
little resolution of feelings or ability to rejoin normal life. Disenfranchised grief is
experienced when a loss is not socially supported.
PTS: 1 DIF: Moderate REF: p. 361
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
7. According to the Uniform Determination of Death Act, which bodily
function must be lost to declare death?
1)
Consciousness
2)
Brain stem function
3)
Cephalic reflexes
4)
Spontaneous respirations
ANS: 2
According to the Uniform Determination of Death Act, death can be declared when there
is a loss of brain stem function. Higher-brain death occurs when there is a loss of
consciousness, cephalic reflexes, and spontaneous respirations.
PTS:1DIF:ModerateREF:p. 362
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall
8. A patients wife tells the nurse that she wants to be with her husband when he
dies. The patients respirations are irregular, and he is congested. The wife tells the nurse
that she would like to go home to shower but that she is afraid her husband might die
before she returns. Which response by the nurse is best?
1)
Certainly, go ahead; your husband will most likely hold on until you return.
2)
Your husband could live for days or a few hours; you should do whatever you are
comfortable with.
3)
You need to take care of yourself; go home and shower, and Ill stay at his bedside while
you are gone.
4)
Dont worry. Your husband is in good hands; Ill look out for him.
ANS: 2
The patient is exhibiting signs that typically occur days to a few hours before death. The
nurse should provide information to the wife so she can make an informed decision about
whether to leave her husbands bedside. The nurse should not offer false reassurance by
stating that the patient will most likely be fine until the wifes return. The nurse should not
offer her opinion by telling the wife that she needs to take care of herself. It is also
unrealistic for the nurse to stay with the patient until his wife returns. The nurse would be
minimizing the wifes concern by telling her not to worry because her husband is in good
hands. The issue for the family member is not trust in the competency of the healthcare
provider but rather wanting to be present with her spouse at the time of death.
PTS:1DIF:ModerateREF:dm 367-368
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
9. Mr. Jackson is terminally ill with metastatic cancer of the colon. His family
notices that he is suddenly more focused and coherent. They are questioning whether he
is really going to die. The nurse recognizes that a sudden surge of activity may occur
1)
Moments before death
2)
Days to hours before death
3)
1 to 2 weeks before death
4)
1 to 3 months before death
ANS: 3
Days to hours before death, patients commonly experience a surge of energy that brings
mental clarity and a desire to speak with family. One to 3 months before death, the dying
person begins to withdraw from the world by sleeping more and eating less. One to 2
weeks before death, the body loses its ability to maintain itself, and body systems begin to
deteriorate. Near the time of death, the dying person does not respond to touch or sound
and cannot be awakened.
PTS:1DIF:ModerateREF:p. 367
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
10. Which intervention takes priority for the patient receiving hospice
care? 1)
Turning and repositioning the patient every 2 hours 2)
Assisting the patient out of bed into a chair twice a day
3)
Administering pain medication to keep the patient comfortable
4)
Providing the patient with small frequent, nutritious meals
ANS: 3
A priority intervention for the hospice team is administering pain medications to keep the
patient comfortable. Turning the patient to prevent skin breakdown and promote comfort
is also important, but it does not take priority over administering pain medications. The
patient may not be able to eat meals or get out of bed into the chair and may tolerate only
small amounts at a meal. During the dying process, bowel activity reduces and digestion is
minimal, which often results in nausea or food intolerance. Additionally, the bodys need
for nutrition and hydration is reduced as the body begins the desiccation process.
PTS:1DIFifficultREF:p. 363
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
11. The nurse has been explaining advance directives to a patient. Which
response by the patient would indicate that he has correctly understood the information?
An advance directive is a document
1)
Specifying your healthcare intentions should you become unable to make self-directed
decisions
2)
Identifying the activities considered to be evidence of quality care
3)
Verifying your understanding of the risks and benefits associated with a procedure
4)
Allowing you the autonomy to leave the hospital when you decide, even if it is against
medical advice
ANS: 1
An advance directive is a group of instructions stating the patients healthcare wishes
should he become unable to make decisions. The Patient Care Partnership is a document
that helps to ensure that patients receive quality care. An informed consent form verifies
the patients understanding of risks and benefits associated with a procedure. An against
medical advice form allows the patient to leave the hospital against medical advice and
releases the hospital of responsibility for the patient.
PTS:1DIF:ModerateREF:p. 364
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive
level: Comprehension
12. A patient with a history of chronic obstructive pulmonary disease has a living
will that states he does not want endotracheal intubation and mechanical ventilation as a
means of respiratory resuscitation. As the patients condition deteriorates, the patient asks
whether he can change his decision. Which response by the nurse is best?
1)
Ill call your physician right away so he can discuss this with you.
2)
You have the right to change your decision about treatment at any time.
3)
Are you sure you want to change your decision?
4)
We must follow whatever is written in your living will.
ANS: 2
The nurse should inform the patient that he has the right to change his decision about
treatment at any time. Next, the nurse should notify the physician of the patients decision
so that the physician can speak to the patient and revise the treatment plan as needed.
Questioning the patients decision is judgmental. The patient has the right to change his
living will at any time. The medical team should not follow the living will if the patient
changes his decision about what is in it.
PTS:1DIF:ModerateREF:p. 364
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
13. Which dysrhythmia confirms
death? 1)
Asystole (absence of heart activity)
2)
Pulseless electrical activity
3)
Ventricular fibrillation
4)
Ventricular tachycardia
ANS: 1
Asystole is a dysrhythmia that commonly serves as a confirmation of death. Pulseless
electrical activity, ventricular fibrillation, and ventricular tachycardia are potentially
lethal dysrhythmias that may respond to treatment.
PTS:1DIF:EasyREF:p. 365
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
14. A patient dying of heart failure has changed his choice about his end-of-life
treatment measures several times. He says, I just cant make up my mind about it. Which
nursing diagnosis is most appropriate for this patient?
1)
Deficient Knowledge
2)
Spiritual Distress
3)
Decisional Conflict
4)
Death Anxiety
ANS: 3
This patient is experiencing Decisional Conflict related to his end-of-life treatment
measures. Deficient Knowledge, Spiritual Distress, or Death Anxiety may be the etiology
of his changing decisions, but his indecision about his treatment option clearly identifies
his Decisional Conflict.
PTS:1DIF:ModerateREF:dm 367-368; high-level question, not stated verbatim in text |
V2, dm 168169; high-level question, not stated verbatim in text
KEY: Nursing process: Nursing diagnosis | Client need: PSI | Cognitive level: Analysis
15. Which nursing intervention should be included in the plan of care for a
patient dying of cancer?
1)
Encourage at least one family member to remain at the bedside at all times.
2)
Follow-up with other healthcare team members during weekly meetings.
3)
Avoid discussing the dying process with family (to reduce sadness).
4)
Encourage family members to participate in care of the patient when possible.
ANS: 4
The plan of care should include encouraging family members to help with the patients
care when they are able. Family members should also be encouraged to take care of
themselves. They often need to be encouraged to take breaks to eat and rest. Provide
them with anticipatory guidance about the stages of death so they know what to expect.
Follow up promptly (not weekly) with other healthcare team members to address family
concerns.
PTS: 1 DIF: Moderate REF: dm 369-371
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
16. Which intervention by the nurse is most appropriate when she notices that
her dying patient has developed a death rattle?
1)
Perform nasotracheal suctioning of secretions.
2)
Turn the patient on his side and raise the head of the bed.
3)
Insert a nasopharyngeal airway as needed.
4)
Administer morphine sulfate intravenously.
ANS: 2
If a death rattle occurs, turn the patient on his side, and elevate the head of the bed.
Nasotracheal suctioning and inserting a nasopharyngeal airway are ineffective against a
death rattle and may cause the patient unnecessary discomfort. The patient may require IV
morphine sulfate to treat pain, but it does not help stop a death rattle. This narcotic
analgesic can also reduce the respiratory drive, leading to hypoventilation and respiratory
depression or arrest.
PTS:1DIF:ModerateREF:p. 376
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
17. Which of the following patient goals is most appropriate when managing
the patient dying of cancer? The patient will
1)
Request pain medication when needed
2)
Report or demonstrate satisfactory pain control
3)
Use only nonpharmacological measures to control pain
4)
Verbalize understanding that it may not be possible to control his pain
ANS: 2
The most important goal is that the patient will report or demonstrate satisfactory pain
control. The nurse should administer pain medication on a regular schedule to ensure
satisfactory pain control; pain may not be controlled if medication is administered on an as
needed basis. Nonpharmacologic measures can be a helpful adjunct in controlling pain, but
they are not likely to be adequate for pain associated with cancer. Effective pain- control
medications are available and can be administered by several routes; it should be possible
to control the pain.
PTS: 1 DIF: Moderate REF: p. 369
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
18. When providing postmortem care, the nurse places dentures in the mouth and
closes the eyes and mouth of the patient within 2 to 4 hours after death. Why is the timing
of the action so important?
1)
To prevent blood from settling in the head, neck, and shoulders
2)
To perform these actions more easily before rigor mortis develops 3)
To set the mouth in a natural position for viewing by the family
4)
To prevent discoloration caused by blood settling in the facial area
ANS: 2
Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should place dentures
in the mouth and close the patients eyes and mouth before that time. The nurse should
place a pillow under the head and shoulders to prevent blood from settling there and
causing discoloration. Closing the patients mouth and tying a strip of soft gauze under the
chin and around the head keeps the mouth set in a natural position for a viewing later.
Closing the eyes after death creates a peaceful resting appearance when the body is later
viewed but has nothing to do with setting the mouth. Placing dentures in the mouth and
closing the eyes and mouth do not prevent discoloration in the facial area.
PTS: 1 DIF: Moderate REF: p. 378
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
19. How should the nurse respond to a family immediately after a patient
dies? 1)
Ask the family to leave the patients room so postmortem care can be performed.
2)
Leave tubes and IV lines in place until the family has the opportunity to view the body.
3)
Express sympathy to the family (e.g., I am sorry for your loss).
4)
Tell the family that they will have limited time with their loved one.
ANS: 3
The nurse should express sympathy to the family immediately after the patients death.
She should give the family as much time as they need with their loved one and take care
to present the body in a restful pose. If family members are not present at the time of
death, remove tubes and IV lines before they see the body, unless an autopsy is planned
or the death is being investigated by the coroner. The body should not be removed from
the patient care area until the family is ready.
PTS:1DIF:ModerateREF:p. 378
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
20. The mother of a preschool child dies suddenly of a ruptured cerebral
aneurysm. What recommendation should the nurse make to the family regarding how to
most therapeutically care for the child?
1)
Take the child to the funeral even if he is frightened.
2)
Notify the physician immediately if the child shows signs of regression.
3)
Spend as much time as possible with the child.
4)
Provide distraction whenever the child begins to express feelings of sadness.
ANS: 3
The nurse should advise the family to spend as much time as possible with the child. If
the child is frightened about attending the funeral, he should not be forced to attend.
Signs of regression are a normal reaction to the loss of a loved one, especially a parent.
The child should be encouraged to express his feelings and fears.
PTS:1DIF:ModerateREF:p. 380
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
21. Which intervention should be included in the plan of care for a patient in
the end-stage death process?
1)
Encourage the patient to accept as much help as possible.
2)
Avoid administering laxatives.
3)
Wet the lips and mouth frequently.
4)
Administer pain medication on an as-needed basis.
ANS: 3
If the patient is unable to take fluids, prevent dryness and cracking of lips and mucous
membranes by wetting the lips and mouth frequently. Encourage the patient to be as
independent as possible. Administer laxatives if constipation occurs. Administer pain
medications on a regular schedule instead of waiting for the patient to request them.
PTS:1DIF:ModerateREF:p. 375
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
22. Throughout the course of his illness, a patient has denied its seriousness, even
though his health professionals have explained prognosis of death very clearly.
Physiologic signs now indicate that he will probably die within a short period of time, but
he is still firmly in a state of emotional denial. The patient says to the nurse, Tell my wife
to stop hovering and go home. Im going to be fine. How should the nurse respond?
1)
Your physical signs indicate that you will likely not live more than a few more days.
2)
You seem very sure that you are not going to die. Please tell me more about what you are
feeling.
3)
It seems to me you would be feeling some anger and wondering why all this is happening
to you.
4)
It would be best for your family if you were able to work through this and come to accept
the reality of your situation.
ANS: 2
Not all patients go through all the traditional stages of grieving. It is not the nurses
responsibility to move patients sequentially through each stage of the dying and grieving
process with the goal that everyone ends life accepting death. It is a nursing responsibility
to accept and support people where they are and help them to express their feelings.
Nurses need to understand patients, not change them. In this situation, denial may be very
important to this patient, as an emotional defense and coping strategy.
You seem sure . . . tell me . . . what you are feeling restates what the patient has said
(indicating understanding) and encourages expression of feelingsboth are supportive.
Even though moving him through stages is not the goal in this situation, support does
facilitate that.
Telling the patient that his physical signs indicate that death is imminent is presenting truth
and reality; however, the exact time of death is not always predictable. Forecasting the
hour of death can have negative impact on the family as they anticipate the event with
emotion and exhaustion. Presenting reality is appropriate in certain circumstances earlier
in the dying process, but not in this situation because it has already been tried with no
change in the patient. Presenting reality does not support the patients needs at this time.
Saying It seems to me you would be feeling some anger . . . is directed toward moving the
patient from denial and suggesting he should feel something he has not yet expressed.
This is not therapeutic. Saying It would be best for your family . . . presumes that the
nurse knows more about what is best for the patients family than the patient himself. This
statement is also judgmental.
PTS: 1 DIF: Difficult REF: dm 362-363
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
23. A home health patient previously lived with her sister for more than 20 years.
Although it has been over a year since her sister died, the patient tells the nurse, Its no
worse now, but I never feel any relief from this overwhelming sadness. I still cant sleep a
full night. The house is a mess; I feel too tired, even to take a bath. But, sometimes at
night, she comes to me and I can see her plain as can be. The patients clothing is not clean
and her hair is not combed. She is apparently not eating adequately. What can the nurse
conclude? The patient is probably
1)
Grieving longer than usual because of the closeness of the relationship with her sister
2)
Experiencing a depressive disorder rather than simply grieving the loss of her sister
3)
Feeling guilt and worthlessness because her sister died and she is still alive
4)
Interpreting the holiday as a trigger event, which is causing her to hallucinate
ANS: 2
The patient is likely experiencing a depressive disorder. Her symptoms include unrelieved,
overwhelming sadness; insomnia; difficulty carrying out ADLs; fatigue; and visual
hallucinations. Note that her sadness is pervasive, not created by a trigger event (holiday).
Of those symptoms, insomnia is common to both grief and depression, but the other
symptoms are signs of depressive disorder. There is, of course, no correct timeline for
what constitutes longer than usual grieving; however, the patients symptoms are typical of
depression, not grief. She has not said she feels guilty or worthless, and there is nothing
from which the nurse could infer that. She has specifically said that the holiday has not
made her feel any worsethat is, it has not been a trigger event.
PTS: 1 DIF: Difficult REF: dm 367-368
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which intervention is appropriate for a client receiving palliative care?
Choose all that apply.
1)
Surgical insertion of a device to decrease the workload of the heart in a patient awaiting
heart transplantation
2)
Administering IV dopamine to raise blood pressure of a patient with end-stage lung
cancer
3)
Providing moisturizing eye drops to an unconscious patient whose eyes are dry
4)
Administering a medication to relieve the nausea of a patient with end-stage leukemia
ANS: 3, 4
Palliative care focuses on relieving symptoms for patients whose disease process no
longer responds to treatment. Providing moisturizing eye drops and administering
antinausea medication in a patient with end-stage leukemia are examples of palliative
care. Surgical insertion of a device to decrease heart workload and administering
dopamine are aggressive treatment measures.
PTS:1DIF:ModerateREF:p. 363
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
2. To be eligible for insurance benefits covering hospice care, a physician
must certify that which of the following apply to the patient? Choose all that apply.
1)
Life expectancy is not more than 6 months.
2)
Life expectancy is not more than 12 months.
3)
Condition is expected to improve slightly.
4)
Condition is not expected to improve.
ANS: 1, 4
For a patient to be eligible for hospice care insurance benefits, a physician must certify
that the patient is not expected to improve or will most likely die within 6 months.
PTS:1DIF:ModerateREF:p. 363
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Recall
3. Which of the following might be a warning sign that a child needs
professional help after the death of a loved one? Choose all that apply.
1)
Interest in his usual activities
2)
Extended regression
3)
Withdrawal from friends
4)
Inability to sleep
5)
Intermittent sadness
ANS: 2, 3, 4
The warning signs that may indicate the need for professional help include inability to
sleep, extended regression, loss of interest in daily activities, and withdrawal from friends.
Interest in usual activities is a sign of coping; intermittent expressions of sadness and
anger are to be expected, even over a long period of time.
Chapter 17 Documenting & Reporting
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A client admitted to the inpatient medical-surgical unit has suffered sudden
respiratory failure. The clients condition is getting worse; he is cyanotic (turning blue)
with periods of labored breathing. What action should the nurse take first?
1)
Study the discharge plan.
2)
Check the graphic data for vital signs.
3)
Examine the history and physical.
4)
Look for an advance directive.
ANS: 4
The advance directive, which should be located in a special section of the patients medical
record, should be examined first because the patients symptoms indicate that he may need
to be resuscitated. The advanced directive contains information about the patients wishes
for intensity of care and actions that should be taken in the event of a life- threatening
event. The discharge plan contains data from utilization review, case managers, or
discharge planners on anticipated needs after discharge. Graphic data are to record
assessment done frequently, such as vital signs. The history and physical provide a
detailed summary of the patients current problem, past medical and social history,
medications taken by the patient, review of systems, and physical examination data.
PTS:1DIF:EasyREF:p. 386
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
2. A hospital uses a source-oriented medical record. What is a major
disadvantage of this charting system?
1)
It involves a cooperative effort among various disciplines.
2)
The system requires diligence in maintaining a current problem list.
3)
Data may be fragmented and scattered throughout the chart.
4)
It allows the nurse to provide information in an unorganized manner.
ANS: 3
A major disadvantage of a source-oriented medical record is that data may be fragmented
and scattered throughout the chart. The problem-oriented medical record requires a
cooperative effort among disciplines and diligence in maintaining a current problem list.
Narrative charting allows the nurse to provide information in a disorganized manner.
PTS:1DIF:ModerateREF:p. 387
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
3. The patients medical record contains the following documentation:
06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104F.
Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18
gauge IV catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt
receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base.
Loose cough present. Pt unable to expectorate secretions.Ann. Davids, RN
Which type of charting has the nurse used?
1)
Narrative
2)
Focus
3)
SOAP
4) PIE
ANS: 1
The nurse used narrative charting when documenting the condition of this newly admitted
patient. This format is free text description of the patient status and nursing care. Focus
charting highlights the patients concerns, problems, and strengths in a three-column
format. SOAP is an acronym for subjective data, objective data, assessment, and plan.
This charting format is used to address single problems or to write summative notes. PIE
is an acronym for problem, interventions, and evaluation. This charting method also
addresses problems.
PTS:1DIF:EasyREF:p. 392
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
4. The department of nursing at a local hospital is considering changing to
charting by exception (CBE). Which statement provides a rationale to support making
this change? CBE
1)
Reduces the time nurses spend charting
2)
Addresses the patients concerns holistically
3)
Establishes an ongoing care plan from admission
4)
Is most useful when constructing a timeline of events
ANS: 1
An advantage of CBE is that it reduces the amount of time that nurses must spend
documenting. CBE assumes that unless a separate entry is made, all standards have been
met with a normal response. Focus charting addresses the patients concerns holistically.
PIE charting establishes an ongoing care plan from admission. Narrative charting is
especially useful when attempting to construct timelines of events.
PTS:1DIF:ModerateREF:p. 387
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
5. A patient is admitted to the emergency department with a stroke. After being
stabilized, the patients needs are best met if the nurse documents a care plan that provides
for
1)
Acute interventions
2)
Patient teaching
3)
Discharge needs 4)
Family health data
ANS: 3
The patients potential discharge needs should be evaluated when the patient first enters
the healthcare facility. After the patient is admitted, discharge needs should be
continually reevaluated and documented throughout the patients hospitalization.
PTS:1DIF:ModerateREF:p. 395
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
6. The patients health record contains the following providers order: furosemide 40
mg intravenously STAT. If the nurse later needed to know when the medication had been
given and the patients response to the medication, where would he look?
1)
Progress notes
2)
Graphic record
3)
Narrative notes 4)
MAR
ANS: 3
The nursing narrative note will contain documentation about the time the medication was
administered and the patients response to the medicine. In contrast, the MAR will only
contain documentation about when the medication was given, not the patients response.
The physicians progress note contains documentation about why the furosemide was
ordered. The graphic record will not contain charting about the medication but will
contain information about the patients output.
PTS: 1 DIF: Easy
REF: dm 386-387; 396; 401
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
7. A client who cannot manage a patient-controlled analgesia pump is prescribed
morphine 4 mg intravenously q 1 hour PRN pain. When should the nurse administer the
medication?
1)
Every hour around-the-clock
2)
Immediately after taking off the order
3)
As needed, but not more than once per hour
4)
1 hour after the last administered dose
ANS: 3
PRN is the abbreviation for as needed. The nurse should administer the medication after
assessing that the patient needs the medication or the patient requests it and at least 1
hour has elapsed since the last dose. STAT medications must be administered
immediately.
PTS:1DIF:ModerateREF:p. 399
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
8. The nurse administers heparin 5000 units subcutaneously at 2100 and
documents in the medication administration record that the dose was administered. What
other information is important for the nurse document?
1)
Injection site
2)
Previous site of administration
3)
Patient response to medication
4)
Heart rate prior to administration
ANS: 1
After administering an injection, the nurse must document the injection site to prevent the
patient from receiving repeated injections in the same location. Heparin 5000 units subQ
was prescribed for the patient. The previous route of administration is already documented
on the MAR from the previous dose and would not be noted in the entry for the current
dose. The patients response to medication is recorded in the nurses narrative note in the
traditional paper for the electronic health record. When the nurse signs out that the drug
was given in the medication administration record, she is validating that she administered
the drug according to the physicians order. Heparin does not affect heart rate.
PTS:1DIF:ModerateREF:p. 399
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
9. A patient with a history of hypertension and rheumatoid arthritis is admitted
for surgery for colon cancer. Which integrated plan of care (IPOC) would be most
appropriate for the nurse to implement?
1)
Hypertension
2)
Rheumatoid arthritis
3)
Postoperative colon resection
4)
Follow all three plans
ANS: 3
The postoperative colon resection integrated plan of care should be followed; however,
modifications should be made to meet the patients other health needs. Therefore, portions
of the hypertension and rheumatoid arthritis integrated plan of care may be added to the
postoperative colon resection plan of care.
PTS: 1 DIF: Difficult REF: p. 400; ESG,
KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitive level:
Application
10. The nurse notifies the primary care provider that the patient is experiencing
pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously
every hour as needed for pain. How should the nurse document this telephone order?
1)
09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews, RN
2)
09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay
Andrews, RN
3)
09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay
Andrews, RN
4)
09/02/13 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN
ANS: 2
Correct documentation of a telephone order is as follows: 09/02/13 0845 morphine 4 mg
intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN (date, time,
medication, route, frequency of dose, circumstances under which it is to be given,
prescribers name and title, nurses name and title.) The other options demonstrate
incomplete documentation of a telephone order.
PTS:1DIF:ModerateREF:dm 403-404
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
11. A patient refuses a dose of medication. How should the nurse document
the event?
1)
Patient is uncooperative and refuses the prescribed dose of digoxin.
2)
Patient refuses the 0900 dose of digoxin.
3)
Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin.
4)
0900 dose of digoxin not given.
ANS: 2
Patient refuses the 0900 dose of digoxin objectively describes the event in which the
patient refuses to take his 0900 dose of digoxin. 0900 dose of digoxin not given provides
no explanation as to why the medication was not given. The other two options offer
judgmental information, which should be avoided when charting.
PTS:1DIF:ModerateREF:p. 399
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
12. The nurse makes a mistake while documenting in the patients health
record. Which action should the nurse take?
1)
Use an opaque white fluid to cover the documentation error.
2)
Completely cover the documentation error with black ink.
3)
Draw a line through the error and initial the change.
4)
Use correction tape to make the documentation correct.
ANS: 3
The nurse should draw a single line through the documentation error and place her initials
next to the change. In some institutions, the nurse must also write the words error or
mistaken entry above the error. The nurse should never use opaque cover-up liquid or
correction tape. It is not acceptable to alter the patients health record as though the error
was not made. Making note of the correction in documentation makes it clear to others
what happened.
PTS:1DIF:ModerateREF:p. 407
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
13. At 1000 on 11/14/10, the nurse takes a telephone order for metoprolol 5 mg
intravenously now. What is the latest date and time the nurse will expect the prescriber to
countersign the order?
1)
11/14/13 at 1200
2)
11/14/13 at 2200
3)
11/15/13 at 1000
4)
11/16/13 at 1000
ANS: 3
The prescriber must countersign all verbal and telephone orders within 24 hours.
PTS:1DIF:ModerateREF:p. 404
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
14. The nurse takes a telephone order from a primary care provider for 40 mEq
potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours.
Which action must the nurse take to ensure the accuracy of the order?
1)
Repeat the order to the prescriber even if she believes she understood the order correctly.
2)
Immediately notify the pharmacy of the order and verify it with a pharmacist.
3)
Ask the unit secretary to listen to the prescriber on the phone to verify the order.
4)
Transcribe the order onto note paper and verify the dosage in a drug handbook.
ANS: 1
The nurse should repeat the order to the prescriber even if she believes she understood it
entirely. If possible, she should have a second nurse (not the unit secretary) listen to the
order to verify accuracy. Only the prescribing provider, not the pharmacist, can verify the
order. The nurse should transcribe the order directly on the patients chart. Transcribing it
on a piece of paper and then copying it again introduces one more chance of error.
PTS:1DIF:ModerateREF:p. 404
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
15. A resident in a long-term care facility receiving Medicare funds requires
care for a stage 2 pressure ulcer. How often must the nurse document this patients care?
1)
Every 2 weeks
2)
Every shift
3)
Every week
4)
Every 3 months
ANS: 2
When a patient requires Medicare-reimbursed services, such as wound care,
documentation is required every shift. Those who require assistance with medications,
nutrition, and activities of daily living must have a summary written by a registered nurse
or licensed practical nurse every 2 weeks. A summary must also be recorded on a weekly
basis for those who require wound care. The Minimum Data Set must be updated every 3
months.
PTS:1DIF:ModerateREF:p. 401
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
16. What is the deadline after admission for using the Minimum Data Set
to evaluate a newly admitted resident of a long-term care facility?
1)
14 days
2)
3 days
3)
2 days
4)
24 hours
ANS: 1
Federal regulations require that a resident be evaluated using the Minimum Data Set
within 14 days of admission to a long-term care facility.
PTS:1DIF:EasyREF:p. 401
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall
17. A client is admitted to a long-term care facility. The nurse knows that
federal law requires the use of
1)
The Minimum Data Set (MDS) for assessment
2)
Situation-background-assessment-recommendation (SBAR) for reporting
3)
Healthcare Financing Administration guidelines prior to surgery
4)
Joint Commission guidelines for discharge planning
ANS: 1
Federal regulations require that a resident be evaluated using the Minimum Data Set
(MDS) within 14 days of admission to a long-term care facility. SBAR is a technique used
for communicating and organizing a hand-off report. HCFA guidelines govern home
healthcare documentation. Joint Commission guidelines do apply to long-term care
facilities, but only the MDS assessment is mandated by federal law.
PTS:1DIF:EasyREF:p. 401
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall
18. The surgeon enters a computerized order for a patient in the postoperative
period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM.
Which action indicates that the nurse is following the surgeons order? The nurse
1)
Performs oral care
2)
Assists the patient out of bed
3)
Assists the patient with bathing
4)
Changes the patients operative dressings
ANS: 2
OOB is the abbreviation for out of bed. The nurse is following the physicians order when
she assists the patient out of bed in the morning. OOB does not indicate that the nurse
should perform oral care, assist with bathing, or change the patients postoperative
dressings.
PTS:1DIF:EasyREF:p. 391
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
19. What is the purpose of completing an occurrence
report? 1)
Provide a legal defense should the patient seek legal action after an unusual occurrence 2)
Track problems and identify areas for quality improvement
3)
Report errors to the Food and Drug Administration
4)
Report medical errors to the Joint Commission
ANS: 2
Occurrence reports are used to track problems and identify areas for quality
improvement. Occurrence reports are not used to provide legal defense should a patient
seek legal action or to report errors to the FDA or Joint Commission.
PTS:1DIF:ModerateREF:p. 400
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
20. The nursing instructor is teaching the student about occurrence reports. Which
statement by the student indicates an understanding of the purpose of occurrence reports?
1)
Occurrence reports track problems and identify areas for quality improvement.
2)
Occurrence reports are required by the Food and Drug Administration to report drug
errors.
3)
The Joint Commission requires occurrence reports for all client falls.
4)
Occurrence reports provide legal information should the patient seek legal action after an
unusual occurrence.
ANS: 1
Occurrence reports are used to track problems and identify areas for quality
improvement. Occurrence reports are not used to provide legal information should a
patient seek legal action. As an internal communication and documentation tool,
occurrence reports are not required to be reported to the FDA or Joint Commission.
PTS:1DIF:ModerateREF:p. 400
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
21. Which of the following is a disadvantage of paper health
records? 1)
Assist collaboration
2)
Provide cautionary reminders 3)
Are sometimes illegible
4)
Serve as a resource
ANS: 3
A disadvantage of paper documentation systems is that they are sometimes illegible. This
increases the risk for medication administration and other errors, as well as taking nurses
time to decipher handwriting and call providers.
PTS:1DIF:ModerateREF:p. 390
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
22. The nursing assistive personnel (NAP) informs the nurse that a patient has
fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify
the correct documentation of the fall.
1)
Patient found on floor in pain after falling out of bed.
2)
Patient found on floor after falling out of bed; found by NAP Smith.
3)
Patient fell out of bed but is currently in bed.
4)
Patient reminded to not climb OOB after falling.
ANS: 2
Charting must be accurate and succinct. Only chart what you observe. Do not chart what
others have observed as your own observation. Avoid judging patients; instead, chart
objectively.
PTS: 1 DIF: Moderate REF: p. 400
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
23. Which set of topics makes up a hand-off report given in a
recommended format?
1)
Data-action-response
2)
Subjective-objective-assessment-plan
3)
Situation-background-assessment-recommendation
4)
Patient-diagnosis-medications-activity
ANS: 3
The SBAR (situation-background-assessment-recommendation) technique is used as a
mechanism to give a hand-off report by enabling a focused communication between
healthcare team members. DAR is used in Focus Charting, and SOAP is a method for
documenting nursing care. The nursing admission assessment is completed and
documented at the time of admission.
PTS: 1 DIF: Easy REF: p. 402
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which statement by the student nurse indicates an understanding of the
nursing Kardex? Choose all correct answers.
1)
The Kardex pulls data from multiple areas of the patients chart.
2)
The Kardex is usually kept at the patients bedside.
3)
The Kardex is used to document patient response to interventions.
4)
The Kardex summarizes the plan of care and guides nursing care.
ANS: 1, 4
The Kardex is a tool that pulls data from multiple areas of the patients health record and
helps guide nursing care. Responses to interventions are documented on flow sheets and
in nurses notes. Kardexes are paper forms that are kept together in a portable file at the
nurses station to allow all team members access to the summary information. The file is
portable, so it could be carried to the bedside briefly; however, it is not stored there, as a
general rule.
PTS:1DIF:ModerateREF:p. 400
KEY: Nursing process: N/A | Client need: Safe-care environment | Cognitive level:
Application
2. Which action by the nurse breaches patient confidentiality? Select all that
apply. 1)
Leaving patient data displayed on a computer screen where others may view it 2)
Remaining logged on to the computer system after documenting patient care
3)
Faxing a patient report to the nurses station where the patient is being transferred
4)
Informing the nurse manager of a change in the patients condition
ANS: 1, 2
Leaving patient data displayed on a computer screen where others may view them
breaches patient confidentiality. The nurse should log off the computer immediately after
use. Faxing a report to the nurses station receiving a patient does not breach patient
confidentiality because it is located at the nurses station out of others view. Anyone
directly involved in the patients care has the right to know about the patients condition
without breaching patient confidentiality.
PTS:1DIF:ModerateREF:p. 408
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
3. Which statement by the new graduate nurse indicates a need for
further instruction about documentation? Select all that apply.
1)
I can wait until the end of the shift to document my care.
2)
Charting every 2 hours is the most appropriate way to document nursing care.
3)
I find it easier to chart before I go to lunch and then after my shift report.
4)
I should chart as soon as possible after nursing care is given.
ANS: 1, 2, 3
Documentation should be performed as soon as possible after the nurse makes an
assessment or provides care. The longer the nurse waits, the less accurate the
documentation will be. Leaving documentation until the end of the shift may cause
important details to be omitted or mistaken. It is not necessary to complete
documentation on a strict schedule, such as every 2 to 4 hours. Even waiting until lunch
or reporting after the shift is over is too long of a period of time for accurate
documentation. In addition, the objectivity of documentation might be influenced by the
discussion that occurs during report.
PTS: 1 DIF: Moderate REF: p. 405-406
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
4. The nurse who understands the electronic health record (EHR) can do which
of the following? Select all that apply.
1)
Facilitate evidence-based nursing practice
2)
Promote efficient use of the nurses documentation time
3)
Reduce the opportunity for interdisciplinary collaboration
4)
Ensure improved client safety and outcomes
ANS: 1, 2, 4
Electronic health records (EHR) have many advantages, including the facilitation of
evidence-based nursing practice, efficient use of the nurses documentation time, and
improved client safety and outcomes. The EHR does not impair interdisciplinary
collaboration; rather, the EHR fosters communication and collaboration among
healthcare team members.
PTS:1DIF:EasyREF:p. 388
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
5. In performing a hand-off report, the nurse should communicate information
on which of the following? Select all that apply.
1)
Teaching performed
2)
Any change in client status
3)
Treatments administered 4)
Hygiene measures performed
ANS: 1, 2, 3
Hand-off reports include any client teaching done, therapies and treatments administered,
and changes in the clients status. Hygiene care is routinely done in inpatient settings and is
usually recorded on a flow sheet. Hand-off reports should be succinct and not contain
routine information.
PTS: 1 DIF: Easy REF: p. 402
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
True/False
Indicate whether the statement is true or false.
1. The nursing Kardex is part of the patients permanent health
record. ANS: F
The Kardex is not part of the patients permanent medical record. It is a tool that helps
guide nursing care. It changes as different care is required.
Chapter 18 Measuring Vital Signs
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A clients vital signs at the beginning of the shift are as follows: oral
temperature 99.3F (37C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and
blood pressure 118/76 mm Hg. Four hours later the clients oral temperature is 102.2F
(39C). Based on the temperature change, the nurse should anticipate the clients heart rate
would be how many beats/min?
1)
62
2)
82
3)
102
4)
122
ANS: 3
Heart rate increases about 10 beats per minute for each degree of temperature to meet
increased metabolic needs and compensate for peripheral dilation.
PTS:1DIF:ModerateREF:p. 426
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
2. The nurse is assessing vital signs for a client after surgical procedure on the
left leg. IV fluids are infusing. It would be most important for the nurse to
1)
Compare the left pedal pulse with the right pedal pulse
2)
Count the clients respiratory rate for 1 full minute
3)
Take the blood pressure in the arm without an IV
4)
Take an oral temperature with an electronic thermometer
ANS: 1
For a client having surgery on the leg, the most important data would be whether the
circulation has been compromised because of the surgery. This can be done only by
comparing one leg with the other. The nurse would, of course, count the respiratory rate
for 1 full minute and take the BP in the arm without the IV. Oral temperatures are
commonly obtained using electronic thermometers.
PTS:1DIF:ModerateREF:p. 449-450
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
3. The nurse hears rhonchi when auscultating a clients lungs. Which nursing
intervention would be appropriate for the nurse to implement before reassessing lung
sounds?
1)
Have the client take several deep breaths.
2)
Request the client take a deep breath and cough.
3)
Take the clients blood pressure and apical pulse.
4)
Count the clients respiratory rate for 1 minute.
ANS: 2
Rhonchi are caused by secretions in the large airways and may clear with coughing. This
is how you differentiate between rhonchi and other adventitious sounds. Deep breathing
will not help to clear rhonchi. Taking the blood pressure and apical pulse and counting the
respiratory rate are not effective for clearing rhonchi and would not be sufficient for the
nurse to identify whether the sounds were, indeed, rhonchi.
PTS:1DIF:ModerateREF:p. 431
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
4. Which of the following sets of vital signs are all within normal limits for
patients at rest?
1)
Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54
2)
Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68
3)
Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84
4)
Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95
ANS:2
All of the adolescents vital signs are within normal parameters for the age. The infants
temperature is below normal for a rectal reading because the core temperature is
approximately 1 degree higher than readings from other sites. The heart rate (HR) for an
infant is high, the respiratory rate (RR) is low, and the blood pressure (BP) is high for the
age. For the typical adult, the temperature is high, the HR is low, the RR is high, and the
BP is elevated for the age. For the older adult, the temperature is high-end normal, the HR
is high, the RR is high, and the BP is high for the age.
PTS:1DIFifficultREF:p. 414; for adult vital signs ESG Table 19-1, Comparison of
Normal Vital Signs for Various Ages
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
5. The nurse assesses the following changes in a clients vital signs. Which
client situation should be reported to the primary care provider?
1)
Decreased blood pressure (BP) after standing up
2)
Decreased temperature after a period of diaphoresis
3)
Increased heart rate after walking down the hall
4)
Increased respiratory rate when the heart rate increases
ANS: 1
A drop in the clients blood pressure when standing indicates orthostatic hypotension, and
the cause should be investigated. The changes in vital signs indicated in the other options
are normal changes for the situations.
PTS:1DIF:ModerateREF:p. 439 for hypotension information but should read content
about all of the vital signs
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
6. The clients temperature is 101.1F. Which is the correct conversion to
centigrade? 1)
38.0C
2)
38.4C
3)
38.8C
4)
39.2C
ANS:2
To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by
5/9.
PTS:1DIFifficultREF:p. 419
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application
7. The client has had a fever, ranging from 99.8F orally to 103F orally, over the
last 24 hours. The clients fever would be classified as
1)
Constant
2)
Intermittent
3)
Relapsing
4)
Remittent
ANS: 4
Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay above
normal with only slight fluctuations. Intermittent fevers alternate between normal or
subnormal temperatures with periods of fever. Relapsing fevers alternate between periods
of fever and periods of normal temperature, each phase lasting 1 to 2 days.
PTS:1DIF:ModerateREF:p. 418
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
8. A clients vital signs 4 hours ago were temperature (oral) 101.4F (38.6C), heart
rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg.
The temperature is now 99.4F (37.4C). Based only on the expected relationship between
temperature and respiratory rate, the nurse might best anticipate the clients respiratory
rate to be
1)
16
2)
18
3)
20
4)
22
ANS:2
For every degree Fahrenheit (0.6C) the temperature falls, the respiratory rate may
decrease up to 4 breaths per minute. The clients temperature has fallen 2 degrees;
multiplied by 4, this is 8. It was 26 breaths/min: 26 8 = 18 breaths/min. Keep in mind,
this is an estimate and would vary depending on the patients baseline health, current
condition, age, and other factors.
PTS:1DIF:EasyREF:p. 430
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
9. Which one of the following clients would probably have a higher than
normal respiratory rate? A client who has
1)
Had surgery and is receiving a narcotic analgesic
2)
Had surgery and lost a unit of blood intraoperatively
3)
Lived at a high altitude and then moved to sea level
4)
Been exposed to the cold and is now hypothermic
ANS: 2
A reduction in hemoglobin from blood loss would increase the respiratory rate. Narcotics
and hypothermia slow the respiratory rate. Going from lower altitudes to higher altitudes
inhibits oxygen binding, so going to a lower altitude would decrease the respiratory rate or
have no effect. Hypothermia decreases the metabolic rate, so the respiratory rate would
likely decrease.
PTS:1DIF:ModerateREF:p. 430
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
10. For which of the following adult clients should the nurse make followup observations and monitor the vital signs closely? A client whose
1)
Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg
2)
Oral temperature is 97.9F in the morning and 99.8F in the evening
3)
Heart rate was 76 beats/min before eating and 88 beats/min after eating
4)
Respiratory rate is 16 breaths/min when standing and 18 when lying down
ANS: 1
Both the blood pressures would be classified as prehypertension according to the JNC 7
Express guidelines. Body temperature normally increases during the course of a day.
Heart rate increases for several hours after eating. Respiratory depth decreases when
lying down, so it would be normal for the rate would increase; both rates are within
normal limits.
PTS:1DIF:ModerateREF:p. 440
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
11. A client who has been hospitalized for an infection states, The nursing
assistant told me my vital signs are all within normal limits; that means Im cured. The
nurses
best response would be which of the following?
1)
Your vital signs confirm that your infection is resolved; how do you feel?
2)
Ill let your healthcare provider know so you can be discharged.
3)
Your vital signs are stable, but there are other things to assess.
4)
We still need to keep monitoring your temperature for a while.
ANS: 3
Vital signs are one indicator of a clients physiological status, but they are not an absolute
indicator of well-being from every aspect. It may be inaccurate to state that the vital signs
indicate the infection is resolved; vital signs could stabilize even if the infection remains
active. The healthcare providers decision regarding the clients readiness for discharge is
not based exclusively on the vital signs but rather is based on a compilation of other
sources of information, primarily the clients clinical status, but also cultures, complete
blood counts, and various other laboratory and possibly radiologic evidence. Although the
nurse will need to continue monitoring the temperature, other clinical signs must also be
monitored; therefore, the statement We still need to keep monitoring your temperature
. . . is incomplete and less useful than the statement that begins Your vital signs are
stable, but . . .
PTS:1DIFifficultREF:p. 414
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
12. The nursing instructor asks students how they would assess the fifth vital
sign. Which student would be correct?
1)
I would have the client rate her pain on a scale of 0 to 10.
2)
I would ask the client when she had her last bowel movement.
3)
I would take the clients pulse oximetry reading.
4)
I would interview the client about history of tobacco use.
ANS: 1
Pain is considered to be the fifth vital sign.
PTS:1DIF:EasyREF:p. 414
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
13. A clients axillary temperature is 100.8F. The nurse realizes this is outside
normal range for this client and that axillary temperatures do not reflect core temperature.
What should the nurse do to obtain a good estimate of the core temperature?
1)
Add 1F to 100.8F to obtain an oral equivalent.
2)
Add 2F to 100.8F to obtain a rectal equivalent.
3)
Obtain a rectal temperature reading.
4)
Obtain a tympanic membrane reading.
ANS: 3
Body temperatures, from lowest to highest, are axillary, oral, rectal, and tympanic. For
oral, axillary, and rectal temperatures, there is a 1F degree difference between each site
and the next higher one. However, mathematical conversions between sites are not
reliable and should be used only when a rough estimate is neededfor instance, to decide
whether a reading needs to be validated by another site or another thermometer. Rectal
temperatures are most reliable and most accurately reflect the core temperature.
Tympanic membrane readings are considered by most to be the least accurate and least
reliable.
PTS:1DIF:ModerateREF:dm 415, 421-422
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
14. In caring for a client who has a fever, it would be important for the nurse
to monitor for increased
1)
Urine output
2)
Sensitivity to pain
3)
Blood pressure 4)
Respiratory rate
ANS: 4
The metabolic rate increases with a fever, increasing a persons respiratory rate. Urine
output would more likely decrease, rather than increase, because of increased insensible
loss and possible loss of intake because of loss of appetite. Change in pain sensation is
not a symptom of a fever. Blood pressure is more likely to decrease with a fever because
of peripheral vasodilation.
PTS:1DIF:ModerateREF:p. 430
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
15. The nurse is teaching a client how to use a portable blood pressure device
to monitor his blood pressure at home. It would be most important for the nurse to
1)
Ask the client to demonstrate the use of the blood pressure device
2)
Explain the importance of frequent calibration of the device
3)
Give the client a chart to record his blood pressure readings
4)
Provide written instructions of the information taught
ANS: 1
All are important things to include in client education, but self-monitoring of blood
pressure is of little value unless it is done using proper technique. Requesting that the
client demonstrate the procedure would allow the nurse to evaluate the clients technique.
PTS: 1 DIF: Difficult REF: p. 437; not stated directly
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
16. At last measurement, the clients vital signs were as follows: oral temperature
98F (36.7C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure
(BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature
103.2F (38.5C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood
pressure 120/66 mm Hg. Which should be the nurses first intervention at this time?
1)
Ask the client if he has had a warm drink in the last 30 minutes.
2)
Notify the primary care provider of the clients temperature.
3)
Ask the client if he is feeling chilled. 4)
Take the temperature by a different route.
ANS: 1
With a fever, the heart rate and respiratory rate are usually elevated. In this case, they are
within normal limits, so the nurse should wonder about the accuracy of the temperature
reading and validate it in some way. Because having a hot drink is a common cause of
false readings, the nurse should determine whether that has occurred before retaking or
otherwise validating the reading.
PTS: 1 DIF: Moderate REF: p. 421; should know norms for all vital signs, p. 414, to
answer question
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
17. A clients average normal temperature is 98F. Which of the following
temperatures would be expected during the night in this healthy young adult client who
does not have a fever, inflammatory process, or underlying health problems?
1)
97.2F
2)
98.0F
3)
98.6F
4)
99.2F
ANS: 1
The lowest temperature occurs during sleep (usually at night) when the metabolic rate is
lowest. Temperature normally increases throughout the day until it peaks in the early
evening.
PTS:1DIF:EasyREF:p. 417
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
18. The nurse is instructing a client how to appropriately dress an infant in cold
weather. Which of the following instructions would be most important for the nurse to
include?
1)
Be sure to put mittens on the baby.
2)
Layer the infants clothing.
3)
Place a cap on the infants head.
4)
Put warm booties on the baby.
ANS: 3
All interventions are correct, but because of the many blood vessels close to the skin
surface in the head, infants lose approximately one third of their body heat through the
head. Therefore, to prevent heat loss, it is most important to cover the head.
PTS:1DIF:ModerateREF:p. 417
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
19. In evaluating a clients blood pressure for hypertension, it
would be most important to
1)
Use the same type of manometer each time
2)
Auscultate all five Korotkoff sounds
3)
Measure the blood pressure in both arms
4)
Monitor the blood pressure for a pattern
ANS: 4
Blood pressure fluctuates a great deal during the day and is influenced by age, sex,
activity, and many other factors. Any determination of hypertension must be done after
two or more BP readings taken on separate occasions. The type of manometer does not
greatly influence the reliability of BP readings, although the mercury manometer is more
accurate. Only the first and last Korotkoff sounds are necessary to determine a BP
reading. The first time BP is assessed for a patient, the nurse should compare the reading
in the left and right arm; however, this is not specific to evaluating for hypertension.
PTS:1DIF:ModerateREF:p. 434
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
20. Which of the following pieces of information in the clients health history
might indicate a risk for primary hypertension?
1)
Consumes a high-protein diet 2)
Drinks three to four beers every day
3)
Has a family history of kidney disease
4)
Does not engage in physical exercise
ANS: 2
Heavy alcohol consumption, age, race, high-sodium diet, tobacco use, family history of
hypertension, and high cholesterol levels put a client at risk for primary hypertension.
Kidney disease is a cause of secondary hypertension.
PTS:1DIF:ModerateREF:dm 434-435
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
21. The nurse provides client education regarding hypertension prevention
and management. Which of these statements indicates that the client understands the
instructions?
1)
I dont have to worry if my blood pressure is high once in a while.
2)
I guess I will have to make sure I dont drink too much water.
3)
I can lose some weight to help lower my blood pressure.
4)
I will need to reduce the amount milk and other dairy products I use.
ANS: 3
A single lifestyle change, such as weight loss, can lower blood pressure (BP). Whenever the
client has an elevated BP, the reading should be monitored even when it occurs just
occasionally. Drinking too much alcohol is associated with hypertension, but water
consumption is not unless accompanied by high sodium intake. A diet high in calcium is
recommended to prevent and manage hypertension; therefore, it is not advisable to limit
the intake of dietary calcium found in dairy products.
PTS:1DIF:ModerateREF:dm 434-435
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
22. For which of the following patients would it be most important to obtain
an apical-radial pulse and calculate the pulse deficit? A patient who
1)
Had abdominal surgery 2 hours ago
2)
Suffered a fractured hip yesterday
3)
Is dehydrated from vomiting
4)
Has a heart or lung disease
ANS: 4
Conditions that require assessment of pulse deficit include digitalis therapy and blood
loss, cardiac or respiratory disease, and other conditions that affect oxygenation status.
PTS:1DIF:ModerateREF:p. 427
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
23. Which of the following procedure techniques has the most effect on
the accuracy of an apical pulse count?
1)
Counting the rate for 1 full minute
2)
Exposing only the left side of the chest
3)
Determining why assessment of apical pulse is indicated
4)
Using your ring finger to palpate the intercostal spaces
ANS: 1
Apical pulse is generally indicated for patients with cardiac conditions or who are taking
cardiac medications. Often they have irregular heartbeats or slow rates. A more accurate
count is obtained when such heartbeats are counted for a full minute. Exposing the chest
is, of course, necessary; exposing only the left side protects the patients privacy but does
not improve the accuracy. The nurse should know why an apical pulse is indicated, but
this would not affect the accuracy of the count. Which finger the nurse uses to palpate
depends on which hand is used. Even if the nurse failed to use the index or ring finger,
this would be unlikely to affect the accuracy of the counting.
PTS:1DIF:ModerateREF:p. 452
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
24. Which assessment data best support a report of severe pain in an adult
client whose baseline vital signs are within an average normal range?
1)
Oral temperature 100F (37.8C)
2)
Respiratory rate 26 breaths/min and shallow
3)
Apical heart rate 56 beats/min
4)
Blood pressure 124/82 mm Hg
ANS: 2
Respiratory rate 26 breaths/min and shallow. Acute pain causes an increase in respiratory
rate but a decrease in depth. Elevated temperature does not indicate pain. The apical pulse
is lower than normal, but because the pulse increases with pain, a rate of 56 beats/min does
not indicate pain. A blood pressure of 124/82 mm Hg is within normal limits. Blood
pressure usually elevates temporarily with acute pain; it may decrease over time with
unremitting chronic pain.
PTS:1DIF:EasyREF:p. 430
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
25. During a clinic interview, a client states he has been experiencing
dizziness upon standing. Which nursing action is appropriate for the nurse to
implement?
1)
Ask the client when in the day dizziness occurs.
2)
Help the client to assume a recumbent position.
3)
Measure both heart rate and blood pressure with the client standing.
4)
Measure vital signs with the client supine, sitting, and standing.
ANS: 4
Dizziness upon standing is a symptom of orthostatic hypotension. The nurse should obtain
orthostatic vital signs (measure pulse and blood pressure with the patient supine, sitting,
and standing) to assess for orthostatic hypotension. The time of day is irrelevant to the
diagnosis. If the nurse observes the patient become dizzy upon standing, the first action
would be to help the client lie down and then obtain orthostatic vital signs; but this is not
necessary when the symptom is not present. The nurse needs to measure both the heart
rate and the blood pressure but not only in the standing position.
PTS:1DIF:ModerateREF:p. 439
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which blood pressure has a pulse pressure within normal limits? Choose all
that apply.
1)
104/50 mm Hg 2)
120/62 mm Hg 3)
120/80 mm Hg 4)
130/86 mm Hg
ANS: 3, 4
The pulse pressure is the systolic blood pressure (BP) minus the diastolic BP. The pulse
pressure is usually approximately one third of the systolic pressure. (120 80 = 40; 40 =
1/3 of 120) (130 86 = 44; 1/3 of 130 = 43.3)
PTS:1DIF:ModerateREF:p. 433
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
2. Which of the following interventions would be appropriate for a client who has
a fever? Choose all that apply.
1)
Put an ice pack on the clients neck and axillae.
2)
Provide the client a blanket when he is shivering.
3)
Offer the client fluids to drink every 1 to 2 hours.
4)
Take the temperature using a tympanic thermometer.
ANS: 1, 3
If ice packs are used, they are applied to the groin, neck, or axillae. A fever increases
metabolic needs, so fluids are necessary to prevent dehydration. A blanket would help
with heat retention. A tympanic thermometer is not appropriate when an accurate
temperature is needed, as when a client has a fever.
PTS:1DIF:EasyREF:p. 423
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
3. Comparing the changes in vital signs as a person ages, which statement
is correct? Select all that apply.
1)
Blood pressure decreases less than heart rate and respiratory rate.
2)
Respiratory rate remains fairly stable throughout a persons life.
3)
Blood pressure increases; heart rate and respiratory rate decline.
4)
Men have higher blood pressure than women until after menopause.
ANS: 3, 4
Heart rate and respiratory rate tend to decrease as people age, whereas the blood pressure
increases because of increased vascular resistance. Mens blood pressure tends to be higher
than womens until after menopause, when womens blood pressure typically increases.
PTS: 1 DIF: Moderate REF: dm 430, 434
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis
4. Which of these steps in taking a blood pressure is correct? Choose all that
apply. 1)
Use a bladder that encircles 40% of the arm.
2)
Wrap the cuff snugly around the clients arm.
3)
Ask the client to hold the arm at heart level.
4)
Have the client sit with feet flat on the floor.
ANS: 2, 4
The cuff should be wrapped snugly around the clients arm. Crossed legs or dangling legs
can increase blood pressure, so feet should be flat on the floor. The bladder should
encircle 80% of the arm. Holding the arm out can cause an erroneously higher blood
pressure measurement; the arm should be supported.
PTS: 1 DIF: Moderate REF: dm 457-460
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:
Comprehension
5. When assessing the quality of a clients pedal pulses, what is the nurse
assessing? Choose all that apply.
1)
Rhythm of the pulses
2)
Strength of the pulses
3)
Bilateral equality of pulses 4)
Rate compared with apical pulse
ANS: 2, 3
The quality of a pulse refers to the pulse volume (strength) and bilateral equality of the
pulses.
PTS:1DIF:EasyREF:dm 427-428
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
6. All of the following clinical signs may be present with hypoxia. However, only
two are specific indicators of hypoxia (that is, if they are present, it means that the patient
is probably hypoxic). Which ones are specific indicators of hypoxia? Choose all that
apply.
1)
Feelings of anxiety
2)
Crackles in the lung bases
3)
Increased heart rate
4)
Improved breathing in upright position
ANS: 1, 3
Apprehension, confusion, dizziness, and an increased heart rate are all specific
manifestations of hypoxia. Although they are not listed in this question, cyanosis of the
tongue and oral mucosa are also good indicators of hypoxia because those areas are not
affected by cold or reduced circulation as are the nails, lips, and skin. Crackles and
orthopnea are abnormal respiratory findings, but they do not necessarily indicate poor
oxygenation.
PTS:1DIFifficultREF:p. 432
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
Matching
Match the breath sound with the appropriate description.
1)
High-pitched sound heard on inspiration in infants
2)
High-pitched, continuous musical sound
3)
High-pitched popping or low-pitched bubbling sounds
4)
Low-pitched continuous sounds that clear with coughing
5)
Labored, snoring sound
1. Crackles
2. Rhonchi
3. Stridor
4. Wheezes
5. Stertor
•
ANS: 3 PTS: 1 DIF: Moderate REF: dm 431-432; descriptions
of the various breath sounds are as stated
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
•
ANS: 4 PTS: 1 DIF: Moderate REF: dm 431-432; descriptions
of the various breath sounds are as stated
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
•
ANS: 1 PTS: 1 DIF: Moderate REF: V1, dm 431-432;
descriptions of the various breath sounds are as stated
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
•
ANS: 2 PTS: 1 DIF: Moderate REF: V1, dm 431-432;
descriptions of the various breath sounds are as stated
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
•
ANS: 5 PTS: 1 DIF: Moderate REF: V1, dm 431-432;
descriptions of the various breath sounds are as stated
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
Other
1. How will each of the errors affect a clients blood pressure reading?
•
Blood pressure cuff too narrow
•
Blood pressure cuff too wide
•
Assessing immediately after smoking
•
Assessing immediately after eating
•
Assessing when the client is in mild-to-moderate pain
•
Assessing when the client experiences severe pain
ANS:
•
Assessing immediately after exercise
A: erroneously high; B: erroneously low; C: temporarily high; D: temporarily high; E:
temporarily high; F: temporarily low; G: temporarily high.
Improper cuff size causes errors in blood pressure (BP) readings: Too narrow a cuff
increases the BP reading, while too wide a cuff decreases it. Tobacco use, eating, mild/
moderate pain, and exercise all stimulate and increase BP. Severe pain can lower BP,
whereas mild to moderate pain can increase blood pressure.
PTS: 1 DIF: Moderate REF: dm 434-435| p. 436; for cuff size implications KEY:
Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall Essay
Describe where to auscultate the apical pulse for an average-size adult.
ANS: Auscultate at approximately 3 inches to the left of adult sternum at the fourth, fifth,
or sixth intercostal spaces in the midclavicular line.
Apical pulse is heard at the apex of the heart. The position of the apex of the heart is
different for a child than an adult.
Chapter 15 Communication & Therapeutic Relationships
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1.Which form of communication is the nurse using when interviewing the
patient during the admission health history and physical assessment?
1)
Small group 2)
Interpersonal
3)
Group
4)
Intrapersonal
ANS:2
The nurse uses interpersonal communication when interviewing the patient about his
health history during the admission assessment. Small-group communication occurs when
a person engages in an exchange of ideas with two or more people at the same time. Group
communication is interaction that occurs among several people. Intrapersonal
communication is conscious internal dialogue.
PTS:1DIF:ModerateREF:p. 464
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension
2.During admission to the unit, a patient states, Im not worried about the results of
my tests. Im sure Ill be all right. As he observes the patient, the nurse notes that the patient
is shaky and tearful and does not make eye contact. Unfortunately, the nurse is called away
to an emergency before he has time to complete this discussion. Which of the following
actions is most appropriate for the nurse to establish when returning to the patient? Patient
will
1)
Explain the reason for his incongruent statements 2)
Engage in diversional activities to cope with stress
3)
Express his concerns to his primary care provider
4)
Discuss his concerns and fears with the nurse
ANS:4
The nurse has observed a mismatch between verbal and nonverbal communication.
Unfortunately, an emergency has required the nurse to leave the patient. To resolve this
mismatch, the nurse will set a goal to have the patient discuss his concerns and fears at
their next interaction. It is inappropriate to ask the patient to explain why his verbal
message did not match the nonverbal message because this will inhibit further
conversation. It may be appropriate to have the patient discuss his concerns with his
primary care provider; however, we do not have enough information to suggest this
course of action. For example, if the patient is upset about some other matter, this action
would not be appropriate. Similarly, it is not appropriate to suggest diversional activities
until the reason for the mismatch between his words and behavior is identified.
PTS: 1 DIF: Moderate REF: p. 476
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
3.The nurse is preparing a patient for a computed tomography (CT) scan of
the abdomen. Which statement by the nurse is best (all contain correct information)?
1)
You will need to remain NPO for the 4 hours prior to your CT scan.
2)
You cannot have anything to eat or drink for 4 hours before your test.
3)
You will need to be NPO and drink this contrast media before your test.
4)
You may need to void before you go down to the department for your CT scan.
ANS:2
Telling the patient that he cannot have anything to eat or drink for a specific time before
his test is the best statement. It uses terms that the patient can understand. The other
options use medical jargon that many patients may not understand.
PTS:1DIF:ModerateREF:p. 465
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
4.The nurse is assigned to the care of the following patients. In planning nursing
care, the nurse knows she should use touch cautiously, especially when communicating
with which patient?
1)
Middle-aged woman just diagnosed with terminal lung cancer
2)
Middle-aged man experiencing the acute phase of myocardial infarction
3)
Older adult with a history of dementia admitted for dehydration
4)
Young adult in the rehabilitative phase after arthroscopic surgery
ANS:3
The nurse should use touch especially cautiously when communicating with a person who
suffers from impaired mental health, such as dementia, because the patient may have
difficulty interpreting the meaning of touch. In general, touch can be used with most
patients, such as patients with cancer, an acute MI, or general orthopedic surgery, and
with all age groups. However, the nurse should always be conscious of the situation,
environment, and receptivity of the patient.
PTS:1DIF:ModerateREF:p. 467
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis
5.The nurse manager of the medical intensive care unit formed a group to help her
staff cope with stress more effectively. Which of the comments by group members will
lead the manager to evaluate the group as successful?
1)
This was a good idea to form a group; Ive been wanting to get to know some of
the people working the other shifts.
2)
It really helps me to share feelings about how hard it is to see pain and suffering every
day.
3)
I now have a group to help me when I need to work through situations in my own life
causing me stress.
4)
It feels good to have a chance to get away from the unit and talk on a regular basis.
ANS:2
Work-related social support groups assist members of a profession to cope with the stress
associated with their work. The focus of the group is to share feelings about the stress of
the work environment. Although this may also be an opportunity to meet other staff
members, get away from the unit, or share personal and family problems, these are not the
primary focus of the group.
PTS:1DIF:ModerateREF:p. 473
KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application
6.A patient who speaks little English is admitted to the hospital after
experiencing severe abdominal pain. Which nursing diagnosis is preferred for this
patient?
1)
Impaired Communication
2)
Readiness for Enhanced Communication
3)
Impaired Verbal Communication
4)
Sensory Alteration
ANS:1
Impaired Communication is the preferred nursing diagnosis when the patient is
unfamiliar with the dominant language. Impaired Verbal Communication is an
appropriate diagnosis for the patient with expressive or receptive aphasia. Readiness for
Enhanced Communication is appropriate when the patient expresses willingness to
enhance communication. Sensory Alteration is appropriate when there is a change in the
characteristics of the patients incoming stimuli.
PTS:1DIFifficultREF:p. 474
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
7. A young adult with a severe episode of asthma bronchoconstriction comes to
the emergency department with signs of respiratory distress. When the nurse performs
the admission assessment, she notes that the patient is not able to say where she is or the
time. Which nursing diagnosis is probably most suitable for this patient?
1)
Chronic Confusion
2)
Acute Confusion
3)
Impaired Verbal Communication
4)
Readiness for Enhanced Communication
ANS: 2
This patient is experiencing Acute Confusion caused by lack of oxygen related to his
respiratory distress. As a young adult with an acute episode of asthma, this patient would
not likely have a history of confusion; therefore, without more data, Chronic Confusion is
not an appropriate diagnosis for this patient. Impaired Verbal Communication is an
appropriate diagnosis for the patient with expressive or receptive aphasia, but not with
confusion. Readiness for Enhanced Communication is appropriate when the patient
expresses willingness to enhance communication.
PTS:1DIFifficultREF:p. 474
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
8.A patient experiences expressive aphasia after a stroke. Which expected
outcome is appropriate for this patient?
1)
Uses alternative methods of communication
2)
Communicates effectively using a translator 3)
Interprets messages accurately
4)
Follows commands when asked
ANS:1
An appropriate outcome for a patient with expressive aphasia is uses alternative methods
of communication. Expressive aphasia means the patient cannot verbalize his intended
message, but the patient may be able to understand and to communicate in other ways.
Communicates effectively using a translator is an appropriate outcome for a patient who
is unfamiliar with the dominant language. Interprets messages accurately and follows
commands when asked are appropriate outcomes for the patient with receptive, not
expressive, aphasia.
PTS:1DIF:ModerateREF:p. 475
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
9.Which intervention by the nurse first helps to establish a trusting nursepatient relationship?
1)
Avoiding topics that may provoke emotional responses from the patient
2)
Listening to the patient while performing care activities
3)
Performing care interventions quietly and respectfully
4)
Greeting the patient by name whenever entering the patients room
ANS:4
The nurse can establish a trusting nurse-patient relationship by always greeting the
patient by name, listening actively, responding honestly to the patients concerns,
providing explanations for care interventions, and providing care competently and
consistently.
PTS:1DIF:ModerateREF:p. 476
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
10.A physician tells a patient that she has cancer and that she should have surgery
as soon as possible. The patient is not certain she wants to pursue this treatment approach
but responds by saying, Ill do whatever you think I should do. Which communication style
is this patient using?
1)
Assertive
2)
Aggressive
3)
Passive aggressive 2
4)
Passive
ANS:4
This patient is using a passive communication style to avoid conflict with others while
allowing the other person to be in control. An aggressive approach forces others to
relinquish control. The goal of the aggressive approach is to win and be in control. With
assertive communication, the person expresses beliefs or feelings without infringing on
anothers rights. The passive aggressive approach uses a submissive style of
communication but is aggressive in the sense that it manipulates the receiver to help the
sender win. This allows the sender to be in control without conflict.
PTS:1DIF:ModerateREF:p. 470
KEY: Nursing process: Analysis | Client need: PSI | Cognitive level: Application
11.Which statement by the nurse manager demonstrates an assertive approach
when communicating with the staff nurse about a patient care issue?
1)
You must assess and document pain status for every patient.
2)
Why havent you been assessing and documenting pain for every patient?
3)
Will you please assess and document pain status for every patient?
4)
Explain why you havent been assessing and documenting pain for every patient.
ANS:1
By stating that pain must be assessed and documented for every patient, the nurse
manager is using an assertive approach. An assertive approach uses the statement of facts,
not judgments. Asking why the nurse has not been assessing and documenting pain is
judgmental and elicits a defensive response by the nurse. Asking the nurse whether she
will assess and document pain for every patient invites a negative response and does not
use an assertive approach. Asking the nurse to explain why she has not been assessing and
documenting pain is also judgmental.
PTS:1DIF:ModerateREF:dm 470-471
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis
12.A patient comes to the emergency department complaining of severe, substernal
chest pain. He is restless and anxious. Which statement by the nurse appropriately offers
reassurance?
1)
Ill give you some medication to help relieve the pain.
2)
If you lie still and relax, youll be fine in a little while.
3)
Please try not to think about the pain as best as you can.
4)
Dont worry; were going to take good care of you.
ANS:1
By telling the patient that she is going to give him some medication to help relieve his
pain, the nurse is offering him realistic reassurance. The other options offer false
reassurance and minimize patient concerns.
PTS:1DIF:ModerateREF:p. 479
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
13.Which statement by the nurse indicates that the nurse-patient relationship
is entering the termination phase?
1)
Ill be admitting you to our nursing unit as soon as I obtain your health history.
2)
You seem upset today. Would you like to talk about whatever is bothering you?
3)
Im leaving for the day. Is there anything I can do for you before I leave?
4)
Hello. My name is Leslie, and Im going to be your nurse today.
ANS:3
When the nurse states, Im leaving for the day. Is there anything I can do for you before I
leave? the nurse-patient relationship is entering the termination phase. The termination
phase is the conclusion of the relationship, which can occur at the end of a nurses shift.
The pre-interaction phase occurs before the nurse meets the patient. The statement Ill be
admitting you to our floor as soon as I obtain your history demonstrates the preinteraction phase of the nurse-patient relationship. The nurse introduces herself to the
patient during the orientation phase. During the working phase of the nurse-patient
relationship, feelings are explored. This phase is demonstrated by the statement, You
seem upset today. Would you like to talk about whatever is bothering you?
PTS:1DIF:ModerateREF:p. 472
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
14.A health center that is interested in purchasing IV infusion pumps organizes a
group of nurses to evaluate pumps provided by a variety of vendors. Which type of group
has been organized?
1)
Short term
2)
Ongoing
3)
Self-help
4)
Work-related social support
ANS:1
The organized group is a short-term group. Short-term groups focus on the task at hand,
which in this case is evaluating infusion pumps. Ongoing groups address issues that are
recurrent. Self-help groups are voluntary organizations composed of people with a
common need. Work-related social support groups assist members of a profession to cope
with the stress associated with their work.
PTS:1DIF:ModerateREF:p. 473
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
15.The nurse must insert a nasogastric (NG) tube into a patient with a bowel
obstruction. Before inserting the tube, the nurse must explain the procedure to the patient.
Which explanation by the nurse is best, assuming that all provide correct information?
1)
Im going to insert an NG tube and connect it to low Gomco to keep your
stomach empty.
2)
Im going to insert a tube through your nose into your stomach to prevent you
from vomiting.
3)
Im going to insert an NG tube through your nares to suction your secretions and prevent
emesis.
4)
Lie still, please; I need to elevate the head of the bed and insert this tube.
ANS:2
Because patients are typically confused by medical terminology, the nurse should use
language that the patient can understand. NG tube, Gomco, suction secretions, nares, and
emesis are all medical jargon that the patient might not understand. Moreover, the nurse
should explain all procedures before performing them to help minimize the patients
anxiety. Lie still, please . . . offers no explanation of why the NG tube is being inserted,
and it conveys that the nurse is impatient.
PTS:1DIF:ModerateREF:p. 465
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
16.A patient had surgery 6 hours ago. When the nurse enters the room to turn
him, she notes that he is restless and grimacing. Considering the patients nonverbal
communication, what action should the nurse take first?
1)
Administer pain medication to the patient.
2)
Turn and reposition the patient.
3)
Assess to determine the cause of the grimacing.
4)
Leave the patients room so he can rest quietly.
ANS:3
The nurse should assess the patient to determine whether he is having pain. The nurse
should not assume by the patients nonverbal communication that the patient is in pain and
administer pain medication; the nurse should validate the message being sent. The nurse
should not turn and reposition the patient without assessing him. Leaving the patient
without addressing his nonverbal cues is neglectful.
PTS:1DIF:ModerateREF:dm 466-467
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis
17.A patient who speaks only French was admitted to the hospital after a motor
vehicle accident. Assuming that the nurse does not speak French, what is the best way to
communicate with this patient?
1)
Use sign language for communicating.
2)
Ask a family member to serve as a translator.
3)
Request the services of a hospital translator.
4)
Speak in English, but speak very slowly.
ANS:3
The nurse should request the services of a hospital translator to communicate with the
patient who does not speak English. A family member should not be used as a translator
unless there are no other options because it is often culturally unacceptable to have a
family member ask personal questions. Also, considering the patients right to
confidentiality, it is not appropriate to share private information about the patient with
family members unless permission is obtained. Using sign language can be an effective
strategy for hearing-impaired persons. Speaking slowly in English is not useful if the
patient does not understand the language.
PTS:1DIF:ModerateREF:p. 475
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
18.After a physician discusses cancer treatment options with a patient, the patient
asks the nurse which treatment he should choose. Which response by the nurse is best?
1)
If I were you, Id go with chemotherapy.
2)
What do you think about radiation therapy?
3)
Why dont you see what your wife thinks.
4)
Ill give you some information about each option.
ANS:4
The nurse should avoid giving a personal opinion; instead offer the patient more
information so he can make an informed decision. Responses such as, If I were you, Id go
with chemotherapy and Why dont you see what your wife thinks do not respect the
patients right to make his own decisions. What do you think about radiation therapy, is
leading the patient without exploring the other options.
PTS:1DIF:EasyREF:dm 478-479
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
19.Which of the following is a nonverbal behavior that enhances
communication? 1)
Keeping a neutral expression on the face
2)
Maintaining a distance of 6 to 12 inches
3)
Sitting down to speak with the patient
4)
Asking mostly open-ended questions
ANS:3
Sitting down to speak with the patient enhances communication because it communicates
a willingness to listen. A concerned expression, not a neutral one, demonstrates interest
and attention. Maintaining a distance of 18 inches to 4 feet, not 6 to 12 inches, while
speaking allows most patients to feel comfortable, thereby enhancing communication.
When the interpersonal distance is too close, patients might feel uncomfortable. Asking
open-ended questions is a verbal communication strategy, not a nonverbal behavior.
PTS:1DIF:ModerateREF:p. 467
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Comprehension
20.A patient being admitted in hypertensive crisis informs the nurse that he stopped
taking his blood pressure medication 3 weeks ago. Which response by the nurse is best?
1)
Youre lucky you didnt have a stroke; you really need to take your medication.
2)
Tell me more about your experience with your high blood pressure medication.
3)
Why did you stop taking your high blood pressure medication?
4)
Its very important to take your blood pressure medication.
ANS:2
The nurse can gather more information about the patients reasons for stopping his blood
pressure medication by asking him to tell her more about his experience with the
medication. Telling the patient he is lucky he did not have a stroke suggests criticism.
Asking the patient why he stopped taking his high blood pressure medication may cause
the patient to become defensive and halt further communication. Telling the patient that it
is very important to take his blood pressure medication is patronizing and also suggests
criticism; at the very least, it fails to elicit more communication from the patient.
PTS:1DIF:ModerateREF:dm 477-478
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
21.The wife of an elderly patient begins crying after she is informed that he has
a terminal illness. Which intervention by the nurse is best?
1)
Sit quietly with the patients wife while she composes her thoughts.
2)
Inform his wife that a chaplain is available if she would like to speak to him.
3)
Remind his wife that her husband has lived a long and happy life.
4)
Tell his wife there are always options and suggest she not give up hope.
ANS:1
The nurse can intervene best by sitting quietly with the patients wife, allowing her to
compose her thoughts. Silence communicates acceptance. After processing the bad news,
the wife can provide the nurse with further information, such as whether she would like to
consult with a chaplain. Telling the wife there are always options offers false reassurance
and would probably discourage her from further communication.
PTS:1DIFifficultREF:p. 476
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
22.A patient newly diagnosed with breast cancer tells the nurse, Im worried I wont
live to see my children grow up. Which response by the nurse best conveys concern and
active listening?
1)
There have been many advances in breast cancer treatment; hope for the best.
2)
Breast cancer is a serious disease; I can understand why youre worried.
3)
Youre strong and have youth on your side to fight the breast cancer.
4)
Id be worried, too; Ive seen a lot of patients die from breast cancer.
ANS:2
Restating the patients concern by saying, Breast cancer is a serious disease; I can
understand why youre worried conveys concern and active listening. Stating that there
have been many advances in breast cancer treatment minimizes the patients concern.
Stating that the patient is young and should have no trouble surviving breast cancer
minimizes the patients concern and offers false reassurance. Stating that the nurse has
seen a lot of patients die from breast cancer could frighten the patient and cause
emotional harm.
PTS:1DIF:ModerateREF:p. 476
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
23.A nurse has sound, scientific evidence to support changing a procedure
that would reduce catheter-related infections on the unit. The unit manager states,
nevertheless, that she is unwilling to make the change because it would be too costly.
Which response by the nurse represents assertive communication?
1)
This is a widely used practice. If you read more research, youd probably wonder why we
arent already doing it.
2)
There is extensive evidence to support the new method, but I dont want to create an issue. 3)
Is the budget more important to the hospital than reducing infections and patient
suffering?
4)
Id like to help gather information regarding the cost of new materials versus the savings
in treating infections.
ANS:4
The statement pertaining to helping to gather information about of the cost of materials is
an assertive response. It does not threaten the authority of the nurse manager and introduce
another element preventing change that is unrelated to the procedure itself. It states the
nurses position and wishes clearly with an I statement, and it does not invite negative
responses. The statement beginning with This is a widely used practice is aggressive and
implies criticism and a judgment that the nurse manager does not read as much as she
should. The statement ending with I wouldnt want to create chaos is passive and
submissive. The statement beginning with Is the budget more important . . . is aggressive
and judgmental.
PTS:1DIF:ModerateREF:dm 470-471
KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application
24.When using the SBAR model to communicate with a physician,
what information does the nurse offer first?
1)
Statement of the problem and its probable cause
2)
Nurses name, patients name, and reason for the communication
3)
History of information related to and leading up to the situation
4)
A solution to the problem or what is needed from the physician
ANS:2
SBAR is an acronym for Situation, Background, Assessment, and Recommendation. The
nurses name, and so forth, are part of the Situation. Statement of the problem and cause
are the Assessment. History of the factors leading up to the current situation make up the
Background. What the nurse thinks will correct the problem is categorized under
Recommendation.
PTS: 1 DIF: Difficult REF: p. 471
KEY:Nursing process: Implementation | Client need: PSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1.Which statement about communication is true? (Choose all that
apply.) Communication is
1)
Used to meet physical and psychosocial needs
2)
Most basically described as talking and listening
3)
The process of sending and receiving information
4)
The basis for forming relationships
ANS:1, 3, 4
People use communication to fulfill basic human needs at all levels: physical,
psychosocial, emotional, and spiritual needs. Communication is a process of sending and
receiving messages. It forms the basis for sharing meaning and building effective
relationships among individuals, families, and the healthcare team. Communication
involves more than just talking and listening. And simply because messages are
verbalized does not mean listening and understanding are achieved.
PTS:1DIF:EasyREF:dm 463-464
KEY:Nursing process: N/A |Client need: PSI | Cognitive level: Recall
2.Which statement by the nurse demonstrates that active listening has
occurred? Choose all that apply.
1)
I listened to my patient while I was changing his IV site.
2)
I made eye contact and listened to my patient to find out his concerns.
3)
I took notes when I listened to my patient describe his symptoms.
4)
I sat with my patient and his wife to talk about their fears before the surgery.
ANS:2, 4
The nurse demonstrates active listening by facing the patient, making eye contact, and
listening while he expresses concerns. Arranging time to sit with the patient and his wife
to discuss fears about an upcoming surgery also indicates active listening. Listening to the
patient while performing activities, such as hanging an IV infusion or bathing him,
distracts the nurse from active listening. Although taking detailed notes can help the nurse
to accurately recall the patients words, this activity while listening to the patient speak
can also be a distraction and could reduce eye contact and nonverbal cues of care and
concern.
PTS:1DIF:ModerateREF:p. 476
KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application
3.A patient tells the nurse, Im having a lot of pain in my hip. Which response by
the nurse is open-ended and would stimulate the patient to provide the most complete
data? Choose all that are correct.
1)
Is your pain severe?
2)
Tell me about your pain.
3)
When did you first notice this pain?
4)
How would you describe your pain?
ANS:2, 4
The responses Tell me about your pain and How would you describe your pain? are
open-ended responses that stimulate conversation. Although it is important information,
the question Is your pain severe? prompts a yes or no response. When did you first notice
this pain?also important informationis likely to stimulate a brief, factual answer. Such
questions allow the nurse to control the patients response. Limiting the response might
lead to an incomplete assessment.
Chapter 19 Health Assessment
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A mother brings her 6-month-old infant to the clinic for a well-baby
checkup. How should the nurse proceed when weighing the patient?
1)
Have the mother remain outside the room.
2)
Ask the mother to remove the infants clothing and diaper.
3)
Weigh the infant wearing only the diaper.
4)
Place the infant supine on the scale with his knees extended.
ANS: 2
The nurse should ask the mother to remove the infants clothing and diaper before
weighing and measuring the infant. An older child can be examined in his underwear;
infants should be undressed. Infants are typically more comfortable with the parent close
by, so the mother should remain in the room. The infant should be supine with knees
extended on the examination table when being measured, not when being weighed.
PTS: 1 DIF: Moderate REF: p. 517
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
2. Where should the nurse assess skin color changes in the dark-skinned
patient? 1)
Nailbeds
2)
Any exposed area
3)
Oral mucosa 4)
Palms of the hands
ANS: 3
In dark-skinned patients, look for color changes in the conjunctiva or oral mucosa. They
should be pink and moist. In dark-skinned patients, skin color changes may not be
apparent in nailbeds, palms of the hands, and other exposed areas.
PTS: 1 DIF: Easy REF: dm 497-498, 519
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
3. While the nurse assesses a newborn of African American descent, the mother
points out a blue-black Mongolian spot on the newborns back and asks, Whats that? Is
something wrong with my baby? Which response by the nurse is best?
1)
Ill ask the physician to look at the spot.
2)
Those spots are quite common and typically fade with time.
3)
You may want a plastic surgeon to look at that.
4)
That spot is benign so its nothing you need to worry about.
ANS: 2
The best response by the nurse is to explain that Mongolian spots are common in dark-
skinned newborns and typically fade over time. The nurse should report the finding in the
patient health record, but there is no need to notify the physician immediately. It is
inappropriate for the nurse to recommend that the mother take her newborn to a plastic
surgeon; Mongolian spots do not require treatment. Although it contains correct
information, nothing you need to worry about is condescending.
PTS: 1 DIF: Moderate REF: p. 497
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
4. An older adult comes to the clinic complaining of pain in the left foot.
While assessing the patient, the nurse notes smooth, shiny skin that contains no hair
on the clients lower legs. Which condition does this finding suggest?
1)
Venous insufficiency
2)
Hyperthyroidism
3)
Arterial insufficiency
4)
Dehydration
ANS: 3
Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little or
no hair. Venous insufficiency leads to thick, rough skin that is commonly
hyperpigmented. Hyperthyroidism is associated with abnormally warm skin. Decreased
turgor would be seen in dehydration.
PTS: 1 DIF: Moderate REF: p. 498
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application
5. Which skin assessment finding would cause the nurse to suspect dehydration in
a middle-aged patient admitted to the hospital with travelers diarrhea?
1)
Edema
2)
Hyperhidrosis
3)
Pallor
4)
Tenting
ANS: 4
Tenting, skin that takes several seconds to return to normal after lifting up a fold, may be
a sign of dehydration. Edema, an excessive amount of fluid in the tissues, may be a sign
of heart failure, kidney disease, peripheral vascular disease, or low albumin levels.
Hyperhidrosis is a term for excessive sweating, which may be a sign of thyrotoxicosis.
Pallor, abnormal loss of skin color, may be a sign of anemia or blood loss.
PTS:1DIF:ModerateREF:p. 498
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
6. A female patient has excessive facial hair. The nurse should document
this finding as:
1)
Alopecia.
2)
Albinism.
3)
Hirsutism.
4)
Lanugo.
ANS: 3
The nurse should document this finding as hirsutism, excess facial or trunk hair. Hair loss
should be documented as alopecia. Albinism is a condition caused by lack of pigment in
which the patient has white hair and very pale skin. Lanugo is the fine, downy growth of
hair that covers the body of a newborn.
PTS: 1 DIF: Moderate REF: p. 499
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
7. The nurse should assess skin temperature by using
the: 1)
Dorsum of the hand.
2)
Pad of the fingertip.
3)
Palm of the hand.
4)
Dorsum of the wrist.
ANS: 1
The dorsum of the hand should be used to assess skin temperature. The nurse should
compare the temperature of the hands with that of the feet and compare the right side of
the body with the left.
PTS: 1 DIF: Easy REF: p. 497
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
8. While assessing an older adult patient, the nurse notes clubbing of the
fingers. This finding is a sign of:
1)
Fungal infection.
2)
Poor circulation.
3)
Iron deficiency.
4)
Long-term hypoxia.
ANS: 4
Clubbing (when the nail plate angle is 180 or more) is associated with long-term hypoxic
states such as chronic lung disease. A thick nail with yellowing indicates a fungal
infection. Spoon-shaped nails may result from iron-deficiency anemia. Brittle nails are
commonly seen with malnutrition and hyperthyroidism.
PTS: 1 DIF: Moderate REF: p. 500
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
9. A 6-week-old infant is brought to the pediatricians office for a well-baby
checkup. The nurse notes a flattening of the skull. Flattening of the skull in the infant
might suggest:
1)
The baby has been lying in the same position for several hours a day.
2)
A disorder associated with excessive growth hormone.
3)
An accumulation of excessive cerebrospinal fluid.
4)
Temporomandibular joint syndrome.
ANS: 1
Abnormal flattening of the skull in infants may result from placing the baby in the same
position for several hours every day. A large head in an adolescent or adult may be
associated with acromegaly, a disorder associated with excess growth hormone. In infants
and children, a head that is growing disproportionately faster than the body may be a sign
of hydrocephalus, which is fluid collection in the cavity within the brain. Irregular jaw
movement and cracking of the jaw in adults may indicate temporomandibular joint (TMJ)
syndrome.
PTS: 1 DIF: Moderate REF: p. 500
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
10. The nurse notes ptosis in a patient who just arrived in the emergency
department. The nurse quickly triages the patient because she knows that this finding,
along with other symptoms, might suggest:
1)
Hyperthyroidism.
2)
Stroke.
3)
Glaucoma.
4)
Macular degeneration.
ANS: 2
Ptosis, or drooping of the eyelid, may be seen in a patient who experienced Bells palsy or
a stroke. Exophthalmos is associated with hyperthyroidism. Mydriasis may be seen with
glaucoma. Macular degeneration has no outward signs.
PTS: 1 DIF: Moderate REF: p. 500
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application
11. Small hemorrhages are noted under the nailbed of a patient with a history
of intravenous drug abuse. This finding is associated with:
1)
Low albumin levels.
2)
Zinc deficiency.
3)
Renal disease.
4)
Bacterial endocarditis.
ANS: 4
Small hemorrhages under the nailbed, known as splinter hemorrhages, are associated
with bacterial endocarditis, a complication of IV drug abuse. A distal band of reddishpink covering 20% to 60% of the nail (half and half nails) is seen in patients with low
albumin levels and renal disease. White spots may indicate zinc deficiency.
PTS: 1 DIF: Difficult REF: p. 499
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
12. A patient is admitted with an acute exacerbation of chronic obstructive
pulmonary disease. Which finding might the nurse expect when assessing the patients
nails?
1)
Soft, boggy nails
2)
Brittle nails
3)
Thickened nails
4)
Thick nails with yellowing
ANS: 1
Soft, boggy nails are seen with poor oxygenation. Brittle nails are seen with
hypothyroidism, malnutrition, calcium, and iron deficiency. Thickened nails may result
from poor circulation. A thick nail with yellowing is an indication of fungal infection
known as onychomycosis.
PTS: 1 DIF: Moderate REF: p. 500
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
13. A patients ankles appear swollen. When the nurse assesses the edema, the
skin depresses 6 mm, and the depression lasts 2 minutes. The nurse should document
this finding as:
1)
Trace edema.
2)
+1 edema.
3)
+2 edema.
4)
+3 edema.
ANS: 4
To assess edema, the nurse presses firmly with her fingertip for 5 seconds over a bony area.
Trace appears as a minimal depression; +1 appears as a 2-mm depression with a rapid
return of skin to position; +2 reveals a 4-mm depression, which disappears in 10 to 15
seconds; +3 displays a 6-mm depression that lasts 1 to 2 minutes; and +4 demonstrates an
8-mm depression that persists for 2 to 3 minutes. The area is grossly edematous.
PTS: 1 DIF: Moderate REF: p. 521
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
14. Which abnormal laboratory value is associated with icteric
sclerae? 1)
Bleeding time
2)
Bilirubin
3)
Hemoglobin
4)
Glucose
ANS: 2
Icteric sclerae are associated with elevated bilirubin levels. Low hemoglobin would
indicate anemia. High hemoglobin is polycythemia, which is like thick blood. Low
glucose is hypoglycemia, and high sugar is hyperglycemia.
PTS: 1 DIF: Easy REF: p. 500
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Recall
15. The left pupil of a patient fails to accommodate. This finding may reflect
an abnormality in which cranial nerve?
1)
CN III
2)
CN V
3)
CN VIII 4)
CN X
ANS: 1
CN III, the oculomotor nerve, is responsible for accommodation. Failure of a pupil to
accommodate reflects an abnormality in this cranial nerve. CN V, the trigeminal nerve,
controls the corneal reflex, chewing, and biting. CN VIII, the acoustic nerve, plays a role
in hearing and the sense of balance. CN X, the vagus nerve, affects heart rate, peristalsis,
swallowing, and the gag reflex.
PTS: 1 DIF: Moderate REF: p. 501
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
16. When testing near vision, the nurse should position printed text how
many inches away from the patient?
1)
20
2)
18
3)
16
4)
14
ANS: 4
Test near vision by having the client read text from a distance of 14 inches.
PTS: 1 DIF: Easy REF: p. 501
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
17. A 48-year-old patient comes to the physicians office complaining of
diminished near vision, which the nurse confirms with testing. She should document this
finding as: 1)
Myopia.
2)
Diplopia.
3)
Presbyopia.
4)
Mydriasis.
ANS: 3
Diminished near vision in a patient over age 40 or so years is known as presbyopia.
Diminished distant vision is known as myopia. Double vision is known as diplopia.
Mydriasis or enlarged pupils may be seen with glaucoma.
PTS: 1 DIF: Moderate REF: p. 501
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
18. Which portion of the ear is responsible for maintaining
equilibrium? 1)
External ear
2)
Inner ear 3)
Middle ear
4)
Ossicles
ANS: 2
The inner ear is responsible for hearing and equilibrium. The middle ear, which contains
the ossicles (auditory structures), conducts sound waves to the inner ear. The external ear
collects and conveys sound waves to the middle ear.
PTS: 1 DIF: Easy REF: p. 502
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
19. Which statement best describes the procedure used to assess capillary
refill? 1)
Briefly press the tip of the nail with firm, steady pressure, then release and observe for
changes in color.
2)
Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and
observe the skin for the reaction.
3)
Tap on the skin with short strokes from your fingers.
4)
Lift a fold of skin, and allow it to return to its normal position.
ANS: 1
To assess capillary refill, the nurse should briefly press the tip of the nail with firm,
steady pressure, then release, and observe for changes in skin color. Tap on the skin . . .
describes the procedure for performing percussion. Lift a fold of skin . . . demonstrates
the procedure for assessing for tenting. The nurse should press firmly with her fingertip
for 5 seconds over a bony area, then release her finger, and observe the skin for the
reaction to grade edema.
PTS: 1 DIF: Moderate REF: p. 528
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
20. Which of the following is an abnormal capillary refill finding that the
nurse should report?
1)
•
second
2)
•
seconds
3)
•
seconds
4)
•
seconds
ANS: 4
Normal capillary refill is less than 3 seconds; therefore, the nurse should report a
capillary refill of 4 seconds.
PTS: 1 DIF: Easy REF: p. 528
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
21. Which of the following is a correct developmental outcome for an infant?
The infants anterior fontanel (soft spot) typically fuses:
1)
At about 8 weeks.
2)
At about 14 months.
3)
By 6 months of age.
4)
Before 1 year of age.
ANS: 2
The large soft spot on the top of the head, known as the anterior fontanel, typically fuses
at about 12 to 18 months. The infant should be able to hold up his head by age 6 months.
The posterior fontanel fuses at about 8 weeks of age.
PTS: 1 DIF: Moderate REF: p. 529
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
22. The nurse assesses a 4-year-old childs vision as 20/40. This finding
is considered:
1)
Myopia.
2)
Hyperopia.
3)
Normal.
4)
Presbyopia.
ANS: 3
Children typically do not have 20/20 vision until the ages of 6 or 7 years. A finding of
20/60 in a 4-year-old child is considered normal, so of course 20/40 is normal as well.
Myopia is diminished distant vision, which is associated with Snellen chart reading of
20/100. Hyperopia is diminished near vision and is represented by a large fraction, such
as 20/15; when found in people over age 45 it is known as presbyopia.
PTS: 1 DIF: Moderate REF: p. 531
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis
23. Which test should the patient undergo when the Weber test is
positive? 1)
Romberg test
2)
Rinne test
3)
Pure tone audiometry
4)
Tympanometry
ANS: 2
If the Weber test is positive, the patient should undergo the Rinne test to assess the type of
hearing loss. The Romberg test is performed to test equilibrium. Pure tone audiometry
uses a machine to hear sounds at different volumes while the patient wears a headset.
Tympanometry assesses pressure in the ear; it does not assess hearing.
PTS: 1 DIF: Moderate REF: p. 502
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
24. The nurse is performing an otoscopic examination on an adult patient. She
has the patient tilt his head to the side not being examined and looks into the ear canal to
make sure a foreign body is not present. Which step should she perform next?
1)
Straighten the ear canal by pulling the helix up and back.
2)
Insert the speculum into the ear canal slowly.
3)
Test the mobility of the tympanic membrane.
4)
Straighten the ear canal by pulling the helix down and back.
ANS: 1
Next, the nurse should straighten the ear canal by pulling the helix up and back. In a
preschool child, the nurse should straighten the ear canal by pulling the helix down and
back. After straightening the ear canal, the nurse should slowly insert the speculum and
observe the ear canal.
PTS: 1 DIF: Moderate REF: p. 538
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
25. An 85-year-old patient is brought to the emergency department with lethargy
and hypotension. When the nurse assesses the patients tongue, she notes that it appears
dry and furry. This finding suggests:
1)
Fungal infection.
2)
Dehydration.
3)
Allergy.
4)
Iron deficiency.
ANS: 2
A dry, furry tongue is associated with dehydration. A black, hairy tongue is characteristic
of a fungal infection. Absence of papillae, reddened mucosa, and ulcerations may indicate
allergy. Patients who have a deficiency of iron may have a smooth, red tongue. PTS: 1
DIF: Moderate REF: p. 503
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
26. Which assessment should the nurse perform if she notes a palpable
thyroid gland?
1)
Illuminate the thyroid gland for the presence of fluid.
2)
Auscultate the thyroid gland for bruits.
3)
Percuss the thyroid gland for mass size.
4)
Measure the thyroid gland to assess change.
ANS: 2
Normally, the thyroid gland is smooth, firm, and nontender. It is often nonpalpable. If the
thyroid gland is palpable, the nurse should auscultate it for bruits. It is not necessary to
measure or illuminate the thyroid gland. The thyroid gland should not be percussed.
PTS: 1 DIF: Moderate REF: p. 548
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
27. While palpating the anterior chest, the nurse notes crackling in the skin
around the patients chest tube insertion site. The nurse recognizes this finding is:
1)
Tactile fremitus.
2)
Egophony.
3)
Bronchophony.
4)
Crepitus.
ANS: 4
The nurse should document this finding as crepitus, crackling skin caused by air leaking
into the subcutaneous tissues. Tactile fremitus involves palpating for vibrations as the
client says 99, which indicates the presence of fluid in the chest. Bronchophony is present
if the words 1, 2, 3 are clearly heard over the lungs as the nurse listens while the patient
says those words. Egophony is present if the sound heard is ay when the nurse listens over
the lung fields as the patient says eee.
PTS: 1 DIF: Easy REF: dm 554-555
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
28. Bronchovesicular breath sounds are best heard over which
area? 1)
Midline over the trachea just below the larynx
2)
Fourth intercostal space, in the midclavicular line
3)
First and second intercostal spaces next to the sternum
4)
At the base of the lungs near the diaphragm
ANS: 3
Bronchovesicular breath sounds are best heard over the first and second intercostal spaces
adjacent to the sternum on the anterior chest.
PTS: 1 DIF: Moderate REF: p. 557
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
29. High-pitched breath sounds produced by airway narrowing are known
as: 1)
Rales.
2)
Crackles.
3)
Rhonchi.
4)
Wheezing.
ANS: 4
Wheezing is a high-pitched sound produced by narrowing of an airway. Rales and
crackles are crackling sounds that indicate atelectasis, pulmonary edema, or pneumonia.
Rhonchi are low-pitched snoring or rumbling sounds that result from mucous secretions
in the large airways.
PTS: 1 DIF: Easy REF: ESG,
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
30. The nurse notes a small pulsation at the fifth intercostal space
midclavicular line. This should be documented as a:
1)
Thrill.
2)
Murmur.
3)
Normal finding.
4)
Heave.
ANS: 3
A small pulsation at the fifth intercostal space midclavicular line is known as the point of
maximal impulse (PMI) and is considered a normal finding. A thrill is a vibration or
pulsation palpated in any area except the PMI. A murmur occurs when structural defects
in the hearts chambers or valves cause turbulent blood flow. A heave, which is a visible
palpation, is associated with an enlarged ventricle.
PTS: 1 DIF: Moderate REF: p. 507
KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level: Application
31. The nurse notes an S3 heart sound while performing an assessment on a
patient admitted with an acute myocardial infarction. The nurse notifies the physician of
the finding, which most likely suggests:
1)
Heart failure.
2)
Coronary artery disease.
3)
Hypertension.
4)
Pulmonic stenosis.
ANS: 1
A third heart sound, commonly referred to as S3, is heard with heart failure or volume
overload. S4 heart sound may be auscultated with coronary artery disease, hypertension,
and pulmonic stenosis.
PTS: 1 DIF: Difficult REF: p. 507
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
32. The admission assessment form indicates that the patient has pedal pulses
that are rated 1 in amplitude. This documentation indicates that the patients pulses are:
1)
Bounding.
2)
Normal.
3)
Full.
4)
Diminished.
ANS: 4
Pulses documented as 1 are diminished and barely palpable; 2 are normal; 3 are full and
increased; and 4 are bounding.
PTS: 1 DIF: Moderate REF: p. 563
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
33. A patients jugular venous pressure measures 5 cm. This finding
indicates: 1)
A normal finding.
2)
Hypovolemia.
3)
Heart failure.
4)
Dehydration.
ANS: 3
Normal jugular venous pressure is less than 3 cm. A jugular venous pressure of 5 cm is
elevated and suggests heart failure.
PTS: 1 DIF: Moderate REF: p. 559
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension
34. The nurse is caring for a patient who underwent abdominal surgery 24
hours ago and has a nasogastric tube to intermittent suction. How should the nurse
proceed when performing an abdominal assessment on this patient?
1)
Avoid palpating the patients abdomen.
2)
Turn off the suction before auscultating bowel sounds.
3)
Listen for bowel sounds for 2 minutes in each quadrant.
4)
Percuss the abdomen before auscultating bowel sounds.
ANS: 2
The sound of suction attached to a nasogastric tube can be mistaken for bowel sounds;
therefore, the nurse should discontinue the suction or clamp off the tube while auscultating
bowel sounds. Light palpation can be performed in the postoperative patient. The nurse
should listen for bowel sounds for at least 5 minutes before determining that they are
absent. Auscultation should be performed before percussion in examining the abdomen.
PTS: 1 DIF: Moderate REF: p. 509
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
35. Abdominal palpation should be avoided in a child who has which
disorder? 1)
Appendicitis
2)
Wilms tumor
3)
Crohns disease
4)
Small bowel obstruction
ANS: 2
Abdominal palpation should be avoided in the child who has Wilms tumor, large diffuse
pulsation, or a history of organ transplant. Abdominal palpation can be performed with
appendicitis, Crohns disease, and small bowel obstruction.
PTS: 1 DIF: Moderate REF: p. 568
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall
36. A father brings his 18-month-old child to the pediatric clinic for a well-baby
checkup. The father tells the nurse that he is concerned because his childs legs are bowed.
Which response by the nurse is appropriate?
1)
Your child will most likely require physical therapy.
2)
You should consider having your child seen by an orthopedic surgeon.
3)
This is a normal finding in children for 1 year after they begin walking.
4)
Your child is walking fine, so you dont need to worry.
ANS: 3
Genu varum, or bowlegs, is a normal finding in children for 1 year after they begin
walking and the bones of the legs become more ossified with development and weightbearing. However, assessment over time is important to be sure the gait and positioning
develop normally. The nurse should allay the fathers concerns by providing him with this
information. The child shows no signs, in the scenario above, that physical therapy is
needed. It is not appropriate for the nurse to recommend an orthopedic surgeon; physician
referrals are given by the physician or advanced practice nurse when appropriate. Your
child is walking fine . . . is condescending and does not appropriately address the fathers
concerns.
PTS: 1 DIF: Moderate REF: p. 571
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
37. The nurse asks the patient to spread his fingers and then bring them
together again. Which of the following is the nurse testing when asking to bring his
fingers together?
1)
Abduction
2)
Adduction
3)
Flexion
4)
Extension
ANS: 2
Asking the patient to spread his fingers tests abduction; asking him to bring them together
assesses adduction. Asking the patient to make a fist tests flexion, whereas asking him to
extend the hand tests extension.
PTS: 1 DIF: Moderate REF: p. 576
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
38. An adult admitted to the hospital after a stroke does not respond to
verbal stimuli. What should the nurse do next to try to provoke a response?
1)
Apply pressure to the mandible at the jaw.
2)
Rub the patients sternum.
3)
Squeeze the trapezius muscle.
4)
Gently shake the patients shoulder.
ANS: 4
If the patient does not respond to verbal stimuli, the nurse should try tactile stimuli by
gently shaking the patients shoulder. If the patient does not respond to tactile stimuli, the
nurse should try painful stimuli by squeezing the trapezius muscle, rubbing the sternum,
applying pressure on the mandible at the angle of the jaw, or applying pressure over the
moon of the nail. But do not start out with painful stimulation before you are sure the
patient is not going to react to a less invasive approach.
PTS: 1 DIF: Moderate REF: p. 579
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
39. Which assessment question helps assess immediate
memory? 1)
How did you get to the hospital today?
2)
Can you repeat the numbers 2, 7, 9 for me?
3)
Do you recall the three items I mentioned earlier?
4)
What was your birth date including the year?
ANS: 2
The nurse can assess immediate memory by asking the patient to repeat a series of three
numbers and gradually increasing the length of the series until the patient cannot repeat the
series correctly. The nurse can assess recent memory by asking the patient how he got to
the hospital or by asking the patient to repeat three items that the nurse mentioned earlier
in the examination. The nurse can assess remote memory by asking the patient his birth
date or the date of a significant historical event.
PTS: 1 DIF: Moderate REF: p. 580
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
40. Assuming that all are accurate, which documentation about a patients level
of consciousness is best?
1)
Patient is lethargic and slept when undisturbed.
2)
Patient responds to tactile stimulation; falls back to sleep immediately after tactile and
verbal stimulation are stopped.
3)
Patient slept throughout the day, missing his meals and bath.
4)
Patient appears to be tired as he slept throughout the day except when bathed.
ANS: 2
The option that includes the most detailed information provides the most accurate
description of the patients level of consciousness. The other documentation provides little
information about the level of consciousness. From those descriptions, the patient might
have a decreased level of consciousness or could simply be exhausted.
PTS: 1 DIF: Moderate REF: p. 510; High-level question; answer not stated verbatim
KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level: Analysis
41. Based on developmental stage, how should the nurse modify the
comprehensive physical examination of an older adult?
1)
Work rapidly to finish as quickly as possible.
2)
Sequence the exam to limit position changes.
3)
Demonstrate equipment before using it.
4)
Omit portions of the exam that may be tiring.
ANS: 2
Because older adults may tire easily and because they may have stiff muscles and arthritic
joints, the nurse should arrange the sequence of the exam to limit position changes. The
nurse should work efficiently; however, speed is not the goal, and the nurse should observe
the patients energy level and stop for periods of rest as needed. It is appropriate to
demonstrate equipment for school-age children but is not usually necessary for older
adults, who have probably experienced other physical examinations. Because this is a
comprehensive exam, it is not appropriate to omit portions of the exam because they may
be tiring. As discussed, the patient should rest and then the nurse should return to the
examination.
PTS: 1 DIF: Moderate REF: p. 515
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
42. The nurse applies resistance to the top of the clients foot and asks him to pull
his toes toward his knee. The nurse observes active motion against some, but not against
full, resistance. How should the nurse document this finding?
1)
5: Normal
2)
4: Slight weakness
3)
3: Weakness
4)
2: Poor ROM
ANS: 2
The nurse should document 4: Slight weakness. The following is the muscle strength
rating scale:
Rating Criteria Classification
5
Active motion against full resistance
Normal
4
Active motion against some resistance
Slight weakness
3
Active motion against gravity
Weakness
2
Passive ROM
Poor ROM
1
Slight flicker of contraction
Severe weakness
0
No muscular contraction
Paralysis
PTS: 1 DIF: Difficult REF: dm 577-578
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:
Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. The nurse obtains vital signs for a 56-year-old patient who underwent
surgery yesterday. Which finding(s) require(s) further assessment? Select all that apply.
1)
Blood pressure 110/64 mm Hg
2)
Pulse rate 118 beats/minute
3)
Respiratory rate 35 breaths/minute
4)
Oral temperature 98.6F (37C)
ANS: 2, 3
The pulse rate of 118 beats/minute and the respiratory rate of 35 breaths/minute are
abnormally elevated and require further assessment. Blood pressure 110/64 mm Hg and
oral temperature 98.6F (37C) are considered normal and do not require further
assessment.
PTS: 1 DIF: Easy REF: p. 517
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
2. Which disorder(s) might limit a patients visual field? Select all that
apply. 1)
Diabetes
2)
Advanced glaucoma
3)
Peripheral vascular disease
4)
Cataracts
ANS: 1, 2, 4
Poorly controlled diabetes, cataracts, macular degeneration, and advanced glaucoma may
limit the visual field. Peripheral vascular disease may be associated with diabetes, but it
occurs in the extremities, not the eyes.
Chapter 20 Promoting Asepsis & Preventing Infection
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which of the following behaviors indicates the highest potential for
spreading infections among clients? The nurse:
1)
disinfects dirty hands with antibacterial soap.
2)
allows alcohol-based rub to dry for 10 seconds.
3)
washes hands only when leaving each room.
4)
uses cold water for medical asepsis.
ANS: 3
Patients acquire infection by contact with other patients, family members, and healthcare
equipment. But most infection among patients is spread through the hands of healthcare
workers. Hand washing interrupts the transmission and should be done before and after
all contact with patients, regardless of the diagnosis. When the hands are soiled,
healthcare staff should use antibacterial soap with warm water to remove dirt and debris
from the skin surface. When no visible dirt is present, an alcohol-based rub should be
applied and allowed to dry for 10 to 15 seconds.
PTS:1DIF:EasyREF:p. 618
KEY:Nursing process: Implementation | Client need: SECE | Cognitive level:
Comprehension
2. What is the most frequent cause of the spread of infection among
institutionalized patients?
1)
Airborne microbes from other patients
2)
Contact with contaminated equipment
3)
Hands of healthcare workers
4)
Exposure from family members
ANS: 3
Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with
other patients, family members, and contaminated healthcare equipment. Some of these
are pathogenic (cause illness) and some are nonpathogenic (do not cause illness). But most
microbes causing infection among patients are spread by direct contact on the hands of
healthcare workers.
PTS:1DIF:EasyREF:p. 609
KEY:Nursing process: Implementation | Client need: SECE | Cognitive level: Recall
3. Which of the following nursing activities is of highest priority for
maintaining medical asepsis?
1)
Washing hands 2)
Donning gloves
3)
Applying sterile drapes
4)
Wearing a gown
ANS: 1
Scrupulous hand washing is the most important part of medical asepsis. Donning gloves,
applying sterile drapes before procedures, and wearing a protective gown may be needed
to ensure asepsis, but they are not the most important aspect because microbes causing
most healthcare-related infections are transmitted by lack of or ineffective hand washing.
PTS: 1 DIF: Easy REF: p. 617
KEY: Nursing process: Interventions | Client need: Safe Care Environment | Cognitive
level: Comprehension
4. A patient infected with a virus but who does not have any outward sign of
the disease is considered a:
1)
pathogen.
2)
fomite.
3)
vector.
4)
carrier.
ANS: 4
Some people might harbor a pathogenic organism, such as the human immunodeficiency
virus, within their bodies and yet do not acquire the disease/infection. These individuals,
called carriers, have no outward sign of active disease, yet they can pass the infection to
others. A pathogen is an organism capable of causing disease. A fomite is a contaminated
object that transfers a pathogen, such as pens, stethoscopes, and contaminated needles. A
vector is an organism that carries a pathogen to a susceptible host through a portal for
entry into the body. An example of a vector is a mosquito or tick that bites or stings.
PTS:1DIF:ModerateREF:p. 607
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application
5. A patient is admitted to the hospital with tuberculosis. Which precautions
must the nurse institute when caring for this patient?
1)
Droplet transmission
2)
Airborne transmission
3)
Direct contact
4)
Indirect contact
ANS: 2
The organisms responsible for measles and tuberculosis, as well as many fungal infections,
are spread through airborne transmission. Neisseria meningitidis, the organism that causes
meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as
Clostridium difficile, are spread by direct contact. The common cold can be spread by
indirect contact or droplet transmission.
PTS:1DIF:ModerateREF:p. 608
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
6. A patient becomes infected with oral candidiasis (thrush) while receiving
intravenous antibiotics to treat a systemic infection. Which type of infection has the
patient developed?
1)
Endogenous nosocomial 2)
Exogenous nosocomial
3)
Latent
4)
Primary
ANS: 1
Thrush in this patient is an example of an endogenous nosocomial infection. This type of
infection arises from suppression of the patients normal floras as a result of some form of
treatment, such as antibiotics. Normal floras usually keep yeast from growing in the
mouth. In exogenous nosocomial infection, the pathogen arises from the healthcare
environment. A latent infection causes no symptoms for long periods. An example of a
latent infection is human immunodeficiency virus infection. A primary infection is the first
infection that occurs in a patient.
PTS: 1 DIF: Difficult REF: p. 608
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
7. A patient admitted to the hospital with pneumonia has been receiving
antibiotics for 2 days. His condition has stabilized, and his temperature has returned to
normal.
Which stage of infection is the patient most likely experiencing?
1)
Incubation
2)
Prodromal
3)
Decline
4)
Convalescence
ANS: 3
The stage of decline occurs when the patients immune defenses, along with any medical
therapies (in this case antibiotics), are successfully reducing the number of pathogenic
microbes. As a result, the signs and symptoms of infection begin to fade. Incubation is
the stage between the invasion by the organism and the onset of symptoms. During the
incubation stage, the patient does not know he is infected and is capable of infecting
others. The prodromal stage is characterized by the first appearance of vague symptoms.
Convalescence is characterized by tissue repair and a return to healing as the organisms
disappear.
PTS:1DIF:ModerateREF:p. 609
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
8. The nurse assists a surgeon with central venous catheter insertion. Which
action is necessary to help maintain sterile technique?
1)
Closing the patients door to limit room traffic while preparing the sterile field
2)
Using clean procedure gloves to handle sterile equipment
3)
Placing the nonsterile syringes containing flush solution on the sterile field
4)
Remaining 6 inches away from the sterile field during the procedure
ANS: 1
To maintain sterile technique, the nurse should close the patients door and limit the
number of persons entering and exiting the room because air currents can carry dust and
microorganisms. Sterile gloves, not clean gloves, should be used to handle sterile
equipment. Placing nonsterile syringes on the sterile field contaminates the field. One
foot, not 6 inches, is required between people and the sterile field to prevent
contamination.
PTS: 1 DIF: Moderate REF: p. 629
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
9. A patient develops localized heat and erythema over an area on the lower
leg. These findings are indicative of which secondary defense against infection?
1)
Phagocytosis
2)
Complement cascade
3)
Inflammation
4)
Immunity
ANS: 3
The classic signs of inflammation, a secondary defense against infection, are erythema
(redness) and localized heat. The secondary defenses phagocytosis (process by which
white blood cells engulf and destroy pathogens) and the complement cascade (process by
which blood proteins trigger the release of chemicals that attack the cell membranes of
pathogens) do not produce visible findings. Immunity is a tertiary defense that protects the
body from future infection.
PTS:1DIFifficultREF:p. 610
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application
10. The patient is just beginning to feel symptoms after being exposed to an
upper respiratory infection. Which antibody would most likely be found in a test of
immunoglobin levels?
1)
IgA
2)
IgE
3)
IgG
4)
IgM
ANS: 4
IgM are the first antibodies made in response to infection. IgE is the antibody primarily
responsible for this allergic response. IgA antibodies protect the body in fighting viral
and bacterial infections, and appear later. IgG antibodies also appear laterperhaps up to
10 days later.
PTS:1DIF:ModerateREF:p. 612
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
11. What type of immunity is provided by intravenous (IV) administration
of immunoglobulin G?
1)
Cell-mediated
2)
Passive
3)
Humoral
4)
Active
ANS: 2
Intravenous administration of immunoglobulin G provides the patient with passive
immunity. Immunoglobulin G does not provide cell-mediated, humoral, or active
immunity. Passive immunity occurs when antibodies are transferred from an immune
host, such as from a placenta to a fetus. Passive immunity is short lived. Active immunity
is longer lived and comes from the host. Humoral immunity occurs by secreted antibodies
binding to antigens. Cell-mediated immunity does not involve antibodies but rather is a
fight of infection from macrophages that kill pathogens.
PTS:1DIF:ModerateREF:ESG,\
12. A patient asks the nurse why there is no vaccine available for the common
cold. Which response by the nurse is correct?
1)
The virus mutates too rapidly to develop a vaccine.
2)
Vaccines are developed only for very serious illnesses.
3)
Researchers are focusing efforts on an HIV vaccine.
4)
The virus for the common cold has not been identified.
ANS: 1
More than 200 viruses are known to cause the common cold. These viruses mutate too
rapidly to develop a vaccine. Although some researchers are focusing efforts on a vaccine
for HIV infection, others continue to research the common cold.
PTS:1DIF:ModerateREF:p. 616
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
13. A patient who has a temperature of 101F (38.3C) most likely
requires: 1)
acetaminophen (Tylenol).
2)
increased fluids.
3)
bedrest.
4)
tepid bath.
ANS: 2
Fever, a common defense against infection, increases water loss; therefore, additional fluid
is needed to supplement this loss. Acetaminophen and a tepid bath are not necessary for
this low-grade fever because fever is beneficial in fighting infection. Adequate rest, not
necessarily bedrest, is necessary with a fever.
PTS:1DIF:ModerateREF:p. 616
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis
14. Why is a lotion without petroleum preferred over a petroleum-based product
as a skin protectant?
1)
It prevents microorganisms from adhering to the skin.
2)
It facilitates the absorption of latex proteins through the skin.
3)
It decreases the risk of latex allergies.
4)
It prevents the skin from drying and chaffing.
ANS: 3
Non-petroleum-based lotion is preferred because it prevents the absorption of latex
proteins through the skin, which can cause latex allergy. Both types of lotion help prevent
the skin from drying and becoming chafed. Neither prevents microorganisms from
adhering to the skin.
PTS: 1 DIF: Moderate REF: p. 634[answer not directly given in the text. Answer must be
inferred from the content.]
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
15. For which range of time must a nurse wash her hands before working in
the operating room?
1)
•
to 2 minutes
2)
•
to 4 minutes
3)
2 to 6 minutes
4)
6 to 10 minutes
ANS: 3
In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of
soap used.
PTS:1DIF:EasyREF:p. 639
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
16. How should the nurse dispose of the breakfast tray of a patient who
requires airborne isolation?
1)
Place the tray in a specially marked trash can inside the patients room.
2)
Place the tray in a special isolation bag held by a second healthcare worker at the patients
door.
3)
Return the tray with a note to dietary services so it can be cleaned and reused for the next
meal.
4)
Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose
of it there.
ANS: 2
Patients who require airborne isolation are served meals on disposable dishes and trays.
To dispose of the tray, the nurse inside the room must wear protective garb and place the
tray and its contents inside a special isolation bag that is held by a second healthcare
worker at the patients door. The items must be placed on the inside of the bag without
touching the outside of the bag.
PTS:1DIF:ModerateREF:p. 625
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
17. As a general rule, how much liquid soap should the nurse use for effective
hand washing? At least:
1)
•
mL
2)
•
mL
3)
•
mL
•
mL
4)
ANS: 2
APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand
washing.
PTS:1DIF:EasyREF:p. 633
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
18. To assure effectiveness, when should the nurse stop rubbing antiseptic
hand solution over all surfaces of the hands?
1)
When fingers feel sticky 2)
After 5 to 10 seconds
3)
When leaving the clients room
4)
Once fingers and hands feel dry
ANS: 4
The nurse should rub the antiseptic hand solution over all surfaces of the hands until the
solution dries, usually 10 to 15 seconds, to ensure effectiveness.
PTS: 1 DIF: Easy REF: p. 634
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
19. A patient is admitted to the hospital for chemotherapy and has a low
white blood cell count. Which precaution should the staff take with this patient?
1)
Contact
2)
Protective
3)
Droplet
4)
Airborne
ANS: 2
Protective isolation is used to protect those patients who are unusually vulnerable to
organisms brought in by healthcare workers. Such patients include those with low white
blood cell counts, with burns, and undergoing chemotherapy. Some hospital units, such as
neonatal intensive care units and labor and delivery suites, also use forms of protective
isolation.
PTS:1DIF:ModerateREF:p. 625
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
20. While donning sterile gloves, the nurse notices the edges of the glove package
are slightly yellow. The yellow area is over 1 inch away from the gloves and only appears
to be on the outside of the glove package. What is the best action for the nurse to take at
this point?
1)
Continue using the gloves inside the package because the package is intact.
2)
Remove gloves from the sterile field and use a new pair of sterile gloves.
3)
Throw all supplies away that were to be used and begin again.
4)
Use the gloves and make sure the yellow edges of the package do not touch the client.
ANS: 2
The gloves should be discarded because the gloves are likely to be contaminated from an
outside source. The supplies do not have to be thrown away because they have not been
contaminated.
PTS:1DIF:ModerateREF:dm 629, 646
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
21. The nurse is removing personal protective equipment (PPE). Which item
should be removed first?
1)
Gown
2)
Gloves
3)
Face shield
4)
Hair covering
ANS: 2
The gloves are removed first because they are usually the most contaminated PPE and
must be removed to avoid contamination of clean areas of the other PPE during their
removal. The gown is removed second, then the mask or face shield, and finally, the hair
covering.
PTS:1DIF:ModerateREF:dm 637-638
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Prioritizing
Prioritize the nurses actions, listing the most important one first.
1. A nurse is splashed in the face by body fluid during a procedure. Prioritize
the nurses actions, listing the most important one first.
•
Contact employee health
•
Complete an incident report
•
Wash the exposed area
•
Report to another nurse that she is leaving
the immediate area. 1)
1, 2, 3, 4
2)
2, 3, 4, 1
3)
3, 4, 1, 2
4)
4, 1, 2, 3
ANS: 3
If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse
she is leaving the area, contact the infection control or employee health nurse immediately,
and complete an incident report. It is most important to remove the source of
contamination (body fluid) as soon as possible after exposure to help prevent the nurse
from becoming infected. The other activities can wait until that is done.
PTS:1DIF:ModerateREF:p. 630
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. In which situation would using standard precautions be adequate? Select all
that apply.
1)
While interviewing a client with a productive cough
2)
While helping a client to perform his own hygiene care
3)
While aiding a client to ambulate after surgery
4)
While inserting a peripheral intravenous catheter
ANS: 3, 4
Standard precautions should be instituted with all clients whenever there is a possibility of
coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous
membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When
interviewing a client, if the disease is not spread by air or droplets, there is no likelihood
of the nurses encountering body fluids. If the disease is spread by air or droplets, then
droplet or airborne precautions would be needed in addition to standard precautions. If
giving a complete bed bath or performing oral hygiene, the nurse would need to use
standard precautions (gloves); if merely assisting a client to perform those ADLs, it is not
necessary. No exposure to body fluids is likely when helping a client to ambulate after
surgery.
PTS: 1 DIF: Easy REF: dm 619-624
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
2. Which of the following protect(s) the body against infection? Select all
that apply.
1)
Eating a healthy, well-balanced diet
2)
Being an older adult or an infant
3)
Leisure activities three times a week
4)
Exercising for 30 minutes 5 days a week
ANS: 1, 3, 4
Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body
against infection. Illness, injury, medical treatment, infancy or old age, frequent public
contact, and various lifestyle factors can make the body more susceptible to infection.
PTS:1DIF:EasyREF:dm 612, 616
KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall
3. The nurse is teaching a group of newly hired nursing assistive personnel
(NAP) about proper hand washing. The nurse will know that the teaching was effective
if the NAP demonstrate what? Select all that apply. The NAP:
1)
uses a paper towel to turn off the faucet.
2)
holds fingertips above the wrists while rinsing off the soap.
3)
removes all rings and watch before washing hands.
4)
cleans underneath each fingernail.
ANS: 1, 3, 4
Hand washing requires at least 15 seconds of washing, which includes lathering all
surfaces of the hands and fingers to be effective. The fingers should be held lower than
the wrists.
PTS: 1 DIF: Moderate REF: dm 633-634
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall
4. Alcohol-based solutions for hand hygiene can be used to combat which types
of organisms? Select all that apply.
1)
Virus
2)
Bacterial spores
3)
Yeast
4)
Mold
ANS: 1, 3, 4
If there is potential for contact with bacterial spores, hands must be washed with soap and
water; alcohol-based solutions are ineffective against bacterial spores.
PTS:1DIF:ModerateREF:p. 618
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
5. A patient with tuberculosis is scheduled for computed tomography (CT).
How should the nurse proceed? Select all that apply.
1)
Question the order because the patient must remain in isolation.
2)
Place an N-95 respirator mask on the patient and transport him to the test.
3)
Place a surgical mask on the patient and transport him to CT lab.
4)
Notify the computed tomography department about precautions prior to transport.
ANS: 3, 4
Transporting a patient who requires airborne precautions should be limited; however, when
necessary the patient should wear a surgical mask (an N-95 respirator mask is not
required) that covers the mouth and nose to prevent the spread of infection. Moreover, the
department where the patient is being transported should be notified about the precautions
before transport.
PTS: 1 DIF: Difficult REF: dm 623-624
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
True/False
Indicate whether the statement is true or false.
1. Bacteria are necessary for human health and wellbeing. ANS: T
Organisms that normally inhabit the body, called normal floras, are essential for human
health and well-being. They keep pathogens in check. In the intestine, these floras function
to aid digestion and promote the release of vitamin K, vitamin B12, thiamine, and
riboflavin.
Chapter 21 Promoting Safety
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Physiological changes associated with aging place the older adult especially
at risk for which nursing diagnosis?
1)
Risk for Falls
2)
Risk for Ineffective Airway Clearance (choking)
3)
Risk for Poisoning 4)
Risk for Suffocation (drowning)
ANS: 1
Loss of muscle strength and joint mobility place older adults at risk for falls. Choking,
drowning, and ingesting poisons are primary safety concerns for infants and toddlers.
PTS:1DIF:ModerateREF:p. 653
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall
2. A 78-year-old patient is being seen in the emergency department. The nurse
observes his gait and balance appear to be slightly unsteady. What assessment should the
nurse perform next?
1)
Perform the Get Up and Go Test.
2)
Ask the patient if he has fallen in the past year.
3)
Refer the patient for a comprehensive fall evaluation.
4)
Administer the Timed Up and Go Test.
ANS: 2
If a patients gait or balance is unsteady, the nurse should question the patient for a history
of falls. If the patient reports a single fall, the nurse should do the Get Up and Go Test. If
the patient has difficulty with that test, or is unsteady with it, the nurse should perform a
follow-up assessment of gait and balance by having the person close the eyes for a few
seconds wile standing in place; stand with eyes closed while the nurse pushes gently on
the sternum; walk, stop, turn around, return to the chair, and sit in the chair without using
his arms for support. Physicians and advanced practitioners perform the Timed Up and Go
Test; it is recommended annually for patients 65 years or older.
PTS:1DIFifficultREF:p. 661
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
3. The nurse notes that the electrical cord on an IV infusion pump is cracked.
Which action by the nurse is best?
1)
Continue to monitor the pump to see if the crack worsens.
2)
Place the pump back on the utility room shelf.
3)
A small crack poses no danger so continue using the pump.
4)
Clearly label the pump and send it for repair.
ANS: 4
Whenever an electrical safety hazard is suspected or visible, the nurse should label the
malfunctioning equipment and send it for repair or inspection. Continuing to use the IV
infusion pump or any other equipment places the patient at risk for injury. Placing the
pump back on the shelf places other healthcare team members at risk for electrical injury
if they attempt to use the equipment.
PTS:1DIF:EasyREF:p. 673
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
4. A patient with a history of falling continually attempts to get out of bed
unassisted despite frequent reminders to call for help first. Which action should the nurse
take first?
1)
Apply a cloth vest restraint. 2)
Encourage a family member to stay with the patient.
3)
Administer lorazepam (an antianxiety medication).
4)
Keep the patients bed side rails up.
ANS: 2
The nurse should use one-to-one supervision with this patient to maintain the patients
safety. One way to accomplish this is by encouraging a family member to stay with the
patient. Restraints should be used only when all other less-restrictive measures have failed
and are absolutely necessary to prevent injury to the patient. Restraints have been shown
to jeopardize patient safety. It is not appropriate to administer sedation for the purpose of
keeping the patient in bed; this is a form of restraint. Keeping the side rails up is also a
form of restraint and increases the risk for falling.
PTS: 1 DIF: Moderate REF: p. 673
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
5. Despite less-restrictive interventions, a patients behavior escalates, requiring
emergency application of restraints. Which of the following must the nurse do in this
situation?
1)
Obtain a physicians order before applying restraints.
2)
Monitor the patients status every 4 hours while restrained.
3)
Release the restraints and check circulation every hour.
4)
Continually reevaluate the patients need for restraint.
ANS: 4
The patient must be continually monitored, and the need for restraint must be continually
reevaluated. As a rule, a medical order should be obtained before applying restraints.
However, in an emergency, the nurse is permitted to apply restraints for behavior
management, but a physician or advanced practice nurse must then evaluate the patient
within 1 hour of restraint application. The order for restraint must be renewed daily. The
restraints must be released at least every 2 hours, and circulation must be checked.
PTS: 1 DIF: Difficult REF: dm 679-681
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
6. A patient has received a radiation implant. The patient is weak and needs
help even to turn in bed. Which action should the nurse take when caring for this
patient? 1)
Avoid giving the patient a complete bed bath.
2)
Limit the amount of time spent with the patient.
3)
Allow extra time for the patient to express feelings.
4)
Do not allow anyone to visit the patient.
ANS: 2
When caring for a patient with a radiation implant, the nurse should organize nursing care
to limit the amount of time with the patient to limit radiation exposure. The nurse must
meet the patients personal hygiene needs by bathing the patient, if necessary. The nurse
should encourage the patient to express her feelings; however, she should limit her
contact with the patient. Pregnant women should not visit the patient; however, others
may visit as long as they uphold the principles of time, distance, and shielding.
PTS: 1 DIF: Moderate REF: p. 660
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
7. A child is brought to the emergency department after swallowing liquid
cleanser. He is awake and alert and able to swallow. Which action should the nurse take
first?
1)
Administer a dose of syrup of ipecac.
2)
Administer activated charcoal immediately.
3)
Give water to the child immediately.
4)
Call the nearest poison control center.
ANS: 3
If the child is awake and able to swallow, and the child has swallowed a household
chemical, give one-half glassful of water immediately. After giving the water, call the
poison control center. The American Academy of Pediatrics does not advise giving syrup
of ipecac. Emergency departments have stopped using ipecac in favor of activated
charcoal, which binds to poison in the stomach and prevents it from entering the
bloodstream. Continued vomiting caused by syrup of ipecac may later result in the child
being unable to tolerate activated charcoal or other poison treatments. No one can tell how
much a child vomits, and therefore, no one would know if all the poison was eliminated
from the stomach. There is also potential for misuse by bulimics. The poison control
center may recommend activated charcoal, depending upon the agent ingested.
PTS: 1 DIF: Difficult REF: ESG
Treatment for Commonly Ingested Poisons
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis
8. A nurse is teaching a group of mothers about first aid. Should poison come in
contact with their childs clothing and skin, which action should the nurse instruct the
mothers to take first?
1)
Remove the contaminated clothing immediately.
2)
Flood the contaminated area with lukewarm water.
3)
Wash the contaminated area with soap and water and rinse.
4)
Call the nearest poison control center immediately.
ANS: 1
The nurse should tell the mother to first remove the contaminated clothing as quickly as
possible. Then, flood the contaminated area with lukewarm water. Next, gently wash the
area with soap and water and rinse. Have someone call the poison control center. It does
not need to be a local poison control center. Additionally, it is most important to remove
contact between the skin and poison before doing anything.
PTS: 1 DIF: Moderate REF: ESG| Cognitive level: Analysis
9. Which of the following instructions is most important for the nurse to
include when teaching a mother of a 3-year-old about protecting her child against
accidental poisoning?
1)
Store medications on countertops out of the childs reach.
2)
Purchase medication in child-resistant containers
3)
Take medications in front of the child, and explain that they are for adults only.
4)
Never leave the child unattended around medications or cleaning solutions.
ANS: 4
The nurse should instruct the mother to avoid leaving her child unattended around
medications or cleaners even for a moment. Medications should never be stored on
kitchen counters or bathroom surfaces because children love to explore and climb and can
get into them. The nurse should explain that medications should not be taken in front of
the child because children imitate adult behavior. The nurse should reinforce that although
child-resistant containers are a deterrent, they are not foolproof because many toddlers
and preschoolers can open them.
PTS:1DIF:ModerateREF:p. 665
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
10. A patient is brought to the emergency department after inhaling mercury. The
nurse should be alert for which acute adverse effects associated with mercury inhalation?
1)
Chest pain, pneumonitis, and inflammation of the mouth
2)
Intestinal obstruction and numbness of the hands
3)
Hypotension, oliguria, and tingling of the feet
4)
Tachycardia, hematuria, and diaphoresis
ANS: 1
Acute adverse effects of mercury inhalation include chest pain, inflammation of mouth,
pneumonitis, respiratory damage, wakefulness, muscle weakness, anorexia, headache,
and ringing in the ears, Chronic effects include numbness or tingling of the hands, lips,
and feet, and personality changes. Intestinal obstruction is an acute effect of mercury
ingestion. Hypotension, oliguria, hematuria, and diaphoresis are not acute effects of
mercury inhalation.
PTS: 1 DIF: Difficult REF: p. 659
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
11. Which aspect of restraint use can the nurse delegate to the nursing
assistive personnel?
1)
Assessing the patients status
2)
Determining the need for restraint
3)
Evaluating the patients response to restraints
4)
Applying and removing the restraints
ANS: 4
The nurse can delegate applying and removing the restraints, skin care, and checking for
skin breakdown. The nurse responsible for care of the patient must assess the patients
need for restraint and the patients status and must evaluate the patients response to
restraints.
PTS: 1 DIF: Moderate REF: p. 675
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
12. The nurse suspects a 3-year-old child who is coughing vigorously has
aspirated a small object. Which action should the nurse take first?
1)
Encourage the child to continue coughing.
2)
Deliver upward abdominal thrusts with a fisted hand.
3)
Deliver five rapid back blows between the shoulder blades.
4)
Perform a blind finger sweep of the childs mouth.
ANS: 1
If the nurse suspects aspiration in a child who is coughing vigorously, the nurse should
encourage the child to continue coughing. If coughing weakens, the nurse should perform
the choking maneuver by administering five rapid back blows alternated with five upward
thrusts to the upper abdomen with a fisted hand, just below the rib cage. A blind finger
sweep should never be performed because it could push the foreign object into the airway.
PTS:1DIF:Moderate
REF: ESG, Box 23-5, Rescue Maneuver for Choking: Adult or Child Over Age 12
Months
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis
13. Which is the most commonly reported incident in
hospitals? 1)
Equipment malfunction
2)
Patient falls
3)
Laboratory specimen errors 4)
Treatment delays
ANS: 2
Patient falls are by far the most common incident reported in hospitals and long-term care
facilities. Although equipment (e.g., infusion pump) malfunctions, missed or incorrectly
identified laboratory specimen collection, and treatment delays sometimes occur, they do
not occur as frequently as patient falls.
PTS:1DIF:EasyREF:p. 657
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
14. The Joint Commissions national Speak Up campaign encourages patients
to become active and informed participants on the healthcare team. The goal is to:
1)
prevent healthcare errors.
2)
help control the cost of healthcare. 3)
reduce the number of automobile accidents.
4)
provide a forum for people without health insurance.
ANS: 1
The Joint Commission, with the Centers for Medicare and Medicaid Services, urges
patients to take a role in preventing healthcare errors by becoming active, involved, and
informed participants on the healthcare team. A reduction in healthcare errors could
indirectly reduce healthcare costs, but this is not the intent of the campaign. The campaign
has nothing to do with automobile accidents, as might be deduced from the fact that the
Joint Commission and Medicare/Medicaid regulate healthcare agencies. The campaign has
little relationship to insurance, other than to encourage clients to speak up, ask questions,
and know their rights.
PTS:1DIFifficultREF:p. 664
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
15. A patient in the emergency department is angry, yelling, cursing, and
waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the
nurse is(are) advisable?
1)
Reassure the patient by entering the room alone.
2)
Ask the patient if he is carrying any weapons.
3)
Stay between the patient and the door; keep the door open.
4)
Make eye contact while stating firmly I will not tolerate cursing and threats.
ANS: 3
The nurse should keep the door open and position herself so that the patient cannot block
her exit from the room (stay between the patient and the door). The nurse should not enter
a room alone with an angry patient. The progression to physical violence is first anxiety,
then verbal aggression, and finally physical aggression. The nurses first priority in this
situation is her own safety and the safety of others in the environment. The object
is to relieve the patients anxiety and not respond to anger with anger. Questioning about
weapons, or being firm and defending against verbal aggression will likely provoke even
more anger from the patient. The nurse must be calm and reassuring.
PTS:1DIFifficultREF:p. 674
KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which point(s) should the nurse include when teaching safety precautions to
a mother of a toddler? Select all that apply.
1)
Make sure the child sleeps on his back at night.
2)
Keep the telephone number of the poison control center accessible.
3)
Use a front-facing car seat placed in the back seat of the car.
4)
Keep syrup of ipecac on hand in case of accidental poisoning.
ANS: 2, 3
The nurse should teach the mother of a toddler to keep the telephone number of the
poison control center accessible because toddlers are at risk for accidental poisonings.
Toddlers should also have front-facing car seats. Syrup of ipecac is no longer
recommended to induce emesis after poisonings. Infants, not toddlers, should sleep on
their backs to prevent sudden infant death syndrome.
PTS: 1 DIF: Moderate REF: dm 664, 670
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
2. During a thermometer exchange program at a local hospital, a person drops a
mercury thermometer on the floor. Assume the nurse has been trained in cleanup of such
a spill. Select all that are appropriate. How should the nurse intervene?
1)
Using gloves and a paper towel, place the mercury in a plastic bag, and dispose of it.
2)
Notify the hazardous material management team immediately.
3)
Evacuate the area immediately.
4)
After putting on a gown, gloves, and a mask, clean up the mercury. 5)
Wash her hands well after removing the spill.
6)
Ventilate the area well for several days.
ANS: 1, 5, 6
The nurse should put on gloves and use a paper towel to pick up the mercury. Then place
the mercury, broken thermometer, and soiled paper towel into a plastic bag along with the
gloves. Next, the nurse should dispose of the plastic bag, wash her hands, and ventilate the
area well. It is not necessary to notify the hazardous material management team or
evacuate the area for a spill this small, unless agency policy actually mandates that. The
nurse does not need to put on a gown and mask to dispose of the mercury.
PTS: 1 DIF: Moderate REF: dm 674-675
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
COMPLETION
•
Rank the following leading causes of accidental death in the United
States according to their frequency of occurrence. Rank as 1 the one that occurs
most frequently; rank as 4 the one that occurs least frequently.
•
Motor vehicle accidents
•
•
•
Falls
Suffocation
Poisoning
s ANS: A,
D, B, C
Motor vehicle accidents are the leading cause of accidental death in the United States,
followed by poisonings, falls, and suffocation.
PTS:1DIF:EasyREF:p. 656
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
•
When the nurse walks into the patients room, she notices fire
coming from the patients trash can. Rank the following actions in the order they
should be performed by the nurse. 1 should be done first; 4 should be last.
•
Activate the fire alarm.
•
Move the patient out of the room.
•
Close all doors and windows.
•
Put out the fire using the
proper extinguisher. ANS: B, A, C, D
The nurse should first move the patient out of the room, then activate the alarm, close all
doors and windows and turn off oxygen valves, and use the proper extinguisher to put out
the fire.
Chapter 22 Facilitating Hygiene
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The patient takes anticoagulants. Which instruction is most important for
the nurse to include on the patients care plan? Teach the patient to:
•
use an electric razor for shaving.
•
apply skin moisturizer.
•
use less soap when bathing.
•
floss
teeth daily.
ANS: 1
The nurse should instruct the patient prescribed an anticoagulant to use an electric razor
instead of a double-edge razor for shaving to prevent the risk of excess bleeding. Older
adults should be encouraged to use skin moisturizers and use less soap while bathing to
combat excess drying of the skin that occurs as a result of aging. However, even if this
patient is an older adult, a risk for bleeding takes priority over a risk for dry skin.
Everyone should be encouraged to floss their teeth daily; however, some patients with
severe bleeding risk may be told not to floss.
PTS: 1 DIF: Easy REF: p. 702
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
2. The nurse is caring for a patient admitted with a closed head injury. Which
action by the nurse is appropriate when providing hygiene for this patient?
1)
Avoid bathing the patient.
2)
Use cool water for bathing.
3)
Provide care in small intervals.
4)
Rub briskly when towel drying.
ANS: 3
The nurse should provide care in small intervals to avoid overstimulating the patient,
thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the
patient. Using cool water to bathe the patient may cause shivering, which may elevate
intracranial pressure and increase metabolic demands. Rubbing briskly when drying
might also overstimulate, leading to an elevation in intracranial pressure.
PTS: 1 DIF: Difficult REF: dm 685-686 answer is not expressly given.
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
3. A patient has sustained a spinal cord injury and is no longer able to get in and
out of the bathtub without assistance. Which nursing diagnosis appropriately addresses
this problem?
1)
Total Self-care Deficit
2)
Bathing/Hygiene Self-care Deficit
3)
Dressing/Grooming Self-care deficit
4)
Activity Intolerance
ANS: 2
The nursing diagnosis Bathing/Hygiene Self-care Deficit is most appropriate for
addressing the patients inability to get in and out of the bathtub independently. There are
no data to suggest that the patient is completely unable to care for himself; therefore,
Total Self-care Deficit is not appropriate. There is nothing to suggest that the patient is
unable to dress or groom himself. Activity Intolerance is present when a patient exhibits
extreme fatigue, which is not mentioned in this scenario.
PTS: 1 DIF: Moderate REF: ESG,
KEY: Nursing process: Nursing diagnosis | Client need: PHSI | Cognitive level: Analysis
4. Which scheduled hygiene care is usually thought of as including a back
massage to help the patient relax?
1)
Afternoon care
2)
Early morning care
3)
Morning care
4)
Hour of sleep care
ANS: 4
The nurse should offer a back massage during hour of sleep (HS) care to promote
relaxation. During afternoon care the nurse should prepare the patient to receive visitors
or for afternoon rest. Early morning care is provided after the patient awakens. It
commonly prepares the patient for breakfast or procedures, such as diagnostic testing.
Early morning care typically consists of assisting with toileting, face and hand washing,
and mouth care. Morning care occurs after breakfast and commonly consists of toileting,
bathing, and mouth, skin, and hair care. It may also include dressing and positioning or
assisting the patient to the chair.
PTS: 1 DIF: Easy REF: p. 687
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
5. For which patient can the nurse safely delegate morning care to the nursing
assistive personnel (NAP)? Assume an experienced NAP, and base your decision on
patient condition. Assume there are no complications other than the conditions stated.
1)
32-year-old admitted with a closed head injury
2)
76-year-old admitted with septic shock
3)
62-year-old who underwent surgical repair of a bowel obstruction 2 days ago
4)
23-year-old admitted with an exacerbation of asthma with dyspnea on exertion
ANS: 3
Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be
safely delegated to the nursing assistive personnel because the patient should be stable.
The patient who sustained a closed head injury may develop increased intracranial
pressure during care. Therefore, he requires the critical thinking skills of a registered nurse
to perform his morning care safely. The patient admitted with septic shock may easily
become unstable with care; therefore, a registered nurse is required to provide his morning
care safely. The patient admitted with an exacerbation of asthma who becomes short of
breath with activity also requires the critical thinking skills of a registered nurse to detect
respiratory compromise quickly.
PTS: 1 DIF: Difficult REF: p. 687
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
6. A clients epidermis has insufficient melanin. Which nursing diagnosis
is appropriate?
1)
Risk for Infection
2)
Risk for Impaired Skin Integrity
3)
Risk for Deficient Fluid Volume
4)
Impaired Skin Integrity
ANS: 2
The epidermis contains melanin, a pigment that protects against the suns ultraviolet rays;
therefore, a person with insufficient melanin is at Risk For Impaired Skin Integrity
(sunburn). There are no symptoms to indicate that the client has a sunburn (actual
Impaired Skin Integrity), only that a risk factor is present. The dermis contains blood and
lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands;
melanin does not prevent fluid loss. Fibroblasts (not melanin), also found in the dermis,
produce new cells and assist in wound healing, thereby helping to prevent infection.
PTS: 1 DIF: Difficult REF: dm 688 for coverage of aging effects including loss of
melanin, 689 for coverage of impaired skin integrity; students must synthesize the
information to answer the question; answer is not directly stated in text
KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Analysis
7. What is the bodys first line of defense against
bacteria? 1)
Intact skin 2)
White blood cells
3)
Lymph glands
4)
Inflammatory response
ANS: 1
Intact skin is the bodys first line of defense against bacteria. Once bacteria enter the body,
the inflammatory response, white blood cells, and lymph glands play a role in fighting
against the bacteria.
PTS: 1 DIF: Easy REF: p. 687
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
8. While bathing a patient with liver dysfunction, the nurse notes yellow skin
tone. The nurse should document this finding as:
1)
Pallor.
2)
Erythema.
3)
Jaundice.
4)
Cyanosis.
ANS: 3
A yellow skin tone, known as jaundice, commonly occurs in patients with impaired liver
function. Pallor is pale skin without underlying pink tones in the light-skinned person.
Pallor occurs with anemia. Erythema, or redness of the skin, commonly occurs with
inflammation or vasodilation. Cyanosis, a bluish coloring of the skin, is caused by poor
peripheral circulation or decreased oxygen in the blood.
PTS: 1 DIF: Moderate REF: p. 688
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
9. A patient with diarrhea is incontinent of liquid stool. The nurse documents
that he now has excoriated skin on his buttocks. Which finding by the nurse led to this
documentation?
1)
Skin was softened from prolonged exposure to moisture.
2)
Superficial layers of skin were absent.
3)
The epidermal layer of skin was rubbed away.
4)
A lesion caused by tissue compression was present.
ANS: 2
Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes
in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a
rubbing away of the epidermal layer of the skin, especially over bony areas, is often
caused by friction or searing forces that occur when a patient moves in bed. Pressure
ulcers are lesions caused by tissue compression and inadequate perfusion that are a result
of immobility.
PTS: 1 DIF: Moderate REF: p. 689
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
10. For which patient is it most important to provide frequent perineal care?
The patient:
1)
with active lower gastrointestinal bleeding.
2)
after an episode of diabetic ketoacidosis.
3)
who has a circumcised penis.
4)
with a history of acute asthma.
ANS: 1
The patient admitted with active lower GI bleeding will require frequent perineal care
because of the irritating effect of enzymes in the stools. The uncircumcised patient, not
the circumcised patient, may require frequent perineal care. Those with diabetic
ketoacidosis or who have had acute asthma do not require frequent perineal care.
PTS: 1 DIF: Moderate REF: dm 692, 714-716
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
11. A patient with dementia becomes belligerent when the nurse attempts to
give him a tub bath. How should the nurse proceed?
1)
Call for assistance to help the patient into the bathtub.
2)
Wait for the patient to calm down, and then give him a towel bath.
3)
Allow the patient to go without bathing for a day or two.
4)
Ask another staff member to attempt the tub bath.
ANS: 2
Nurses need to individualize bathing to meet the needs of the patient. If the patient
becomes belligerent, the nurse should wait until the patient calms down and then attempt
a towel bath. Towel baths have been shown to reduce agitation significantly. The patient
should not be forced into the tub. Having another staff member attempt the tub bath will
most likely increase the patients agitation, as consistency of caregivers is important for
patients with dementia.
PTS: 1 DIF: Moderate REF: dm 692-693
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
12. The nurse is teaching nursing assistive personnel (NAP) how to give a
complete bed bath. Which instruction should the nurse include?
1)
Cleanse only those areas likely to cause odor.
2)
Provide the patient with warm water for washing his perineum.
3)
Wash the patients back, buttocks, and perineum first.
4)
Bathe the patient from head-to-toe, cleanest areas first.
ANS: 4
The nurse should instruct the NAP to give a complete bed bath (a bath for patients who
must remain in bed but who are able to bathe themselves), in head-to-toe fashion,
beginning with the cleanest part of the body and ending with the dirtiest. The NAP should
provide the patient with a basin of warm water and allow him to wash his perineum when
giving an assist bath or bed bath (this is a total bed bath). During a partial bath, the NAP
should cleanse only the areas that may cause odor or discomfort. The NAP should never
begin the bath with the back, buttocks, and perineum because this violates the principle of
clean to dirty.
PTS: 1 DIF: Moderate REF: dm 690-691; 707-711
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
13. Which action should the nurse take when preparing a patient for a bed
bath? 1)
Place the nurse call device within reach for safety.
2)
Cover the patient with the top linens from the bed.
3)
Have the patient completely bathe himself to promote independence.
4)
Wash the patients body without assistance from the patient.
ANS: 1
When preparing a patient for a bed bath (a bath for patients who must remain in bed but
who are able to bathe themselves), place a basin of warm water, bath linens, a clean gown,
and other bathing supplies on the overbed table. Provide privacy, and place the nurse call
device within reach. Remove the top linens from the bed, and cover the patient with a bath
blanket. If the patient cannot bathe all areas of his body, complete the bath for him. The
nurse performs at least part of a bed bath; if the patient bathes himself completely while
remaining in bed, it is referred to as an assist bath.
PTS: 1 DIF: Moderate REF: p. 690
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
14. A patient admitted with an acute exacerbation of chronic obstructive
pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is
preferred for this patient?
1)
Tub bath 2)
Complete bed bath
3)
Towel bath
4)
Bed bath
ANS: 3
A towel bath is a modification of the bed bath, in which a large towel and a bath blanket
are placed in a plastic bag and saturated with a commercially prepared mixture of
moisturizer, nonrinse cleaning agent, and water. The bag and its contents are then placed in
the microwave, and they are used to bathe the patient. This bathing method is preferred for
patients who have Activity Intolerance. A tub bath, complete bed bath, and conventional
bed bath may deplete this patients energy.
PTS: 1 DIF: Easy REF: p. 690
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
15. Wearing poorly fitting shoes may result in which
condition? 1)
Tinea pedis
2)
Plantar wart
3)
Excoriation
4)
Ingrown toenail
ANS: 4
Wearing poorly fitting shoes and improperly trimming the toenails may cause an ingrown
toenail. Tinea pedis occurs when moisture accumulates in unventilated shoes. Plantar wart
is a painful growth that is caused by a virus. Excoriation occurs when digestive enzymes
come in contact with skin.
PTS: 1 DIF: Moderate REF: p. 694
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
16. The school nurse is teaching a group of middle school students how to
prevent tinea pedis. Which remark by a student provides evidence of learning?
1)
I can contract the infection by walking barefoot in the gymnasiums showers.
2)
The best way to avoid contracting the infection is to use good hand washing.
3)
Wearing unventilated shoes prevents the fungus from gaining contact with my feet.
4)
There is really no way to prevent its spread; its highly contagious.
ANS: 1
One can contract the infection by walking barefoot in public showers, such as those in the
schools gymnasium. Good hand washing does not prevent a person from contracting tinea
pedis. Wearing unventilated shoes may actually aggravate the infection by allowing
moisture to accumulate in the shoes. Although the infection is highly contagious, the
spread of infection can be prevented by wearing special footwear in the shower.
PTS: 1 DIF: Moderate REF: p. 694
KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application
17. Bath water should be prepared at which temperature to prevent chilling
and excess drying of the skin?
1)
99F (37.2C)
2)
102F (38.9C)
3)
103F (39.4C)
4)
105F (40.6C)
ANS: 4
Bath water temperature should be 105F (40.6C) to prevent chilling, burning, and excess
drying of the skin.
PTS: 1 DIF: Easy REF: p. 707
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
18. While assessing a patient, the nurse notes that the patients nails are
excessively brittle. What does this finding suggest?
1)
Inadequate dietary intake
2)
Normal aging process
3)
Fungal infection
4)
Excessive use of silver salts
ANS: 1
Inadequate dietary intake or metabolic changes can cause the nails to become brittle. As a
person ages, nails thicken, become ridged, and may yellow or become concave in shape.
Brown or black discoloration of the nail plate may indicate a fungal infection. Bluish gray
discoloration of the nail plate signals excessive intake of silver salts.
PTS: 1 DIF: Moderate REF: p. 695
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
19. A patient with a history of seizures who takes phenytoin is at risk for which
oral problem?
1)
Dryness of the mouth
2)
Bitter taste
3)
Demineralization of the tooth enamel
4)
Gingival hyperplasia
ANS: 4
Phenytoin causes gingival hyperplasia. Medications, such as atropine, cause dry mouth.
Bitter taste can result from drugs, such as docusate sodium, a stool softener. Phenytoin
does not cause demineralization of the tooth enamel.
PTS: 1 DIF: Moderate REF: p. 698
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension
20. The nurse has been teaching a student how to perform mouth care for her
unconscious patient. The student will show evidence of learning if she places the patient
in which position for this care?
1)
Supine
2)
Prone
3)
Semi-Fowlers
4)
Side-lying
ANS: 4
The nurse should position an unconscious patient in a side-lying position to provide
mouth care to prevent aspiration. Supine, prone, and semi-Fowlers positions are unsafe
positions for providing mouth care for the unconscious patient.
PTS: 1 DIF: Moderate REF: p. 725
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Comprehension
21. Which item is best for providing mouth care for an unconscious
patient? 1)
Foam swabs
2)
Lemon-glycerin swabs
3)
Hydrogen peroxide
4)
Cotton-tipped applicator soaked in mouthwash
ANS: 1
Commercially packaged applicators or foam swabs are typically used to provide mouth
care. Lemon-glycerin swabs are not recommended because they are drying to the oral
mucosa. Hydrogen peroxide should be avoided because it is irritating to oral mucosa and
may alter the balance of normal floras that occur in the mouth. Mouthwash can be used by
conscious patients as part of their routine mouth care. However, cotton-tipped applicators
should not be soaked in it to perform mouth care.
PTS: 1 DIF: Moderate REF: p. 725
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall
22. After receiving a course of chemotherapy, a patient begins losing hair.
This adverse effect of chemotherapy should be documented as:
1)
pediculosis.
2)
alopecia.
3)
dandruff.
4)
hirsutism.
ANS: 2
Alopecia is abnormal hair loss that can occur as a result of chemotherapy. Pediculosis is
an infestation of head lice. Dandruff is a condition in which there is excessive shedding
of the epidermal layer of the scalp. Hirsutism is the excessive growth of body hair in
women.
PTS: 1 DIF: Moderate REF: p. 702
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
23. Which of the following is a correct step in removing and cleaning a hearing
aid? 1)
Clean only the external surfaces, not the canal portion. 2)
Clean the top part of the canal portion of the device.
3)
Insert a wax loop or toothpick into the hearing aid.
4)
Remove the battery before taking the hearing aid from the ear.
ANS: 2
The nurse should clean the top part of the canal portion of the hearing aid using the wax
loop and wax brush, cotton-tipped applicator, pipe cleaner, or toothpick. Nothing should
be inserted into the hearing aid. The external surfaces are cleaned with a damp cloth. The
hearing aid should be turned off before removing it from the ear, but the battery is not
removed at that step of the procedure. It would not likely be possible to remove the
battery while the device was still in the ear.
PTS: 1 DIF: Difficult REF: dm 739-742
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
24. The patient is sitting in a chair at the bedside. The nurse is preparing to
remove the patients artificial eye. What should the nurse do to best position the patient
for this procedure? Ask the patient to:
1)
Lean forward and rest the arms on the overbed table.
2)
Sit back in the chair and tilt the head back.
3)
Move to the bed and lie down.
4)
Stand up and lean over the bed.
ANS: 3
The nurse should have the patient lie down so that if the eye is dropped when removing it,
it will fall onto the bed instead of the floor. Sitting back in the chair would allow access to
the eye but would not protect the artificial eye from falling to the floor. Leaning forward
and resting the arms on an overbed table, as well as standing up and leaning over the bed,
would not provide the nurse access to the eye to remove the prosthesis.
PTS: 1 DIF: Moderate REF: p. 739
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which area(s) should the nurse inspect when assessing for cyanosis in a
dark- skinned patient? Select all that apply.
1)
Buccal mucosa 2)
Around the lips
3)
Palms
4)
Tongue ANS:
1, 3, 4
In dark-skinned people, cyanosis can be best assessed by examining the palms of the
hands, soles of the feet, tongue, conjunctivae, or the buccal mucosa. In light-skinned
people, the nailbeds and the area around the lips can be used.
PTS: 1 DIF: Moderate REF: p. 689
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
2. Which of the following is/are a benefit of bathing? Choose all that
apply. 1)
Constricts blood vessels 2)
Increases depth of respirations
3)
Gives opportunity for assessments 4)
Reduces sensory input
ANS: 2, 3
Bathing presents an opportunity to perform a variety of assessments. Bathing also dilates
blood vessels near the skins surface, increasing circulation. Moreover, bathing stimulates
the depth of respirations and provides sensory input.
PTS: 1 DIF: Easy REF: p. 690
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
3. For which patient(s) should the nurse avoid using back massage? One
who (select all that apply):
1)
underwent heart surgery 3 days ago.
2)
sustained rib fractures from a fall.
3)
underwent a lumbar laminectomy.
4)
sustained a leg fracture in a sledding accident.
ANS: 1, 2
Back massage is contraindicated with rib fractures, burns, and recent heart surgery.
Massage is acceptable for the patients with lumbar laminectomy or leg fracture.
PTS: 1 DIF: Moderate REF: p. 690
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
Completion
•
The nurse is making an occupied bed. Arrange the following
steps in the order in which the nurse should perform them.
•
Position the patient laterally near the side rail farthest
from you (that side rail is up); roll the soiled linens under him.
•
Lower the side rail on the side of the bed you are working on.
•
Raise the side rail on the side of the bed you are working on.
•
After placing clean linens and tucking them under the
soiled linens, roll the patient over the hump and position him facing
you on the near side of the bed.
ANS: B, A, D, C
First lower the side rail on your side of the bed. This allows you to maintain good body
mechanics while positioning the patient. Position the patient laterally near the far side rail,
and roll soiled linens under him. Then place clean linens on the side nearest you, and tuck
them under soiled linens. Next, roll the patient over the hump, and position him on his
other side, facing you. Do this before raising the near side rail so you do not have to reach
across the side rail to help the patient roll and turn to his other side.
Chapter 23 Administering Medication
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The primary care provider prescribes furosemide 40 mg IV for a patient
with heart failure. Which drug name is used in this prescription?
1)
Chemical
2)
Brand
3)
Trade
4)
Generic
ANS: 4
Furosemide, the generic name, was used by the physician in the drug order. The brand or
trade name of the drug is Lasix; the chemical name is 4-chloro-N-furfuryl-5sulfamoylanthranilic acid.
PTS:1DIFifficultREF:p. 746
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension
2. A patient is prescribed fluoxetine 20 mg by mouth daily for treatment of
depression. The nurse caring for the patient is unfamiliar with this drug. Which action
should she take before administering the medication?
1)
Inform the prescriber that she is not comfortable administering the drug.
2)
Ask a nursing colleague for relevant information about the drug.
3)
Consult the drug formulary accessible to staff at the patient care unit. 4)
Trust the prescriber writes the dose and administer the drug as intended.
ANS: 3
The nurse is responsible for every medication she administers. Therefore, the nurse must
be familiar with the indications, routes of administration, dosages, contraindications,
adverse reactions, drug interactions, and any special administration guidelines associated
with each drug before administration. There are numerous ways to become more
informed about medication, such as a drug formulary, Physicians Desk Reference, or
registered pharmacist before administration. The nurse should not rely on information
from a colleague because as a secondary source of information, there is a risk for
inaccuracy, which can be dangerous in a patient care situation.
PTS:1DIF:ModerateREF:dm 746-747
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
3. A surgeon prescribes potassium chloride 20 mEq by mouth for a patient with
a nasogastric (NG) tube for gastric drainage. How should the nurse proceed?
1)
Seek clarification from the surgeon about the medication order.
2)
Clamp the NG tube while administering the dose by mouth.
3)
Instill the medication through the NG tube.
4)
Withhold the oral potassium chloride elixir.
ANS: 1
The nurse should seek clarification from the surgeon about the medication ordered via the
nasogastric route. If the patient has a nasogastric tube in place to release gastric drainage,
any medication given by mouth would be lost into the drainage collection unit and,
therefore, be unavailable to the patient for therapeutic use. The nurse does not have
authority to electively withhold or alter the route of prescribed treatment without seeking
clarification and resolving any discrepancy in the route by which the medication would be
administered.
PTS: 1 DIF: Moderate REF: dm 750, 767
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
4. A patient calls the nurse because he is having incision pain and wants a dose
of analgesic medication. When the nurse checks the patients medication administration
record, she notes that he is prescribed the narcotic, hydromorphone (Dilaudid). Where
should the nurse expect to retrieve this drug for administration?
1)
Cabinet in the patients room
2)
Double-locked medication drawer
3)
Stock supply cabinet
4)
Portable medication cart
ANS: 2
Hydromorphone (Dilaudid) is a controlled substance and must be kept in a double-locked
medication drawer for control of inventory. Frequently used Schedule II medications, such
as ibuprofen, are stored in the stock supply. Other prescribed medications may be stored in
a locked cabinet in the patients room or in the medication cart.
PTS:1DIF:ModerateREF:dm 747-748
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
5. Which term refers to the movement of a drug from the site of administration
to the bloodstream?
1)
Absorption
2)
Distribution
3)
Metabolism
4)
Excretion
ANS: 1
Absorption refers to the movement of drug from the site of administration into the
bloodstream. Distribution involves the transport of the drug in body fluids, such as blood,
to the tissues and organs. Metabolism is the biotransformation of the drug into a more
water-soluble form or into metabolites that can be excreted from the body. Excretion, or
the removal of drugs from the body, takes place in the kidneys, liver and gastrointestinal
tract, lungs, and exocrine glands.
PTS:1DIF:ModerateREF:p. 749
KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
6. A patient who just returned from the postanesthesia care unit is complaining of
severe incision pain. Which drug contained in his medication administration record will
offer him the fastest relief?
1)
Liquid acetaminophen with codeine
2)
Intravenous morphine sulfate 3)
Intramuscular meperidine
4)
Oral oxycodone tablets
ANS: 2
Drugs administered by the intravenous route are injected directly into the bloodstream
and do not have to be absorbed into it. Therefore, they act more quickly than drugs
administered by the oral or intramuscular routes.
PTS: 1 DIF: Moderate REF: dm 750-753
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
7. The time it takes for drug concentration to reach a therapeutic level in the
blood is known as:
1)
peak action.
2)
duration of action.
3)
onset of action.
4)
half-life.
ANS: 3
The onset of action is the time needed for drug concentration to reach a high enough level
in the blood for its effects to appear. Peak action occurs when the concentration of a
medication is highest in the blood. Duration of action is that period when the medication
has a pharmacological effect. Half-life is the amount of time required for half of the drug
to be eliminated.
PTS:1DIF:ModerateREF:p. 755
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
8. A patient is given furosemide 40 mg orally at 0900. The duration of action for
this drug is approximately 6 hours after oral administration. At which time in military
hours should the nurse no longer expect to see the effects of this drug?
1)
0930
2)
1000
3)
1100
4)
1500
ANS: 4
The nurse should no longer see the effects of furosemide around 1500 hours (3:00 p.m.).
The effects of oral furosemide should be seen 30 to 60 minutes after administration,
which is 0900 (9:30 a.m. in this case). Peak diuresis should occur in 1 to 2 hours, which
is 1000 hours (10:00 a.m.) to 1100 (11:00 a.m.) in the scenario above.
PTS:1DIF:EasyREF:p. 755
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
9. Which factor in a patients medical history is most likely to prolong the halflife of certain drugs?
1)
Heart disease
2)
Liver disease
3)
Rheumatoid arthritis
4)
Tobacco use
ANS: 2
Metabolism takes place largely in the liver. If there is a decrease in liver function (e.g.,
because of liver disease), the drug will be eliminated more slowly, prolonging the drugs
half-life. Tobacco use can increase the elimination of some drugs, decreasing their
effectiveness.
PTS:1DIF:ModerateREF:p. 754
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
10. The nurse receives a laboratory report that states her patients digoxin level is 1.2
ng/mL; therapeutic range for this drug is 0.5 to 2.0 ng/mL. Which action should the nurse
take?
1)
Notify the prescriber to reduce the dose.
2)
Withhold the next dose of digoxin.
3)
Administer the next dose as prescribed.
4)
Notify the prescribing healthcare provider to increase the dose.
ANS: 3
Therapeutic range is a range whereby the medication is at a concentration to produce the
desired effect. This patients level is within the therapeutic range, so the nurse should
administer the next dose as prescribed. The dose should not be increased or decreased
because the prescribed dose is producing a level within the therapeutic range. The dose
should not be withheld; this action could result in detrimental cardiac effects for the
patient.
PTS:1DIFifficultREF:dm 755-756
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
11. The primary care provider orders peak and trough levels for a patient who is
receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood
specimen to measure the trough?
1)
With the morning routine laboratory studies
2)
Approximately 30 minutes before the next dose
3)
Two hours after the next dose infuses
4)
While the drug infuses
ANS: 2
Trough levels are typically obtained approximately 30 minutes before administering the
next dose of the drug. Therefore, the trough cannot be collected with the morning routine
laboratory studies. The vancomycin peak should be obtained 2 hours after the next dose
infuses. Peak level must be measured when absorption is complete. This depends on all
the factors that affect absorption. Trough levels would be inaccurate if the specimen is
obtained while the drug infuses.
PTS:1DIFifficultREF:p. 756
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
12. Teratogenic drugs should be avoided in which patient
population? 1)
Pregnant women
2)
Elderly
3)
Children
4)
Adolescents
ANS: 1
Drugs that are known to cause developmental defects are termed teratogenic. These
drugs are contraindicated during pregnancy because of the likelihood of adverse effects
on the embryo or fetus.
PTS:1DIF:EasyREF:p. 756
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall
13. A patient with end-stage cancer is prescribed morphine sulfate to reduce
pain. For which effect is this medication prescribed?
1)
Supportive
2)
Restorative
3)
Substitutive
4)
Palliative
ANS: 4
Morphine was prescribed for its palliative effectsto relieve pain, a symptom of cancer.
Supportive effects support the integrity of body functions until other medications or
treatments become effective. Restorative effects return the body to or maintain the body
at optimal levels of health. Substitutive effects replace either body fluids or a chemical
required by the body for improved functioning.
PTS:1DIF:ModerateREF:p. 756
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
14. After receiving diphenhydramine, a patient complains that his mouth is very
dry. This is not uncommon for patients taking this medication. Which drug effect is this
patient experiencing?
1)
Side effect 2)
Adverse reaction
3)
Toxic reaction
4)
Supportive effect
ANS: 1
Dry mouth is a side effect of diphenhydramine. Side effects are unintended, often
predictable, physiological effects that are well tolerated by patients. Adverse reactions are
harmful, unintended, usually unexpected reactions to a drug administered at a normal
dosage. They are commonly more severe than side effects. Toxic reactions are dangerous,
damaging effects to an organ or tissue. Supportive effects are intended effects that support
the integrity of body functions.
PTS:1DIF:ModerateREF:p. 758
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
15. While receiving an intravenous dose of an antibiotic, levofloxacin, a patient
develops severe shortness of breath, wheezing, and severe hypotension. Which action
should the nurse take first?
1)
Administer epinephrine IM.
2)
Give bolus dose of intravenous fluids.
3)
Stop the infusion of medication.
4)
Prepare for endotracheal intubation.
ANS: 3
The patient is experiencing an anaphylactic reaction (severe shortness of breath, wheezing,
and severe hypotension), a life-threatening allergic reaction. Therefore, the nurse should
immediately discontinue the medication. The first priority is to eliminate the cause of the
problem. Next, the nurse should notify the physician, give IV fluids, and administer
epinephrine, steroids, and diphenhydramine. Respiratory support ranging from oxygen to
endotracheal intubation and mechanical ventilation may also be necessary.
PTS:1DIFifficultREF:p. 759
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis
16. A patient develops urticaria and pruritus 5 days after beginning phenytoin
for treatment of seizures. Which type of reaction is the patient most likely
experiencing? 1)
Mild adverse reaction
2)
Dose-related adverse reaction
3)
Toxic reaction
4)
Anaphylactic reaction
ANS: 1
Urticaria and pruritus are considered minor adverse reactions. Dose-related adverse
reactions are undesired effects that result from known pharmacological effects of the
medication. Toxic reactions are dangerous, damaging effects to an organ or tissue.
Anaphylactic reaction is a life-threatening allergic reaction that occurs during or
immediately after administration.
PTS:1DIFifficultREF:p. 758
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application
17. Laboratory test results indicate that warfarin anticoagulant therapy is
suddenly ineffective in a patient who has been taking the drug for an extended time. The
nurse suspects an interaction with herbal medications. What type of interaction does she
suspect?
1)
Antagonistic drug interaction
2)
Synergistic drug interaction
3)
Idiosyncratic reaction
4)
Drug incompatibility
ANS: 1
In an antagonistic drug interaction, one drug interferes with the actions of another and
decreases the resultant drug effect. In a synergistic drug interaction, there is an additive
effect; that is, the effects of both drugs combined are greater than the individual effects.
An idiosyncratic reaction is an unexpected, abnormal, or peculiar response to a
medication. Drug incompatibilities occur when drugs are physically mixed together,
causing a chemical deterioration of one or both drugs.
PTS:1DIF:ModerateREF:p. 759
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis
18. A patient with terminal cancer requires increasing doses of an opioid
pain medication to obtain relief from pain. This patient is exhibiting signs of drug:
1)
Abuse
2)
Misuse
3)
Tolerance
4)
Dependence
ANS: 3
Patients in the terminal stages of cancer commonly exhibit drug tolerance, a decreasing
response to repeated doses of a medication. Therefore, pain management must be
carefully planned to promote patient comfort. Drug abuse is the inappropriate intake of a
substance continually or periodically. Drug misuse is the nonspecific, indiscriminate, or
improper use of drugs, including alcohol, over-the-counter preparations, and prescription
drugs. Drug dependence occurs when a person relies on or needs a drug. Dependence
leads to lifestyle changes that focus around obtaining and administering the drug.
PTS:1DIF:ModerateREF:p. 760
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
19. Before administering a medication, the nurse must verify the rights
of medication administration, which include:
1)
right patient, right room, right drug, right route, right dose, and right time.
2)
right drug, right dose, right route, right time, right physician, and right documentation.
3)
right patient, right drug, right route, right time, right documentation, and right equipment.
4)
right patient, right drug, right dose, right route, right time, and right documentation.
ANS: 4
The six rights of medication administration are the right patient, right drug, right dose,
right route, right time, and right documentation.
PTS: 1 DIF: Moderate REF: dm 771-773
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
20. Which expected outcome is best for a patient with a nursing diagnosis
of Deficient Knowledge related to new drug treatment regimen?
1)
After an explanation and written materials, describes the expected actions and adverse
reactions of his medication
2)
In 1 week after instructional session, describes the expected actions and adverse reactions
of his medications
3)
Follows the treatment plan as prescribed
4)
Experiences no adverse effect from his prescribed treatment plan
ANS: 2
The best phrasing for the expected outcome is the one with a specific, measurable time
frame (1 week) and details for how to resolve the patients knowledge deficit. The other
options provide no timeline for achieving the goal and are therefore not measurable.
Expected outcome statements must be measurable.
PTS:1DIF:Moderate
REF:p. 770; Also requires knowledge of goals
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
21. When the nurse enters a patients room to administer a medication, he calls
out from the bathroom telling her to leave his medication on the bedside table. He
reassures her that he will take the medication as soon as he is finished. How should the
nurse proceed?
1)
Inform the patient that she will return when he is finished in the bathroom.
2)
Wait outside the bathroom door until the patient is ready for the dose.
3)
Withhold the dose until the next administration time later in the day.
4)
Document that the dose was omitted in the medication administration record.
ANS: 1
The nurse should inform the patient that she will return with the medication when he is
finished in the bathroom. The nurse likely would not have time to stand outside the door
and wait for the patient to finish in the bathroom. If the medication is left at the bedside
for the patient, the nurse cannot be sure that the patient actually took the medication.
Withholding the dose until the next administration time may compromise the patients
condition and is not appropriate nursing action. The drug should not be omitted;
therefore, the nurse should not document a missed dose in the medication administration
record.
PTS:1DIF:ModerateREF:dm 771-772
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
22. Which documentation entry related to PRN medication administration
is complete?
1)
6/5/14 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 110
scale, J. Williams RN
2)
0600 famotidine 20 mg IV given in right hand, S. Abraham RN
3)
9/2/14 0900 levothyroxine 50 mcg PO given
4)
1/16/14 furosemide 40 mg PO given, J. Smith RN
ANS: 1
The longest option, signed by J. Williams, is complete because it contains the date and
time the medication was administered, the name of the medication, the route of
administration and injection site, and the name of the nurse administering the medication.
Because the medication administered was a PRN order, the nurse also included the reason
why the medication was administered. Other options are incomplete.
PTS:1DIF:ModerateREF:dm 772-773
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
23. A patient has difficulty taking liquid medications from a cup. How should
the nurse administer the medications?
1)
Request that the prescriber change the order to the IV route.
2)
Administer the medication by the IM route.
3)
Use a needleless syringe to place the medication in the side of the mouth.
4)
Add the dose to a small amount of food or beverage to facilitate swallowing.
ANS: 3
When a patient has difficulty taking liquid medications from a cup, the nurse should use a
syringe without a needle to place the medication in the side of the patients mouth. After
placing the syringe between the gum and cheek, the nurse should push the plunger to
administer the medication slowly. It is not necessary to ask the prescriber to change the
order to the IV route; it is preferable to use the least invasive route. The nurse cannot
administer a drug by another route without a prescription to do so. Dosing might not
necessarily be the same between oral and IM routes; thus, a prescription is needed to
change the route. Some drugs are not compatible with various food or liquid substances
and should be taken on an empty stomach. Consult a pharmacist, prescriber, or drug
formulary.
PTS:1DIF:Moderate
REF:dm 774-775; under Special Situations. Inductive reasoning needed to determine
correct answer.
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
24. The primary care provider prescribes nitroglycerin 1/150 g SL for a
patient experiencing chest pain. How should the nurse administer the drug?
1)
Place the drug in the cheek and allow it to dissolve.
2)
Place the drug under the tongue and allow it to dissolve.
3)
Inject the drug superficially into the subcutaneous tissue.
4)
Give the pill and water to the patient for him to swallow the tablet.
ANS: 2
Drugs administered by the sublingual (SL) route should be placed under the patients
tongue and allowed to dissolve. Drugs administered by the buccal route are placed in the
cheek and allowed to dissolve. A subcutaneous injection is administered into the
subcutaneous tissue. Placing the drug into the patients mouth, giving him water, and
instructing him to swallow the tablet describe oral administration.
PTS: 1 DIF: Moderate REF: p. 800
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
25. Which action should the nurse take immediately after administering
a medication through a nasogastric tube?
1)
Verify correct nasogastric tube placement in the stomach.
2)
Auscultate the abdomen for presence of bowel sounds.
3)
Immediately administer the next prescribed medication.
4)
Flush the tube with water using a needleless syringe.
ANS: 4
The nurse should flush the nasogastric tube with water using a needleless syringe after
administering each medication. Some medications are less effective when given in
combination with others. The nurse should verify nasogastric tube placement and
auscultate the abdomen for bowel sounds before administering the medication.
PTS: 1 DIF: Moderate REF: p. 801
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
26. How should the nurse dispose of a contaminated needle after administering
an injection?
1)
Place the needle in a specially marked, puncture-proof container.
2)
Recap the needle, and carefully place it in the trash can.
3)
Recap the needle, and place it in a puncture-proof container.
4)
Place the needle in a biohazard bag with other contaminated supplies.
ANS: 1
To avoid needlestick injuries, the nurse should place the uncapped needle, pointing
downward, directly into a specially marked, puncture-proof container. Recapping the
needle should only be done when no other feasible alternative is available. When
recapping is necessary, use an acceptable technique such as the one-handed scoop
technique in which the nurse places the needle cap on a sterile surface and, using one
hand, scoops up the cap with the needle. Placing the needle in an improper container
(biohazard bag) that could be punctured by the contaminated needle places other staff
members at risk.
PTS:1DIF:ModerateREF:dm 785, 819
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
27. The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly
to a 3-day-old infant born to an HB Ag-positive mother. Which injection site should the
nurse choose to administer this injection?
1)
Ventrogluteal
2)
Vastus lateralis
3)
Deltoid
4)
Dorsogluteal
ANS: 2
The preferred site for IM injections for infants who are not yet walking is the vastus
lateralis muscle because there are no major blood vessels or nerves in the area and the
gluteal muscles have not been developed by walking. For children who are walking, the
site of choice is the ventrogluteal muscle. The dorsogluteal site is not recommended for
children or adults. The deltoid muscle can be used for small volumes in older children
and adults.
PTS: 1 DIF: Moderate REF: p. 787
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
28. Which action should the nurse take to relax the vastus lateralis muscle
before administering an intramuscular injection into the site?
1)
Apply a warm compress.
2)
Massage the site in a circular motion.
3)
Apply a soothing lotion.
4)
Have the client assume a sitting position.
ANS: 4
To relax the vastus lateralis for injection, the nurse should have the patient assume a
sitting position or lie flat with his knee slightly flexed. Applying a warm compress,
massaging the site, and applying soothing lotion are inappropriate interventions before
administering an IM injection. After injection, massaging the site can enhance the
absorption of medication into the muscle. Applying a warm compress increases
circulation to the site, which can also enhance absorption. This action would be
performed after the injection and not before.
PTS:1DIF:ModerateREF:p. 834
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
29. The physician prescribes warfarin 5 mg orally at 1800 for a patient who
underwent open reduction and internal fixation of his right hip. After administering the
medication, the nurse realizes that she administered a 10 mg tablet instead of the
prescribed 5 mg PO. Which of the following actions by the nurse is appropriate?
1)
No action is necessary because an extra 5 mg of warfarin is not harmful.
2)
Call the prescriber and ask her to change the order to 10 mg. 3)
Document on the chart that the drug was given and indicate the drug was given in error.
4)
Complete an incident report according to the facilitys policy.
ANS: 4
When a medication error is made, the nurse should first check the patient to assess for
negative effects. If she is unfamiliar with the side effects of the medication, she should
consult a drug reference, the licensed pharmacist at the institution, or the prescriber. Next
she should verify that she made an error and identify the type. Notify the nurse in charge
and the physician. Follow any orders the physician prescribes. Document the drug, the
dose, site, route, date, and time in the patients healthcare record but do not document that
the drug was given in error. Complete an incident report according to the facilitys policy;
submit the signed report to the nurse manager. Finally, critically review the error, and
identify ways to improve your practice.
PTS: 1 DIF: Moderate REF: p. 769
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application
30. The nurse must administer eardrops to an infant. How should she
proceed? 1)
Pull the pinna down and back before instilling the drops.
2)
Pull the pinna upward and outward before instilling the drops.
3)
Instill the drops directly; no special positioning is necessary.
4)
Position the patient supine with the head of the bed elevated 30.
ANS: 1
For a child younger than 3 years old, the nurse should pull the pinna down and back. For
older children and adults, the nurse should pull the pinna upward and outward. Doing each
straightens the ear canal for proper channeling of the medication. The patient should be
assisted into a side-lying position with appropriate ear facing up before instillation.
PTS: 1 DIF: Moderate REF: p. 806
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
31. The nurse is teaching parents ways to give oral medication to their child.
Which action would they implement to improve compliance?
1)
Crush time-release capsules to put in his favorite food.
2)
Give medication quickly before he knows what is happening.
3)
Allow the child to eat a frozen pop before receiving the medication.
4)
Mask the flavor of medication in a toddler cup with orange juice.
ANS: 3
The parent can give the child a frozen fruit bar or frozen flavored ice pop just before the
medication. This helps to numb the taste buds to weaken the taste of the medication.
To mask bad-tasting medicines, parents can crush pills or empty the contents of a capsule
as long as it is not a time-release dose, and mix with soft foods, such as applesauce, hot
cereal, or pudding. This is helpful for patients who might aspirate liquids, as well.
If the child is old enough to understand, warn him when a medication has an
objectionable taste. Otherwise, his trust might be compromised if he is surprised with a
bad taste.
Do not use essential foods in the childs diet (e.g., milk or orange juice) to mask the taste
of medications. The child may later refuse a food that he associates with the medicine.
PTS:1DIF:ModerateREF:p. 775
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
32. An adult patient admitted with lower gastrointestinal bleeding is prescribed a
unit of packed red blood cells. Which gauge needle should be inserted to administer this
blood product?
1)
18 gauge
2)
22 gauge
3)
24 gauge
4)
26 gauge
ANS: 1
Large-gauge needles, 14 to 18 gauge, are used for blood products in adults because the
bore is large enough to allow transfusion without cell damage (lysis). Smaller-gauge
bores can cause clumping and breakage of the cell, thus leading to reduced effectiveness
of the transfusion as well as contributing to fragmented by-product of red blood cell
waste.
PTS:1DIF:EasyREF:p. 779
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
True/False
Indicate whether the statement is true or false.
1. At times, patients may self-administer medications when
hospitalized. ANS: T
Occasionally, even in the hospital setting, patients self-administer medications, as their
condition permits. For example, a patient admitted with chest pain may keep sublingual
nitroglycerin at his bedside so he has quick access should he experience chest pain.
PTS:1DIF:EasyREF:p. 748
KEY:Nursing process: N/A |Client need: PHSI | Cognitive level: Recall
Completion
•
The nurse is drawing up a medication from an ampule. Arrange
the following steps in the order in which they should be performed.
•
Use an ampule opener to break ampule neck.
•
Tap the ampule to remove medication trapped in the top of ampule.
•
Invert the ampule, and draw up the medication.
•
Dispose of the top and bottom of the ampule and filter needle in
sharps container.
•
Hold the syringe vertically, and tap it to
remove air bubbles. ANS: B, A, C, E, D
Medication must be removed from the ampule neck before breaking the top off the
ampule. Otherwise, the dosage may be incorrect. There is no need to remove air bubbles
until after the medication is drawn into the syringe. Finally, you would not dispose of the
ampule and filter needle until you finish the procedure.
PTS: 1 DIF: Difficult REF: dm 818-819
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
•
A nurse is administering a medication using a volume-control
administration set (e.g., Buretrol, Volutrol). Arrange the following steps in the
order in which they would be performed.
•
Inject the ordered medication into the volume-control chamber.
•
Fill the volume-control chamber with the correct amount of
intravenous fluid from the primary bag.
•
Cleanse the port on the volume-control chamber.
•
Prime the volume-control tubing.
•
Open the lower clamp and start the infusion at
the correct flow rate. ANS: B, D, C, A, E
You must fill the volume-control chamber before injecting the medication so you can
prime the tubing without the risk of wasting medication. You must cleanse the port on the
volume-control chamber before injecting the medication into it. The last thing you do is
open the clamp and start the infusion.
Chapter 16 Patient Education
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which teaching technique is best for teaching a nursing assistant how to
perform finger-stick glucose testing?
1)
Provide a manufacturers pamphlet with detailed instruction.
2)
Explain the best technique for performing glucose testing.
3)
Demonstrate the procedure; then ask for a return demonstration.
4)
Suggest that the assistant watch a DVD showing the procedure.
ANS: 3
The best way to teach a psychomotor skill is to demonstrate the procedure and then ask
for a return demonstration. Supplementary written information or DVD can also be
supplied to the patient to reinforce learning. However, they are not the best method for
teaching a psychomotor skill; enacting the procedure is more effective.
PTS: 1 DIF: Moderate REF: dm 871, 873
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
2. A patient with a diabetic foot ulcer will need to perform dressing changes
after discharge. When should the nurse schedule the teaching session(s)?
1)
Within 10 minutes after his next dose of oral pain medication
2)
After the patient wakes up from a restful nap
3)
Before the surgeon dbrides the wound
4)
Before the patient undergoes flow studies of his affected leg
ANS: 2
For learning to be most effective, teaching must occur when the patient is most ready. A
patients capacity to take in new information is reduced when he is anxious, in this example
about testing or treatment, or is tired, or is experiencing pain. Therefore, the best time to
teach this patient is when he is rested, such as after a restful nap. Ten minutes is not
enough time for oral medication to take effect and relieve pain.
PTS: 1 DIF: Difficult REF: dm 857-858
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
3. Which intervention by the nurse would be best to motivate a patient
newly diagnosed with hypertension to learn about the prescribed treatment plan?
1)
Explain that when left untreated, hypertension may lead to stroke.
2)
Ask the patient to let you know when he is ready to learn.
3)
Encourage the patient to learn about various treatment options.
4)
Reassure the patient that adhering to the treatment produces a good outcome.
ANS:1
A patient newly diagnosed with hypertension may not be motivated to learn because he
most likely has not experienced physical symptoms or other outward complications.
Therefore, the nurse should motivate the patient by pointing out serious risks to the quality
of life if the blood pressure control is not achieved. Although readiness to learn is an
important consideration, treatment might be delayed too long if the patient does not
appropriately perceive the immediacy of the health risk. Simply encouraging a patient to
learn about blood pressure and treatment options might not be suitable motivation to
engage in active learning and to comply with prescribed treatment. Reassuring the patient
and promising a good outcome by complying with medical treatment is not appropriate.
Adhering to medical therapy reduces the risk for stroke and other complications; however,
this cannot be guaranteed.
PTS:1DIF:ModerateREF:dm 856-857
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
4. Assume all of the following written instructions about digoxin provide
correct information for patient care. Which one is best worded for patient
understanding?
1)
Obtain your radial pulse every morning before taking your digoxin dose.
2)
Return to your healthcare provider for monthly laboratory studies of your digoxin levels.
3)
Call your provider if you notice that objects look yellow or green.
4)
Always take the same brand of medication because certain brands may not be
interchangeable.
ANS: 3
The nurse should provide written instructions that contain short sentences and easy-toread words. If instructions are written at too high a reading level, the patient may not
understand and make a harmful error in dosing. Calling the provider when objects look
yellow or green is the clearest statement for patient teaching because the instruction is
short, concrete, and written with easy-to-understand words. Patient instructions must not
contain words that require a higher level of reading or medical jargon. The instruction
pertaining to being consistent with brand use is too wordy, especially for patients who are
ill or for whom English is not a primary language.
PTS:1DIFifficultREF:p. 873
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
5. Which teaching strategy is typically most effective for presenting information
to large groups?
1)
Distributing printed materials
2)
Lecturing using audiovisual format
3)
Providing online sources of information
4)
Role modeling
ANS: 2
Lecturing using audiovisual materials appeals to learners who best process information by
hearing and seeing. From a practical point of view, a lecture format (traditional classroom
or webinar) is efficient and effective with large groups. Although printed materials can
help to reinforce information taught during a lecture, this can be problematic for auditory
learners or those whose primary spoken language is not English. Online sources of
information are ideal for learners who learn best by doing (kinesthetic learners). Role
modeling is most effective for individuals or small groups of learners, especially when the
relationship between the instructor and learner is meaningful.
PTS:1DIF:EasyREF:p. 872
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Recall
6. A patient with attention deficit disorder is admitted to the hospital with type 1
diabetes. Which nursing diagnosis is commonly yet inappropriately used but should be
avoided for this type of patient? Assume there are data to support all the diagnoses.
1)
Deficient Knowledge (disease process)
2)
Impaired ability to learn related to fear and anxiety
3)
Difficulty learning related to cognitive developmental level
4)
Lack of motivation to learn related to feelings of powerlessness
ANS: 1
Patients who have a learning disability should not have an identified nursing diagnosis of
Deficient Knowledge; instead, they should have a diagnosis that accurately identifies
their problem, such as Impaired Ability to Learn related to Fear and Anxiety; Difficulty
Learning related to Delayed Cognitive Development; or Lack of Motivation to Learn
related to Feelings of Powerlessness. Note that these are not NANDA-I diagnoses.
PTS:1DIF:ModerateREF:dm 864-865
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Comprehension
7. Which phrase is stated as a teaching goal (as compared with an objective) for
a patient who had bowel resection with creation of a colostomy? The patient
1)
empties the colostomy appliance when half filled. 2)
performs skin care around the stoma site.
3)
will perform ostomy self-care within 3 days after surgery.
4)
applies a new ostomy appliance, making sure it adheres properly.
ANS: 3
Performing ostomy self-care is an appropriate goal for a patient who needs to learn
colostomy self-care after surgery. Emptying the colostomy appliance demonstrates a
behavioral learning objective, not a broad teaching goal. Performing skin care is also a
desired skill stated by a learning objective. Applying an ostomy device is another
observable learning objective.
PTS:1DIFifficultREF:p. 866
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Analysis
8. During advanced cardiac life support (ACLS) training, a nurse
performs defibrillation using a mannequin. Which teaching strategy is being
employed?
1)
One-to-one instruction
2)
Computer-assisted instruction
3)
Role modeling
4)
Simulation
ANS: 4
ACLS training utilizes this strategy by creating a scenario using resuscitation mannequins
and teaching healthcare workers to respond appropriately to life-threatening
cardiopulmonary events. The nurse is demonstrating the skill of defibrillation. ACLS
certification requires learners to perform the skill back to the examiner. With one-to-one
instruction, one instructor orally presents information to one student. With ACLS training,
the healthcare team is involved and not just individual nurses. In role modeling, the
teacher teaches by example, demonstrating the behaviors (not skills) that need to be
acquired by learners.
PTS:1DIF:ModerateREF:p. 872
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
9. During family therapy, to improve communication skills the nurse teaches family
members to rehearse responses to situations involving interpersonal conflict. What is the
primary drawback of using this teaching strategy?
1)
Some people might have difficulty with an interactive approach when there is conflict
among participants.
2)
Nurses might rehearse responses that are not effective for resolving interpersonal conflict.
3)
Nurses do not use the rehearsal technique because it is an inefficient use of time for
participants.
4)
This type of interactive teaching strategy is not as effective as dispersing information
verbally or in print.
ANS: 1
The teaching strategy described is role-playing. Role-playing may cause participants to
feel self-conscious; to be effective, participants must be willing to participate as an
observer or role player, particularly in a situation where there is conflict among those
involved in the exercise. With role-playing, the participant may be unaware that teaching
is occurring. The strategy can therefore be a productive use of time while modeling
effective responses and desired behavior. Rehearsing real-life situations common to
family dynamics is typically more effective for conflict resolution than reading about the
topic or discussing approaches for effective communication.
PTS:1DIF:ModerateREF:ESG
10. An older adult patient who underwent bowel resection is recovering from
surgery without complication. He ambulates in the hallway and requires little analgesia
for pain. During the healthcare teams morning rounds, the surgeon informs the patient
that the lesion removed was cancerous. Which factor will likely be the patients most
significant obstacle for learning?
1)
The patients baseline physical condition
2)
A negative environmental influence
3)
Anxiety associated with the new diagnosis
4)
Reduced ability to understand the diagnosis
ANS: 3
Anxiety associated with the new diagnosis of cancer will most likely be a barrier to
learning in this patient. Fear of the unknown, fear of pain, fear of physical discomfort
with treatment options, fear of altered role in home or work life, and many other fears
accompany the anxiety patients often experience when potentially life-threatening
diagnoses are communicated. The patient has been ambulating and requiring minimal
amount of pain medication; therefore, his physical condition is probably not the most
significant barrier to learning. Simply because the patient is an older adult does not
suggest he has reduced capacity to learn.
PTS: 1 DIF: Difficult REF: dm 857-858
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Analysis
11. How can the nurse best provide teaching for a patient whose primary
spoken language is not the same as hers?
1)
Provide written materials in the patients primary language.
2)
Make arrangements to teach using an interpreter.
3)
Provide a demonstration and request a return demonstration.
4)
Use visual teaching aids to convey information.
ANS: 2
The nurse can best provide teaching for the patient whose primary spoken language is not
the same as her own by requesting the aid of an interpreter. An interpreter can help the
nurse to communicate clearly and accurately when assessing learning needs; dispersing the
information; providing feedback to learners; and determining if teaching is effective. An
interpreter also allows the patient to ask questions when necessary and the healthcare
provider to respond with meaningful information. Written materials in the patients primary
language can help reinforce teaching. Demonstrating and requesting a return
demonstration may be difficult if the patient does not understand the spoken language of
the nurse. Visual aids may also be helpful for some learners, but they should not be the
primary method for teaching because they do not offer an opportunity for the exchange of
information through questions, demonstration, or discussion.
PTS: 1 DIF: Moderate REF: p. 862
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension
12. A preschool-age child is scheduled for a tonsillectomy. Which strategy
might help lessen the childs anxiety before surgery?
1)
Show the child a short, animated video (DVD) about the hospital visit and procedure.
2)
Give the child a tour of the hospital a week before the surgery is scheduled.
3)
Allow the child to use computer-assisted instruction to teach him about the procedure.
4)
Provide one-to-one instruction about the care he will need after surgery.
ANS: 1
To reduce anxiety in a preschool-age child requiring surgery, show a short, animated video
showing the area of the hospital where the child will be. The video should include a simple
explanation of what is going to happen while he is in the hospital and afterward in a
manner that is upbeat and friendly. A tour of the hospital with the sights and smells of
sicker people might be more frightening to the young child. It is best to avoid exposure to
pathogens before surgery, such as what could be acquired when touring the building.
One-to-one instruction is a teaching strategy that is effective with adults and older
children.
PTS:1DIF:Moderate
REF: p. 860 [Preoperational Stage]; answer not directly stated in text.
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension
13. The nurse manager is devising a teaching schedule for the staff who are about
to begin using a new type of patient bed in the ICU. Implementation is planned in 6 weeks.
When is the best time for the manager to schedule the teaching sessions?
1)
Immediately
2)
One week before implementation
3)
Two weeks before implementation
4)
Four weeks before implementation
ANS: 2
People retain information better when they have the opportunity to use it soon after it is
presented. Therefore, the nurse manager should schedule teaching sessions 1 week before
implementation of the equipment. If classes are scheduled too early, the nurses might
forget how to use the equipment before it is implemented. If the teaching is offered
immediately prior to use with patients, there would not be an adequate opportunity to
practice skills and ask appropriate questions regarding use of the new device.
PTS:1DIF:ModerateREF:p. 858
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
14. For which patient is the nursing diagnosis Deficient Knowledge
most appropriate?
1)
Adolescent with Down syndrome and newly diagnosed with cardiac problem
2)
Young adult admitted with acute renal failure who requires hemodialysis
3)
Middle-aged woman with breast cancer receiving the last round of chemotherapy
4)
Older adult with a long-standing history of type 1 diabetes admitted with a foot ulcer
ANS: 2
The young adult patient admitted with acute renal failure who needs hemodialysis will
probably have Deficient Knowledge related to his treatment regimen. Patients with
chronic illness, such as diabetes or cancer, are most likely to be knowledgeable about the
disease and course of treatment; therefore, the nursing diagnosis Deficient Knowledge is
less relevant than it is to a patient who is newly diagnosed. The adolescent patient with
Down syndrome would have a nursing diagnosis of Impaired Ability to Learn.
PTS:1DIFifficultREF:dm 864-865
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application
15. Prior to discharge, a patient with diabetes needs to learn how to check a fingerstick blood sugar before taking insulin. Which action will best help the patient remember
proper technique?
1)
Encouraging the patient to check the blood sugar each time the nurse gives insulin
2)
Providing feedback after the patient takes his blood sugar for the first time
3)
Verbally instructing the patient about how to obtain a finger-stick blood sugar
4)
Offering a brochure that describes the technique for checking blood sugar
ANS: 1
Having the patient check the finger-stick with the nurse each time insulin is administered
is the best way to practice the correct technique and gain confidence prior to discharge.
Repetition increases the likelihood that the patient will retain information and incorporate
it into the daily management of his diabetes care. Although feedback is important, the
patient might need it on more than one occasion. Verbal instructions for performing a new
skill are most useful when the patient has an opportunity to perform the technique. A
brochure is informative and useful for later reference; however, information about
performing a new skill is best offered when the patient can see it demonstrated and has the
opportunity to practice it with feedback from the nurse.
PTS:1DIF:ModerateREF:p. 858
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
16. It is a busy day on the medical-surgical floor, and the nurse must teach a patient
ready for discharge about his medications. How can the nurse most efficiently utilize her
time and provide this education?
1)
Write down instructions so the patient can read them at home.
2)
Discuss the information while assisting the patient with his bath.
3)
Educate the patient about his medications as each one is given.
4)
Follow up with the patient after discharge with a phone call.
ANS: 3
Teaching does not have to be performed in a formal session but is often most effective at a
teachable moment when the information is perceived as most relevant, such as at the time
the medication is given to the patient. Additionally, the information is more memorable
when the patient can see the actual dose and identify it with the information presented. A
teaching session about wound care would be appropriate during bathing but not
medication teaching. Providing the patient written instructions without discussing the
information does not allow the patient an opportunity to ask questions or the nurse to
verify the patient understands the instruction. The patient should not be discharged
without education about his prescribed medications, including what they are for, how to
take them, instructions regarding dosing, what side effects can occur, and when to stop
taking the medications.
PTS:1DIF:ModerateREF:p. 859
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
Completion
Complete each statement.
•
The physician prescribes a new drug with which the nurse
is unfamiliar. She consults the hospital formulary to learn about the drug.
Which learning domain is the nurse utilizing?
ANS: Cognitive
Learning through the use of reading materials uses the cognitive domain of learning.
Learning a skill through mental and physical activity uses the psychomotor domain. The
affective domain involves changing feelings, beliefs, attitudes, and values.
Chapter 14 Promoting Health
Identify the choice that best completes the statement or answers the question.
1. A client informs the nurse that he has quit smoking because his father died
from lung cancer 3 months ago. Based on his motivation, smoking cessation should be
recognized as an example of which of the following?
1)
Healthy living
2)
Health promotion
3)
Wellness behaviors
4)
Health protection
ANS: 4
Although health promotion and health protection may involve the same activities, their
difference lies in the motivation for action. Health protection is motivated by a desire to
avoid illness. Health promotion is motivated by the desire to increase wellness. Smoking
cessation may also be a wellness behavior and may be considered a step toward healthy
living; however, neither of these addresses motivation for action.
PTS:1DIF:ModerateREF:p. 879
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension
2. A patient with morbid obesity was enrolled in a weight loss program last month
and has attended four weekly meetings. But now he believes he no longer needs to attend
meetings because he has learned what to do. He informs the nurse facilitator about his
decision to quit the program. What should the nurse tell him?
1)
By now you have successfully completed the steps of the change process. You should be
able to successfully lose the rest of the weight on your own.
2)
Although you have learned some healthy habits, you will need at least another 6 weeks
before you can quit the program and have success.
3)
You have done well in this program. However, it is important to continue in the program
to learn how to maintain weight loss. Otherwise, you are likely to return to your previous
lifestyle.
4)
You have entered the determination stage and are ready to make positive changes that you
can keep for the rest of your life. If you need additional help, you can come back at a later
time.
ANS: 3
Prochaska and Diclemente identified four stages of change: the contemplation stage, the
determination stage, the action stage, and the maintenance stage. This patient demonstrates
behaviors typical of the action stage. If a participant exits a program before the end of the
maintenance stage, relapse is likely to occur as the individual resumes his previous
lifestyle.
PTS:1DIF:ModerateREF:dm 881-882
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
3. The school nurse at a local elementary school is performing physical fitness
assessments on the third-grade children. When assessing students cardiorespiratory
fitness, the most appropriate test is to have the students:
1)
Step up and down on a 12-inch bench.
2)
Perform the sit-and-reach test.
3)
Run a mile without stopping, if they can.
4)
Perform range-of-motion exercises.
ANS: 3
Field tests for running are good for children and can be utilized when assessing
cardiorespiratory fitness. The step test is appropriate for adults. The 12-inch bench height
is too high for young children. The sit-and-reach test as well as range-of-motion exercises
would be appropriate when assessing flexibility.
PTS:1DIF:ModerateREF:dm 884-885
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
4. In the Leavell and Clark model of health protection, the chief distinction
between the levels of prevention is:
1)
The point in the disease process at which they occur.
2)
Placement on the Wheels of Wellness.
3)
The level of activity required to achieve them.
4)
Placement in the Model of Change.
ANS: 1
Leavell and Clark identified three levels of activities for health protection: primary,
secondary, and tertiary. Interventions are classified according to the point in the disease
process in which they occur.
PTS:1DIFifficultREF:p. 879
KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Analysis
5. The muscle strength of a woman weighing 132 pounds who is able to lift
72 pounds would be recorded as 0.55. The nurse explains this to the client as the
1)
Ratio of weight lifted divided by body weight
2)
Measure of weight pushed divided by BMI
3)
Ability of a muscle to perform repeated movements
4)
Ability to move a joint through its range of motion
ANS: 3
Muscle strength measures the amount of weight a muscle (or group of muscles) can move
at one time. This is recorded as a ratio of weight pushed (or lifted) divided by body weight.
A woman weighing 132 pounds who is able to lift 72 pounds has a ratio of 72 divided by
132, or 0.55.
PTS:1DIF:ModerateREF:dm 884-885
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
6. Which is one of the greatest concerns with heavy and chronic use of alcohol
in teens and young adults?
1)
Liver damage
2)
Unintentional death
3)
Tobacco use 4)
Obesity
ANS: 2
Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and
injuries and intentional death (suicide and homicide). Although alcohol as a depressant
slows metabolism, chronic alcohol use is more likely associated with poor nutrition,
which may or may not lead to obesity. Chronic alcohol use causes damage to liver cells
over time in the later years. Alcohol intake is often associated with tobacco and
recreational drug use; however, the risk of unintentional injury, such as car accident,
suicide, or violence, is more concerning than smoking.
PTS:1DIF:EasyREF:p. 879
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
7. A 55-year-old man suffered a myocardial infarction (heart attack) 3 months ago.
During his hospitalization, he had stents inserted in two sites in the coronary arteries. He
was also placed on a cholesterol-lowering agent and two antihypertensives. What type of
care is he receiving?
1)
Primary prevention
2)
Secondary prevention
3)
Tertiary prevention
4)
Health promotion
ANS: 3
Primary prevention activities are designed to prevent or slow the onset of disease.
Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt
laws, and getting immunizations are examples of primary-level interventions. Secondary
prevention activities detect illness so it can be treated in the early stages. Tertiary
prevention focuses on stopping the disease from progressing and returning the individual
to the pre-illness phase. The patient has an established disease and is receiving care to
stop the disease from progressing.
PTS:1DIFifficultREF:p. 879
KEY:Nursing process: Planning | Client need: PSI | Cognitive level: Application
8. Health screening activities are designed to:
1)
Detect disease at an early stage.
2)
Determine treatment options.
3)
Assess lifestyle habits.
4)
Identify healthcare beliefs.
ANS: 1
Health screening activities are designed to detect disease at an early stage so that
treatment can begin before there is an opportunity for disease to spread or become
debilitating.
PTS: 1 DIF: Moderate REF: p. 879
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
9. Which individuals should receive annual lipid
screening? 1)
All overweight children
2)
All adults 20 years and older
3)
Persons with total cholesterol greater than 150 mg/dL
4)
Persons with HDL less than 40 mg/dL
ANS: 1
The American Academy of Pediatrics takes a targeted approach, recommending that
overweight children receive cholesterol screening, regardless of family history or other
risk factors for cardiovascular disease. The American Heart Association recommends that
all adults age 20 years or older have a fasting lipid panel at least once every 5 years. If
total cholesterol is 200 mg/dL or greateror HDL is less than 40 mg/dLfrequent
monitoring is required.
PTS: 1 DIF: Moderate REF: p. 888; Box 27-1
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
10. A mother of three young children is newly diagnosed with breast cancer. She
is intensely committed to fighting the cancer. She believes she can control her cancer to
some degree with a positive attitude and feelings of inner strength. Which of the
following traits is she demonstrating that is linked to health and healing?
1)
Invincibility
2)
Hardiness
3)
Baseline strength
4)
Vulnerability
ANS: 2
Research has also demonstrated that in the face of difficult life events, some people
develop hardiness rather than vulnerability. Hardiness is a quality in which an individual
experiences high levels of stress yet does not fall ill. There are three general characteristics
of the hardy person: control (belief in the ability to control the experience), commitment
(feeling deeply involved in the activity producing stress), and challenge (the ability to view
the change as a challenge to grow). These traits are associated with a strong resistance to
negative feelings that occur under adverse circumstances.
PTS:1DIF:ModerateREF:p. 887
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. The World Health Organizations definition of health includes which of
the following? Choose all that apply.
1)
Absence of disease
2)
Physical well-being
3)
Mental well-being 4)
Social well-being
ANS: 2, 3, 4
The World Health Organization defines health as a state of complete physical, mental,
and social well-being, not merely the absence of disease or infirmity.
PTS:1DIF:EasyREF:p. 878
KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall
2. According to Penders health promotion model, which variables must be
considered when planning a health promotion program for a client? Choose all that apply.
1)
Individual characteristics and experiences
2)
Levels of prevention 3)
Behavioral outcomes
4)
Behavior-specific cognition and affect
ANS: 1, 3, 4
Pender identified three variables that affect health promotion: individual characteristics
and experiences, behavior-specific cognition and affect, and behavioral outcomes. Levels
of prevention were identified by Leavell and Clark; three levels relate to health
protection. The levels differ based on their timing in the illness cycle.
PTS: 1 DIF: Difficult REF: dm 880-881
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
3. Goals for Healthy People 2020 include which of the following? Choose all
that apply.
1)
Eliminate health disparities among various groups.
2)
Decrease the cost of healthcare related to tobacco use.
3)
Increase the quality and years of healthy life.
4)
Decrease the number of inpatient days annually.
ANS: 1, 3
The four overarching goals of Healthy People 2020 are to (1) increase the quality and
years of healthy life, free of disease, injury, and premature death; (2) eliminate health
disparities and improve health for all groups of people; (3) create physical and social
environments for people to live a healthy life; and (4) promote healthy development for
people in all stages of life.
PTS: 1 DIF: Moderate REF: p. 890
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Recall
4. The nurse is implementing a wellness program based on data gathered from a
group of low-income seniors living in a housing project. He is using the Wheels of
Wellness as a model for his planned interventions. Which of the following interventions
would be appropriate based on this model? Choose all that apply.
1)
Creating a weekly discussion group focused on contemporary news
2)
Facilitating a relationship between local pastors and residents of subsidized housing
3)
Coordinating a senior tutorial program for local children at the housing center
4)
Establishing an on-site healthcare clinic operating one day per week
ANS: 1, 2, 3, 4
The Wheels of Wellness model identifies the following dimensions of health: emotional,
intellectual, physical, spiritual, social/family, and occupational. A weekly discussion group
stimulates intellectual health. A relationship between local pastors and those living in
subsidized housing creates a climate for spiritual health. A tutorial program offered by
seniors to local children will facilitate occupational health. An on-site healthcare clinic
addresses physical health.
PTS:1DIFifficultREF:p. 881
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Analysis
5. The nurse working in an ambulatory care program asks questions about the
clients locus of control as a part of his assessment because of which of the following?
Choose all that apply.
1)
People who feel in charge of their own health are the easiest to motivate toward change.
2)
People who feel powerless about preventing illness are least likely to engage in health
promotion activities.
3)
People who respond to direction from respected authorities often prefer a health
promotion program supervised by a health provider.
4)
People who feel in charge of their own health are less motivated by health promotion
activities.
ANS: 1, 2, 3
Identifying a persons locus of control helps the nurse determine how to approach a client
about health promotion. People who feel powerless about preventing illness are least
likely to engage in health promotion activities. People who respond to direction from
respected authorities often prefer a health promotion program that is supervised by a
health provider. Clients who feel in charge of their own health are the easiest to motivate
toward positive change.
PTS:1DIFifficultREF:p. 888
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension
6. Health promotion programs assist a person to advance toward optimal health.
Which of the following activities might such programs include? Choose all that apply.
1)
Disseminating information
2)
Changing lifestyle and behavior 3)
Prescribing medications to treat underlying disorders
4)
Environmental control programs
ANS: 1, 2, 4
Health promotion programs may be categorized into four types: disseminating
information, programs for changing lifestyle and behavior, environmental control
programs, and wellness appraisal and health risk assessment programs. Prescribing
medications to treat underlying disorders is an activity that fosters health focused at an
individual level rather than at a group program level.
PTS:1DIF:ModerateREF:p. 881
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Recall
7. Which of the following actions demonstrate how nurses promote
health? 1)
Role modeling
2)
Educating patients and families
3)
Counseling
4)
Providing support
ANS: 1, 2, 3, 4
Nurses promote health by acting as role models, counseling, providing health education,
and providing and facilitating support.
PTS:1DIF:EasyREF:dm 891-892
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:
Comprehension
Completion
Complete each statement.
1.A middle-aged woman performs breast self-examination monthly. This intervention is
prevention.
considered to be
ANS: secondary
Secondary prevention activities detect illness so that it can be treated in the early stages.
Health activities such as mammograms, testicular examinations, regular physical
examinations, blood pressure and diabetes screenings, and tuberculosis skin tests are
examples of secondary interventions. Primary prevention activities are designed to
prevent or slow the onset of disease and promote health. Activities such as eating healthy
foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations
are examples of primary-level interventions. Tertiary prevention focuses on stopping the
disease from progressing and returning the individual to the pre-illness phase.
Chapter 24 Nutrition
Identify the choice that best completes the statement or answers the question.
1. Which food provides the body with no usable
glucose? 1)
Wheat germ 2)
Apple
3)
White bread 4)
White rice
ANS: 1
Dietary fiber, such as wheat germ, contains no usable glucose. Apples, white bread, and
white rice all contain carbohydrates, which provide usable glucose.
PTS: 1 DIF: Easy REF: p. 902; does not specify wheat germ, just indicates that fiber
provides no glucose.
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
2. Which organ relies almost exclusively on glucose for
energy? 1)
Liver
2)
Heart
3)
Pancreas
4)
Brain
ANS: 4
The brain relies almost exclusively on glucose for energy. The heart and liver do not. The
pancreas produces insulin for glucose utilization but does not use glucose.
PTS:1DIF:Easy
REF: p. 902; ESG
3. A patient with type 1 diabetes mellitus is admitted with hyperglycemia and
associated acidosis. The presence of which alternative fuel in the body is responsible for
the acidosis?
1)
Glycogen
2)
Insulin
3)
Ketones
4)
Proteins
x
ANS: 3
When fats are converted to ketones for use as alternative fuel, as in diabetic ketoacidosis
when glucose cannot by used by the cells, the acidity of the blood rises, leading to the
acidosis. Glycogen is converted to glucose to meet energy needs. Insulin, a pancreatic
hormone, promotes the movement of glucose into cells for use. Proteins would not be
used for fuel as long as fats were available.
PTS:1DIFifficultREF:dm 902, 925
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
4. Which patient is most likely experiencing positive nitrogen balance? A
patient admitted:
1)
With third-degree burns of his legs.
2)
In the sixth month of a healthy pregnancy.
3)
From a nursing home who has been refusing to eat.
4)
With acute pancreatitis.
ANS: 2
A positive nitrogen balance typically exists during pregnancy when new tissues are being
formed. Patients with burns, malnutrition, and serious illness commonly experience
negative nitrogen balance because tissues are lost.
PTS:1DIF:ModerateREF:p. 902
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
5. Which polysaccharide is stored in the
liver? 1)
Insulin
2)
Ketones
3)
Glycogen
4)
Glucose
ANS: 3
Humans store glucose in the liver as polysaccharides, known as glycogen. Glycogen can
then be converted back into glucose to meet energy needs through a process known as
glycogenolysis. If fats must be used for energy, they are converted directly into ketones.
Insulin is a pancreatic hormone that promotes the movement of glucose into cells.
PTS: 1 DIF: Moderate REF: p. 902
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
6. While addressing a community group, the nurse explains the importance of
replacing saturated fats in the diet with mono- and polyunsaturated fats. She emphasizes
that doing so greatly reduces the risk of which complication?
1)
Kidney failure
2)
Liver failure 3)
Stroke
4)
Lung cancer
ANS: 3
Replacing saturated fats in the diet with mono- and polyunsaturated fats reduces the risk
of heart disease, atherosclerosis, and stroke, not kidney failure, liver failure, or lung
cancer.
PTS:1DIF:ModerateREF:p. 903
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
7. Patients may be deficient in which vitamin during the winter
months? 1)
A
2 )
D
3 )
E
4 )
K
ANS: 2
The body can synthesize vitamin D from a cholesterol compound in the skin when
exposed to adequate sunlight. People at risk for vitamin D deficiency are those who spend
little time outdoors, older people, and people who live in an institution (e.g., a nursing
home). The deficiency can also occur in the winter at northern and southern latitudes, in
people who keep their bodies covered (e.g., traditional Muslim women), and in those who
use sunscreen. Also, because breast milk contains only small amounts of vitamin D,
breastfed infants who are not exposed to enough sunlight are at risk of the deficiency and
rickets. There is no seasonal tie to deficiencies in the other fat-soluble vitamins, A, E, and
K.
PTS: 1 DIF: Easy REF: p. 905
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
8. Which nutrient deficiency increases the risk for pressure
ulcers? 1)
Carbohydrate
2)
Protein
3)
Fat
4)
Vitamin K
ANS: 2
Protein is necessary for growth and maintenance of body tissues. Protein deficiency places
the patient at risk for skin breakdown and pressure ulcer formation. Carbohydrates are the
primary fuel of the body. Fat is a source of energy and contains essential nutrients. Vitamin
K aids blood clotting.
PTS:1DIF:Moderate
REF:p. 902; application is based on principle presented
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
9. A patient has anemia. An appropriate goal for that the patient would be for him
to increase his intake of which nutrient?
1)
Calcium
2)
Magnesium
3)
Potassium
4)
Iron
ANS: 4
Iron deficiency causes anemia; therefore, the nurse should encourage the patient with
anemia to increase his intake of iron. Increasing calcium intake helps prevent osteoporosis.
Magnesium supplementation may decrease the risk of hypertension and coronary artery
disease in women. Potassium is essential for muscle contraction, acidbase balance, and
blood pressure control.
PTS:1DIF:EasyREF:p. 907
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
10. A patient is brought to the emergency department experiencing leg cramps.
He is irritable, his temperature is elevated, and his mucous membranes are dry. Based on
these findings, the patient most likely has excess levels of which mineral?
1)
Sodium
2)
Potassium
3)
Phosphorus
4)
Magnesium
ANS: 1
Signs and symptoms associated with sodium excess include thirst, fever, dry and sticky
tongue and mucous membranes, restlessness, irritability, and seizures. Findings
associated with potassium excess include cardiac arrhythmias, weakness, abdominal
cramps, diarrhea, anxiety, and paresthesia. Phosphorus excess leads to tetany and
seizures. Magnesium excess causes weakness, nausea, and malaise.
PTS:1DIFifficultREF:p. 908
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
11. A patient who was prescribed furosemide (Lasix) is deficient in potassium.
Which of the following is an appropriate goal for this patient? The patient will increase
his consumption of:
1)
Bananas, peaches, molasses, and potatoes.
2)
Eggs, baking soda, and baking powder.
3)
Wheat bran, chocolate, eggs, and sardines.
4)
Egg yolks, nuts, and sardines.
ANS: 1
Foods rich in potassium include bananas, peaches, molasses, meats, avocados, milk,
shellfish, dates, figs, and potatoes. Eggs, baking soda, and baking powder have high
sodium content. Dairy products, beef, pork, beans, sardines, eggs, chicken, wheat bran,
and chocolate are rich in phosphorus. Egg yolks, nuts, sardines, dairy products, broccoli,
and legumes are rich in calcium.
PTS:1DIF:ModerateREF:p. 908
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
12. During the day shift, a patients temperature measures 97F (36.1C) orally.
At 2000, the patients temperature measures 102F (38.9C). What effect does this rise in
temperature have on the patients basal metabolic rate?
1)
Increases the rate by 7%
2)
Decreases the rate by 14%
3)
Increases the rate by 35%
4)
Decreases the rate by 28%
ANS: 3
Basal metabolic rate increases 7% for each degree Fahrenheit (0.56C); therefore, this
patients temperature rise is an increase of 35%.
PTS:1DIFifficultREF:p. 910
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
13. A mother brings her 4-month-old infant for a well-baby checkup. The mother
tells the nurse that she would like to start bottle feeding her baby because she cannot keep
up with the demands of breastfeeding since returning to work. Which response by the
nurse is appropriate?
1)
Make sure you give your baby an iron-fortified formula to supplement any stored breast
milk you have.
2)
You really need to continue breastfeeding your baby.
3)
Give your baby formula until he is 6 months old; then you can introduce whole milk.
4)
Your baby weighs 14 pounds, so he will require about 36 ounces of formula a day.
ANS: 1
The nurse should not make the mother feel guilty about her decision to stop breastfeeding.
Instead, she should provide the mother with instruction about bottle feeding. She can give
it to supplement any stored breast milk she might have in supply. She should emphasize
the importance of giving the baby iron-fortified formula because fetal iron stores become
depleted by 4 to 6 months of age. Infants younger than 1 year of age should not receive
regular cows milk because it may place a strain on the immature kidneys. Because the
baby weighs 14 pounds, he will require about 21 ounces of formula a day (not 36 ounces),
based on the nutritional recommendations that infants require 80 to 100 mL of formula or
breast milk per kilogram of body weight per day.
PTS:1DIF:ModerateREF:p. 912
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
14. After instructing a mother about nutrition for a preschool-age child,
which statement by the mother would indicate correct understanding of the topic?
1)
I usually use dessert only as a reward for eating other foods. 2)
I will hide vegetables in casseroles and stews to get my child to eat them.
3)
I do not give my child snacks; they simply spoil his appetite for meals.
4)
I know that lifelong food habits are developed during this stage of life.
ANS: 4
Lifelong food habits are developed during the preschool stage of life. Therefore, the
mother should widen the variety of foods she introduces to her child. Desserts should not
be used as rewards for eating other foods. This practice can shape an attitude about food
that can lead to eating disorders later in life. Preschool-age children often refuse combined
foods such as casseroles and stews. Because they are active, preschoolers require
nutritious between-meal snacks.
PTS: 1 DIF: Moderate REF: p. 913
KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application
15. The nurse is providing nutrition counseling for a patient planning
pregnancy. The nurse should emphasize the importance of consuming which nutrient to
prevent neural tube defects?
1)
Folic acid
2)
Calcium
3)
Protein
4)
Vitamin D
ANS: 1
The nurse should emphasize the importance of consuming folic acid even before
conception to prevent neural tube defects from developing. Calcium and protein needs
also increase during pregnancy; however, their consumption does not prevent neural tube
defects. Vitamin D consumption does not prevent neural tube defects.
PTS:1DIF:EasyREF:p. 913
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:
Comprehension
16. A middle-aged patient with a history of alcohol abuse is admitted with
acute pancreatitis. This patient will most likely be deficient in which nutrients?
1)
Iron
2)
B vitamins 3)
Calcium
4)
Phosphorus
ANS: 2
Patients who regularly abuse alcohol may be deficient in many nutrients; however, they
are commonly deficient in the B vitamins and folic acid. Vitamin A deficiency can be
associated with night blindness in heavy drinkers; vitamin D deficiency leads to softening
of the bones. Because some alcoholics are deficient in vitamins A, C, D, E, and K and the
B vitamins, they experience delayed wound healing. In particular, because vitamin K, the
vitamin needed for blood clotting, is commonly deficient in those who regularly abuse
alcohol, those patients can have delayed clotting, resulting in excess bleeding.
Deficiencies of other vitamins involved in brain function can cause severe neurological
damage.
PTS:1DIF:ModerateREF:p. 915
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
17. A patient who underwent surgery 24 hours ago is prescribed a clear liquid
diet. The patient asks for something to drink. Which item may the nurse provide for the
patient?
1)
Tea with cream
2)
Orange juice
3)
Gelatin
4)
Skim milk
ANS: 3
A clear liquid diet consists of water; tea (without cream); coffee; broth; clear juices, such
as apple, grape, or cranberry; popsicles; carbonated beverages; and gelatin. Skim milk, tea
with cream, and orange juice are included in a full liquid diet.
PTS:1DIF:EasyREF:p. 917
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
18. A patient with trigeminal neuralgia is prescribed a mechanical soft diet.
This diet places the patient at risk for which complication?
1)
Dehydration
2)
Constipation
3)
Hyperglycemia
4)
Diarrhea
ANS: 2
Because of its lack of fiber, a mechanical soft diet places the patient at risk for
constipation. It does not place the patient at risk for dehydration, hyperglycemia, or
diarrhea.
PTS:1DIF:ModerateREF:p. 917
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
19. Which nutritional goal is appropriate for a patient newly diagnosed
with hypertension? The patient will:
1)
Limit his intake of protein.
2)
Avoid foods containing gluten.
3)
Restrict his use of sodium.
4)
Limit his intake of potassium-rich foods.
ANS: 3
Patients with hypertension should limit their intake of sodium. Those with liver disease
should control their protein intake. Patients with renal disease must limit their intake of
potassium-rich foods. Patients with celiac disease should avoid foods containing gluten.
PTS: 1 DIF: Easy REF: p. 917
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
20. The nurse notices that a patient has spoon-shaped, brittle nails. This
suggests that the patient is experiencing Imbalanced Nutrition: Less Than Body
Requirements related to deficiency of which of the following nutrients?
1)
Iron
2)
Vitamin A
3)
Protein
4)
Vitamin C
ANS: 1
Patients with iron deficiency may have spoon-shaped, brittle nails. Other abnormal nail
findings include dull nails with transverse ridge (protein deficiency); pale, poor blanching,
or mottled nails (vitamin A or C deficiency); splinter hemorrhages (vitamin C deficiency);
and bruising or bleeding beneath nails (protein or caloric deficiency).
PTS:1DIFifficultREF:p. 920
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension
21. Which portion of a nutritional assessment must the registered nurse
complete? 1)
Analyzing the data
2)
Obtaining intake and output
3)
Weighing the patient 4)
Obtaining the history
ANS: 1
The registered nurse should review and interpret (analyze) the data collected as part of a
nutritional assessment. The registered nurse can delegate height, weight, and intake and
output to nursing assistive personnel. History taking can be safely delegated to the
licensed practical nurse.
PTS:1DIF:ModerateREF:p. 925
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
22. Which laboratory test result most accurately reflects a patients
nutritional status?
1)
Albumin
2)
Prealbumin
3)
Transferrin
4)
Hemoglobin
ANS: 2
Prealbumin levels fluctuate daily and give the best indication of the patients immediate
nutritional status. Albumin level is not as accurate because the half-life of albumin is 18 to
21 days, causing a delay in detection of nutritional problems. Transferrin, a protein that
binds to iron, has a half-life of 8 to 9 days; therefore, it allows for faster detection of
protein deficiency than does albumin. However, transferrin is not as fast as prealbumin.
Hemoglobin level reflects iron intake or blood loss.
PTS:1DIF:ModerateREF:p. 925
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
23. A 52-year-old man has a triceps skinfold thickness of 18 mm, and his weight
exceeds the ideal body weight for his height by 23%. Which nursing diagnosis should the
nurse identify for this patient?
1)
Imbalanced Nutrition: More Than Body Requirements
2)
Risk for Imbalanced Nutrition: More Than Body Requirements
3)
Imbalanced Nutrition: Less Than Body Requirements
4)
Readiness for Enhanced Nutrition
ANS: 1
This patient has defining characteristics for the nursing diagnosis Imbalanced Nutrition:
More Than Body Requirements: triceps skinfold thickness more than 15 mm in men and
weight that is 20% over ideal for height and frame. The patient does not have defining
characteristics for the other nursing diagnoses.
PTS:1DIF:ModerateREF:p. 929
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
24. A patients 2:1 parenteral nutrition container infuses before the pharmacy
prepares the next container. This places the patient at risk for which complication?
1)
Sepsis
2)
Pneumothorax
3)
Hypoglycemia
4)
Thrombophlebitis
ANS: 3
Because of the high glucose content of 2:1 parenteral nutrition, any interruption in therapy
places the patient at risk for hypoglycemia. A PN of this type should not be discontinued
abruptly, but rather over several (as many as 48) hours to prevent a sudden drop in blood
sugar. Hypoglycemia is unlikely to occur with a 3:1 solution (containing lipids), as the
final concentration of glucose is less than 10%. Sepsis is a complication that can occur if a
break in aseptic technique occurs during therapy. Pneumothorax can occur as a result of
central venous catheter insertion. Central venous catheters are typically employed for
parenteral nutrition. Thrombophlebitis is a complication of central venous catheter use.
PTS: 1 DIF: Difficult REF: dm 959-960
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
25. Which of the following interventions would help to prevent or relieve
persistent nausea?
1)
Assess for signs of dehydration.
2)
Provide dietary supplements.
3)
Have the patient sit in an upright position for 30 minutes after eating.
4)
Immediately remove any food that the patient cannot eat.
ANS: 4
Dehydration can occur as a result of continued nausea and vomiting, so the nurse should
assess for it. However, this intervention does not prevent nausea. Dietary supplements
might help to prevent malnutrition. However, they do not prevent nausea; in fact, they
often cause nausea. Having the patient sit upright helps to prevent respiratory aspiration
should the patient vomit; it does not prevent or relieve nausea. Odors (even pleasant
ones) and even the sight of food can cause nausea, so any uneaten food should be
removed immediately from the room.
PTS:1DIFifficultREF:p. 928
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. To promote wound healing, the nurse is teaching a patient about choosing
foods containing protein. The nurse will evaluate that learning has occurred if the patient
recognizes which food(s) as an incomplete protein that should be consumed with a
complementary protein? Choose all that apply.
1)
Whole grain bread 2)
Peanut butter
3)
Chicken
4)
Eggs ANS:
1, 2
Incomplete protein foods do not provide all of the essential amino acids necessary for
protein synthesis. Therefore, the nurse should inform the patient that whole grain bread
and peanut butter should be consumed with a complementary protein. For example, they
could be eaten together as a peanut butter sandwich.
PTS:1DIF:ModerateREF:p. 901
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension
2. The nurse is teaching a patient about the importance of reducing saturated fats
in his diet. The nurse will recognize that learning has occurred if, upon questioning, the
patient replies that he should read product labels to eliminate the intake of which
saturated fat(s)? Choose all that apply.
1)
Palm oil
2)
Coconut oil
3)
Canola oil
4)
Peanut oil
ANS: 1, 2
Palm and coconut oils are sources of saturated fat that are contained in many processed
foods. The patient should be encouraged to read product labels to eliminate them from his
diet. Olive, canola, and peanut oils are unsaturated fats and should be substituted for
saturated fats in the diet.
PTS: 1 DIF: Moderate REF: p. 901
KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Comprehension
3. Which instruction(s) should the nurse give to the patient complaining
of constipation? Choose all that apply.
1)
Drink at least eight glasses of water or non-caffeinated fluid per day.
2)
Include a minimum of four servings of meat per day.
3)
Consume a high-fiber diet. 4)
Exercise as you feel necessary.
ANS: 1, 3
To prevent constipation, the nurse should instruct the patient to consume a high-fiber
diet, drink at least eight glasses of water or non-caffeinated fluid per day, exercise
regularly, and eat meals on a regular schedule. Caffeine can aggravate constipation.
PTS:1DIF:ModerateREF:p. 929
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
4. Where in the body is glucose stored? Choose all that
apply. 1)
Brain
2)
Liver
3)
Skeletal muscles
4)
Smooth muscles
ANS: 2, 3
Human beings store glucose in liver and skeletal muscle tissue as glycogen. Glycogen is
converted back into glucose to meet energy needs.
PTS:1DIF:ModerateREF:p. 902
KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall
5. For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements
related to Impaired Swallowing, which nursing interventions are appropriate? Choose all
that apply.
1)
Check inside the mouth for pocketing of food after eating.
2)
Provide a full liquid diet that is easy to swallow.
3)
Remind the patient to raise the chin slightly to prepare for swallowing.
4)
Keep the head of the bed elevated for 30 to 45 minutes after feeding.
ANS: 1, 4
The nurse should check for pocketing of food that the patient has not been able to
swallow, and should keep the head of the bed elevated for 30 to 45 minutes after feeding.
Liquids should be avoided unless thickeners are added. The patient should flex the head
forward (tuck the chin) in preparation for swallowing.
Chapter 26 Bowel Elimination
Identify the choice that best completes the statement or answers the question.
1. When changing a diaper, the nurse observes that a 2-day-old infant has passed
a green-black, tarry stool. What should the nurse do?
1)
Notify the provider immediately.
2)
Do nothing; this is normal.
3)
Give the baby sterile water until the mothers milk comes in.
4)
Apply a skin barrier cream to the buttocks to prevent irritation.
ANS: 2
The nurse should do nothing; this is normal. During the first few days of life, a term
newborn passes green-black, tarry stools known as meconium. Stools transition to a
yellow-green color over the next few days. After that, the appearance of stools depends
upon the feedings the newborn receives. Sterile water does nothing to alter this
progression. Meconium stools are more irritating to the buttocks than other stools
because they are so sticky and the skin usually must be rubbed to cleanse it. However,
meconium leads to skin breakdown like a watery stool does.
PTS:1DIF:ModerateREF:p. 968
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
2. Considering normal developmental and physical maturation in children, for
which age would a goal of Achieves bowel control by the end of this month be most
realistic?
1)
18 months
2)
•
years
3)
•
years
4)
•
years
ANS: 2
Between ages 2 and 3 years, a child can typically control defecation, thereby making
toilet training possible. Nevertheless, some children, especially boys, may not achieve
consistent bowel control until somewhat later.
PTS:1DIF:ModerateREF:dm 968-969
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
3. The nurse educates a patient about the primary risk factors for irritable bowel
syndrome. Which behavior by the patient would be evidence of learning? The patient:
1)
Reduces her intake of gluten-containing products.
2)
Does not consume foods that contain lactose.
3)
Consumes only two servings of caffeinated beverages per day.
4)
Takes measures to reduce her stress level.
ANS: 4
Stress is a primary factor in the development of irritable bowel syndrome. Other risk
factors include caffeine consumption and lactose intolerance; however, they are not
primary risk factors. Celiac disease is associated with gluten intake.
PTS:1DIF:ModerateREF:p. 969
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
4. Which of the following goals is appropriate for a patient with a nursing
diagnosis of Constipation? The patient increases the intake of:
1)
Milk and cheese.
2)
Bread and pasta.
3)
Fruits and vegetables.
4)
Lean meats.
ANS: 3
The nurse should encourage the patient to increase his intake of foods rich in fiber because
they promote peristalsis and defecation, thereby relieving constipation. Low- fiber foods,
such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean
meat, slow peristalsis.
PTS:1DIF:ModerateREF:p. 978
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
5. A patient is diagnosed with an intestinal infection after traveling abroad.
The nurse should encourage the intake of which food to promote healing?
1)
Yogurt
2)
Pasta
3)
Oatmeal
4)
Broccoli
ANS: 1
Although the patient may have diarrhea, the goal is not to stop the diarrhea, but to
eliminate the pathogens from the digestive tract. The active bacteria in yogurt stimulate
peristalsis and promote healing of intestinal infections. Pasta is a low-fiber food that slows
peristalsis. It does not promote healing of intestinal infections. Oatmeal stimulates
peristalsis, but it does not promote healing of intestinal infections. Broccoli stimulates gas
production; it is ineffective against intestinal infections.
PTS: 1 DIF: Moderate REF: p. 969
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
6. A nurse is teaching wellness to a womens group. The nurse should explain
the importance of consuming at least how much fluid to promote healthy bowel
function (assume these are 8-ounce servings)?
1)
3 to 4 servings a day
2)
5 to 6 servings a day
3)
7 to 8 servings a day
4)
9 to 10 servings a day
ANS: 3
A minimum of 7 to 8 servings of fluid should be consumed each day to promote healthy
bowel function.
PTS:1DIF:EasyREF:p. 969
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Recall
7. A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg
orally q 12 hours. The patient complains that the last time he took this medication, he had
frequent episodes of loose stools. Which recommendation should the nurse make to the
patient?
1)
Stop taking the drug immediately if diarrhea develops.
2)
Take an antidiarrheal agent, such as diphenoxylate.
3)
Consume yogurt daily while taking the antibiotic.
4)
Increase your intake of fiber until the diarrhea stops.
ANS: 3
Antibiotics such as cephalexin, given to combat infection, decrease the normal flora in the
colon that cause diarrhea. Bacterial populations can be maintained by encouraging the
patient to consume yogurt daily while taking the drugs. Diarrhea is a common adverse
effect of antibiotics; stopping the drug is not necessary. The patient should not be
encouraged to take an antidiarrheal agent at this time. Increasing the intake of fiber
combats constipation, not diarrhea.
PTS:1DIF:ModerateREF:p. 969
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
8. Which collaborative interventions will help prevent paralytic ileus in a
patient who underwent right hemicolectomy for colon cancer?
1)
Administer morphine 4 mg IV every 2 hours for pain.
2)
Administer IV fluids at 125 mL/hr.
3)
Insert an indwelling urinary catheter to monitor I&O.
4)
Keep the patient NPO until bowel sounds return.
ANS: 4
Patients who require bowel surgery typically remain NPO until peristalsis returns,
helping to prevent paralytic ileus, a complication that can occur after the bowel is
surgically manipulated. Administering morphine promotes comfort but may increase the
risk of ileus. Administering IV fluids prevents dehydration but does not directly prevent
ileus. Inserting an indwelling urinary catheter prevents urine retention and facilitates
monitoring postoperative urine output.
PTS: 1 DIF: Moderate REF: p. 969; not stated directly in text
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
9. The nurse in a long-term care facility is teaching a group of residents
about increasing dietary fiber. Which foods should she explain are high in fiber?
1)
White bread, pasta, and white rice
2)
Oranges, raisins, and strawberries
3)
Whole milk, eggs, and bacon
4)
Peaches, orange juice, and bananas
ANS: 2
Oranges, raisins, and strawberries are high in fiber. White bread, pasta, and white rice are
carbohydrates. Whole milk, eggs, and bacon are high in cholesterol. Peaches, orange juice,
and bananas are sources of potassium.
PTS:1DIF:ModerateREF:p. 969
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:
Comprehension
10. The nurse is assessing a patient who underwent bowel resection 2 days ago.
As she auscultates the patients abdomen, she notes low-pitched, infrequent bowel sounds.
How should she document this finding?
1)
Hyperactive bowel sounds
2)
Abdominal bruit sounds
3)
Normal bowel sounds
4)
Hypoactive bowel sounds
ANS: 4
Hypoactive bowel sounds are low-pitched, infrequent, and quiet. An abdominal bruit is a
hollow, blowing sound found over an artery, such as the iliac artery. Normal bowel sounds
are high pitched with approximately 5 to 35 gurgles occurring every minute.
Hyperactive bowel sounds are very high pitched and more frequent than normal bowel
sounds.
PTS:1DIFifficultREF:p. 972
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
11. The healthcare team suspects that a patient has an intestinal infection.
Which action should the nurse take to help confirm the diagnosis?
1)
Prepare the patient for an abdominal flat plate.
2)
Collect a stool specimen that contains 20 to 30 mL of liquid stool.
3)
Administer a laxative to prepare the patient for a colonoscopy.
4)
Test the patients stool using a fecal occult test.
ANS: 2
To confirm the diagnosis of an infection, the nurse should collect a liquid stool specimen
that contains 20 to 30 mL of liquid stool. An abdominal flat plate and a fecal occult blood
test cannot confirm the diagnosis. Colonoscopy is not necessary to obtain a specimen to
confirm the diagnosis.
PTS:1DIF:ModerateREF:dm 974-975
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
12. The nurse is instructing a patient about performing home testing for fecal occult
blood. The nurse can conclude that learning occurs if the patient says, For 3 days prior to
testing, I should avoid eating:
1)
Beef.
2)
Milk.
3)
Eggs.
4)
Oatmeal.
ANS: 1
The nurse should instruct the patient to avoid red meat, chicken, fish, horseradish, and
certain raw fruits and vegetables for 3 days prior to fecal occult blood testing.
PTS: 1 DIF: Moderate REF: dm 989-990
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension
13. The nurse is instructing a patient about performing home testing for fecal
occult blood. The nurse should explain that ingestion of which substance may cause a
false- negative fecal occult blood test?
1)
Vitamin D
2)
Iron
3)
Vitamin C
4)
Thiamine
ANS: 3
Ingestion of vitamin C can produce a false-negative fecal occult blood test; ingestion of
vitamin D, iron, and thiamine does not. Iron can lead to a false-positive result.
PTS: 1 DIF: Moderate REF: dm 989-990
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
14. Which action should the nurse take to assess a 2-year-old child for
pinworms? 1)
Press clear cellophane tape against the anal opening at night to obtain a specimen.
2)
Collect a freshly passed stool from a diaper using a wooden specimen blade.
3)
Place a smear of stool on a slide and add two drops of reagent.
4)
Prepare the patient for a flat plate (x-ray) of the abdomen.
ANS: 1
To assess for pinworms, the nurse should press cellophane tape against the childs anal
opening during the night or as soon as he awakens. Remove the tape immediately, and
place it on a slide. Perineal swabs may also be necessary for microscopic study.
Collecting a fresh stool specimen from a diaper describes the method for an infant or
toddler. Placing a smear of stool on a slide and adding a reagent describes fecal occult
blood testing. An abdominal flat plate is not a method of assessing for pinworms.
PTS: 1 DIF: Moderate REF: p. 975
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
15. The nurse must irrigate the colostomy of a patient who is unable to
move independently. How should the nurse position the patient for this procedure?
1)
Semi-Fowlers position
2)
Left side-lying position
3)
Supine with the head of the bed lowered flat
4)
Supine with the head of bed raised to 30 degrees
ANS: 2
The nurse should position an immobile patient in a left side-lying position to irrigate his
colostomy. Semi-Fowlers, supine with the bed lowered flat, and the supine position with
the head of bed elevated to 30 are not appropriate positions for colostomy irrigation.
PTS:1DIF:ModerateREF:p. 1008
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
16. A mother of a school-age child seeks healthcare because her child has had
diarrhea after being ill with a viral infection. The patient states that after vomiting for 24
hours, his appetite has returned. Which recommendation should the nurse make to this
mother?
1)
Consume a diet consisting of bananas, white rice, applesauce, and toast.
2)
Drink large quantities of water regularly to prevent dehydration.
3)
Take loperamide (an antidiarrheal) as needed to control diarrhea.
4)
Increase the consumption of raw fruits and vegetables.
ANS: 1
The nurse should encourage the patient with diarrhea who has an appetite to consume a
diet that consists of bananas, white rice, applesauce, and toast. These foods are easy to
digest, provide calories for energy, and help provide a source of calcium. The patient
should sip liquids frequently to prevent dehydration; large quantities might worsen
diarrhea. Medication, such as loperamide (Imodium), is usually reserved for chronic
diarrhea. Raw fruits and vegetables may worsen diarrhea.
PTS:1DIF:ModerateREF:p. 978
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
17. Which is a key treatment intervention for the patient admitted
with diverticulitis?
1)
Antacid
2)
Antidiarrheal agent
3)
Antibiotic therapy
4)
NSAIDs
ANS: 3
A key treatment for diverticulitis (an infected diverticulum) is antibiotic therapy; if
antibiotic therapy is ineffective, surgery may be necessary. Antacids, antidiarrheal agents,
and NSAIDs are not indicated for treatment of diverticulitis.
PTS:1DIF:ModerateREF:p. 970
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
18. The nurse assesses a patients abdomen 4 days after abdominal surgery and
notes that bowel sounds are absent. This finding most likely suggest which postoperative
complication?
1)
Paralytic ileus
2)
Small bowel obstruction
3)
Diarrhea
4)
Constipation
ANS: 1
Absent bowel sounds on the fourth postoperative day suggests paralytic ileus, a
complication associated with abdominal surgery. A small bowel obstruction and diarrhea
produce hyperactive bowel sounds. Constipation might be associated with hypoactive
bowel sounds.
PTS:1DIF:ModerateREF:p. 972
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
19. A patient with a colostomy complains to the nurse, I am noticing really bad
odors coming from my pouch. To help control odor, which foods should the nurse advise
him to consume?
1)
White rice and toast
2)
Tomatoes and dried fruit
3)
Asparagus and melons
4)
Yogurt and parsley
ANS: 4
Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and
toast (also bananas and applesauce) help control diarrhea. Asparagus, peas, melons, and
fish are known to cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that
might cause blockage in a patient with an ostomy.
PTS:1DIF:ModerateREF:p. 987
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
20. A patient with severe hemorrhoids is incontinent of liquid stool. Which of
the following interventions is contraindicated?
1)
Apply an indwelling fecal drainage device.
2)
Apply an external fecal collection device.
3)
Place an incontinence garment on the patient.
4)
Place a waterproof pad under the patients buttocks.
ANS: 1
An indwelling fecal drainage device is contraindicated for children; for more than 30
consecutive days of use; and for patients who have severe hemorrhoids, recent bowel,
rectal, or anal surgery or injury; rectal or anal tumors; or stricture or stenosis. External
devices are not typically used for patients who are ambulatory, agitated, or active in bed
because the device may be dislodged, causing skin breakdown. External devices cannot
be used effectively when the patient has Impaired Skin Integrity because they will not
seal tightly. Absorbent products are not contraindicated for this patient unless Impaired
Skin Integrity occurs. Even with absorbent products or an external collection device, the
nurse should place a waterproof pad under the patient to protect the bed linens.
PTS:1DIFifficultREF:p. 1001
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
21. A patient has a colostomy in the descending (sigmoid) colon and wants to
control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve
this goal, nurse should teach the patient to:
1)
Call the primary care provider if the stoma becomes pale, dusky, or black.
2)
Limit the intake of gas-forming foods such as cabbage, onions, and fish.
3)
Irrigate the stoma to produce a bowel movement on a schedule.
4)
Avoid returning to the use of an ostomy appliance if he becomes ill.
ANS: 3
Patients with an ostomy in the descending or sigmoid colon may use colostomy irrigation
as a means to control and schedule bowel evacuation and possibly eliminate the need to
wear an ostomy pouch. Limiting the intake of gas-forming foods is a good idea from a
social perspective; however, it does not help achieve the goal of having regular bowel
movements and thus, eliminating the need to wear a pouch. When illness occurs, it may
be difficult to control the output, so the patient can use an ostomy appliance. This will not
make it more difficult to schedule the bowel movements after the illness passes.
PTS:1DIF:ModerateREF:p. 971
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which factor(s) place(s) the patient at risk for constipation? Choose all
that apply.
1)
Sedentary lifestyle 2)
High-dose calcium therapy
3)
Lactose intolerance
4)
Consuming spicy foods
ANS: 1, 2
Physical activity stimulates peristalsis and bowel elimination. Therefore, those with a
sedentary lifestyle commonly experience constipation. High-dose calcium therapy also
predisposes a patient to constipation. Lactose intolerance and consuming spicy foods are
associated with a nursing diagnosis of Diarrhea, not Constipation.
PTS:1DIF:ModerateREF:p. 969
KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Comprehension
2. A patient who has been immobile since sustaining injuries in a motor vehicle
accident complains of constipation. The nurse encourages him to consume eight to ten 8ounce servings of fluid daily. Which fluid(s) should the patient avoid because of the
diuretic effect? Choose all that apply.
1)
Cranberry juice 2)
Water
3)
Coffee
4)
Ginger ale
5)
Tea
ANS: 3, 5
Coffee, tea, and caffeine-containing sodas should be avoided because caffeine promotes
diuresis, placing the patient at further risk for constipation. Water is the preferred fluid;
however, fruit juices and decaffeinated sodas are also acceptable.
PTS:1DIF:ModerateREF:p. 977
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
3. The nurse must administer an enema to an adult patient with constipation.
Which of the following would be a safe and effective distance for the nurse to insert the
tubing into the patients rectum? Choose all that apply.
1)
2 in (5.1 cm)
2)
3 in (7.6 cm)
3)
4 in (10.2 cm)
4)
5 in (12.7 cm)
ANS: 2, 3
When administering an enema, the nurse should insert the tubing about 3 to 4 inches into
the patients rectum. Two inches would not be effective because it would not place the
fluid high enough in the rectum. Five inches is too much.
PTS:1DIF:ModerateREF:p. 994
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
Completion
1.When performing an abdominal assessment, what sequence of assessment techniques
should the nurse use? Label the steps from A to D, with A being the first step to perform.
•
Auscultation
•
Palpation
•
Percussion
•
Inspection
ANS: D,
A, C, B
When performing an abdominal assessment, the nurse should follow the sequence:
inspection, auscultation, percussion, and palpation. Percussion and palpation may
stimulate peristalsis, so the techniques with the least contact should be done first.
PTS:1DIF:ModerateREF:p. 972
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 2.The
nurse is collecting a stool specimen. Arrange the following steps in the order in
which the nurse should perform them. Label the steps from A to D, with A being the first
step to perform.
•
Have the patient defecate into a special container placed under the
toilet seat.
•
Put on gloves and place the specimen in a specimen container.
•
Ask the patient to void to empty the bladder.
•
Place a label on the
specimen container. ANS: C, A, B,
D
The nurse should ask the patient to void and then have him defecate into a special
container placed under the toilet seat. Next, the nurse should put on gloves and, using a
tongue blade, place the specimen into the container. Finally, she should label the
specimen and send it to the laboratory for analysis.
PTS: 1 DIF: Difficult REF: dm 989-990
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
3.When administering an enema, list the following steps in the order in which they should
be performed. Label the steps from A to F, with A being the first step to perform.
•
Document the results of the procedure.
•
Assess the patient for cramping.
•
Insert the tubing about 3 to 4 inches into the rectum.
•
Lubricate the tip of the enema tubing generously.
•
Raise the container to the correct height and instill the solution at a
slow rate.
•
Encourage the patient to hold the solution for 3 to 15 minutes,
depending on the type of enema.
ANS: D, C, E, B, F, A
You must lubricate the tip before inserting the tubing. You would then insert the tubing and
begin instilling the solution before assessing for cramping that the instillation might
produce. Only after the solution is instilled would you ask the patient to hold the solution.
The last action is to document the results of the procedure, after the procedure is finished.
Chapter 25 Urinary Elimination
Identify the choice that best completes the statement or answers the question.
1. What is the most significant change in kidney function that occurs with
aging? 1)
Decreased glomerular filtration rate
2)
Proliferation of micro blood vessels to renal cortex
3)
Formation of urate crystals
4)
Increased renal mass
ANS: 1
Glomerular filtration rate is the amount of filtrate formed by the kidneys in 1 minute.
Renal blood flow progressively decreases with aging primarily because of reduced blood
supply through the micro blood vessels of the kidney. A decrease in glomerular filtration is
the most important functional deficit caused by aging. Urate crystals are somewhat
common in the newborn period. They might indicate that the infant is dehydrated. In older
people, they result from too much uric acid in the blood, although this is not related to
aging. Renal mass (weight) decreases over time, starting around age 30 to 40.
PTS:1DIFifficultREF:p. 1013
KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
2. While performing a physical assessment, the student nurse tells her instructor
that she cannot palpate her patients bladder. Which statement by the instructor is best? You
should:
1)
Try to palpate it again; it takes practice but you will locate it.
2)
Palpate the patients bladder only when it is distended by urine.
3)
Document this abnormal finding on the patients chart.
4)
Immediately notify the nurse assigned to the care of your patient.
ANS: 2
The bladder is not palpable unless it is distended by urine. It is not difficult to palpate the
bladder when distended. The nurse should document her finding, but it is not an abnormal
finding. It is not necessary to notify the nurse assigned to the patient.
PTS:1DIF:EasyREF:p. 1014
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
3. Which urine specific gravity would be expected in a patient admitted
with dehydration?
1)
1.002
2)
1.010
3)
1.025
4)
1.030
ANS: 4
Normal urine specific gravity ranges from 1.010 to 1.025. Specific gravity less than 1.010
indicates fluid volume excess, such as when the patient has fluid overload (too much IV
fluid) or when the kidneys fail to concentrate urine. Specific gravity greater than 1.025 is a
sign of deficient fluid volume that occurs, for example, as a result of blood loss or
dehydration.
PTS:1DIF:ModerateREF:p. 1015
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application
4. Which medication class will the primary care provider most likely prescribe
to increase urine output in the patient admitted with congestive heart failure?
1)
Thiazide diuretic
2)
Loop diuretic
3)
MAO inhibitor
4)
Anticholinergic
ANS: 2
A loop diuretic [e.g., Furosemide (Lasix)] increases urine elimination. It works by limiting
the reabsorption of water in the renal tubules and is used to reduce congestion in the
cardiopulmonary circulation. A thiazide diuretic is used to treat high blood pressure by
reducing the amount of sodium and water in the blood vessels. An MAO inhibitor [e.g.,
phenelzine (Nardil)] is an antidepressant that is used after other medications have proven
unsuccessful in lifting symptoms of serious depression. Anticholinergics [e.g., ipratropium
(Atrovent)] relax smooth muscle in the airways. Also known as antispasmodics, they
reduce airway constriction experienced by those with asthma, for example.
is a cholesterol-lowering drug. Although high cholesterol is a leading factor for heart
disease, the medication is used to reduce cholesterol in the bloodnot to promote diuresis
to reduce the demand on the heart and backflow into the lungs.
PTS:1DIF:ModerateREF:p. 1016; not stated directly in the text and requires critical
thinking
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
5. The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an
older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk
for which complication?
1)
Skin breakdown 2)
Urinary tract infection
3)
Bowel incontinence
4)
Renal calculi
ANS: 1
Urine contains ammonia, which may cause excoriation with prolonged contact with the
skin. Bowel incontinence, not urinary incontinence, increases the patients risk for urinary
tract infection. Immobility and high consumption of calcium-containing foods increase the
risk for renal calculi.
PTS: 1 DIF: Moderate REF: p. 1021
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
6. The nurse is caring for a patient who underwent a bowel resection 2 hours ago.
His urine output for the past 2 hours totals 50 mL. Which action should the nurse take?
1)
Do nothing; this is normal postoperative urine output.
2)
Increase the infusion rate of the patients IV fluids.
3)
Notify the provider about the patients oliguria.
4)
Administer the patients routine diuretic dose early.
ANS: 3
50 mL in 2 hours is not normal output. The kidneys typically produce 60 mL of urine per
hour. Therefore, the nurse should notify the provider when the patient shows diminished
urine output (oliguria). Patients who undergo abdominal surgery commonly require
increased infusions of IV fluid during the immediate postoperative period. The nurse
cannot provide increased IV fluids without a providers order. The nurse should not
administer any medications before the scheduled time without a prescription. The provider
may hold the patients scheduled dose of diuretic if he determines that the patient is
experiencing deficient fluid volume.
PTS: 1 DIF: Difficult REF: p. 1025
KEY: Nursing process: Interventions | Client need: PSI| Cognitive level: Application
7. The nurse measures the urine output of a patient who requires a bedpan to
void. Which action should the nurse take first? Put on gloves and:
1)
Have the patient void directly into the bedpan.
2)
Pour the urine into a graduated container.
3)
Read the volume with the container on a flat surface at eye level.
4)
Observe the color and clarity of the urine in the bedpan.
ANS: 1
First, the nurse should put on gloves and have the patient void directly into the bedpan.
Next, she should pour the urine into a graduated container, place the measuring device on a
flat surface, and read the amount at eye level. She should observe the urine for color,
clarity, and odor. Then, if no specimen is required, she should discard the urine in the toilet
and clean the container and bedpan. Finally, she should record the amount of urine voided
on the patients intake and output record.
PTS: 1 DIF: Easy REF: p. 1041
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
8. The nurse instructs a woman about providing a clean-catch urine specimen.
Which of the following statements indicates that the patient correctly understands the
procedure?
1)
I will be sure to urinate into the hat you placed on the toilet seat.
2)
I will wipe my genital area from front to back before I collect the specimen midstream.
3)
I will need to lie still while you put in a urinary catheter to obtain the specimen.
4)
I will collect my urine each time I urinate for the next 24 hours.
ANS: 2
To obtain a clean-catch urine specimen, the nurse should instruct the patient to cleanse the
genital area from front to back and collect the specimen midstream. This follows the
principle of going from clean to dirty. The nurse should have the ambulatory patient void
into a hat (container for collecting the urine of an ambulatory patient) when monitoring
urinary output, but not when obtaining a clean-catch urine specimen. A urinary catheter is
required for a sterile urine specimen, not a clean-catch specimen. A 24-hour urine
collection may be necessary to evaluate some disorders, but a clean-catch specimen is a
one-time collection.
PTS: 1 DIF: Moderate REF: dm 1043-1044
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis
9. What position should the patient assume before the nurse inserts an
indwelling urinary catheter?
1)
Modified Trendelenburg
2)
Prone
3)
Dorsal recumbent
4)
Semi-Fowlers
ANS: 3
The nurse should have the patient lie supine with knees flexed, feet flat on the bed (dorsal
recumbent position). If the patient is unable to assume this position, the nurse should help
the patient to a side-lying position. Modified Trendelenburg position is used for central
venous catheter insertion. Prone position is sometimes used to improve oxygenation in
patients with adult respiratory distress syndrome. Semi-Fowlers position is used to prevent
aspiration in those receiving enteral feedings.
PTS: 1 DIF: Easy REF: p. 1031
KEY: Nursing process: Interventions | Client need: Physiological Integrity | Cognitive
level: Application
10. A patient complains that she passes urine whenever she sneezes or coughs.
How should the nurse document this complaint in the patients healthcare record?
1)
Transient incontinence
2)
Overflow incontinence
3)
Urge incontinence 4)
Stress incontinence
ANS: 4
Stress incontinence is an involuntary loss of urine that occurs with increased intraabdominal pressure. Activities that typically produce the symptom include sneezing,
coughing, laughing, lifting, and exercise. Transient incontinence is a short-term
incontinence that is expected to resolve spontaneously. It is typically caused by urinary
tract infection or medications, such as diuretics. Overflow incontinence is the loss of
urine when the bladder becomes distended; it is commonly associated with fecal
impaction, enlarged prostate, and neurological conditions. Urge incontinence is the
involuntary loss of urine associated with a strong urge to void.
PTS:1DIF:ModerateREF:p. 1018
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
11. Which outcome is appropriate for the patient who underwent urinary
diversion surgery and creation of an ileal conduit for invasive bladder cancer?
1)
Patient will resume his normal urination pattern by (target date).
2)
Patient will perform urostomy self-care by (target date).
3)
Patient will perform self-catheterization by (target date).
4)
Patients urine will remain clear with sufficient volume.
ANS: 2
The most appropriate outcome for this patient is the patient will perform urostomy selfcare by a specific date. The patient with an ileal conduit is unable to resume a normal
urination pattern; urine, along with mucus, drains continuously from the stoma site, so the
urine will not be clear. Also, the phrase sufficient volume is too vague for an outcome
statement. The patient with a continent urostomy inserts a catheter into the stoma to drain
urine.
PTS:1DIF:ModerateREF:p. 1039
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
12. Which intervention should the nurse take first to promote micturition in
a patient who is having difficulty voiding?
1)
Insert an indwelling urinary catheter.
2)
Notify the provider immediately.
3)
Insert an intermittent, straight catheter. 4)
Pour warm water over the patients perineum.
ANS: 4
The nurse should perform independent nursing measures, such as pouring warm water
over the patients perineum before notifying the provider. If nursing measures fail, the
nurse should notify the provider. The provider may order an indwelling urinary catheter
or a straight catheter to relieve the patients urinary retention.
PTS:1DIF:ModerateREF:p. 1028
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis
13. The student nurse asks the provider if she will prescribe an indwelling urinary
catheter for a hospitalized patient who is incontinent. The provider explains that catheters
should be utilized only when absolutely necessary because:
1)
They are the leading cause of nosocomial infection.
2)
They are too expensive for routine use.
3)
They contain latex, increasing the risk for allergies. 4)
Insertion is painful for most patients.
ANS: 1
Indwelling urinary catheters should not be routinely used for hospitalized patients with
incontinence because they are the leading cause of healthcare-acquired infection
(nosocomial). The cost of an indwelling urinary catheter should not deter its use if
necessary. Latex-free catheters are available for patients with or at risk for latex allergy.
Insertion may be somewhat uncomfortable, but it should not be painful.
PTS:1DIF:ModerateREF:p. 1028
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
14. A patient who sustained a spinal cord injury will perform intermittent selfcatheterization after discharge. After discharge teaching, which statement by the patient
would indicate correct understanding of the procedure?
1)
I will need to replace the catheter weekly.
2)
I can use clean, rather than sterile, technique at home.
3)
I will remember to inflate the catheter balloon after insertion.
4)
I will dispose of the catheter after use and get a new one each time.
ANS: 2
The nurse should inform the patient that clean technique can be used after discharge. The
patient should wash his hands before the procedure, then wash the reusable catheter in
soap and water, and rinse and store it in a clean, dry place. It is not necessary for the
patient to use a new catheter for each catheterization. The patient should use a straight
catheter; therefore, a balloon is not inflated after insertion. Straight catheters are removed
immediately after use.
PTS: 1 DIF: Moderate REF: p. 1029
KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application
15. The nurse notes that a patients indwelling urinary catheter tubing
contains sediment and crusting at the meatus. Which action should the nurse take?
1)
Notify the provider immediately.
2)
Flush the catheter tubing with saline solution.
3)
Replace the indwelling urinary catheter.
4)
Encourage fluids that increase urine acidity.
ANS: 3
The catheter needs to be changed when sediment collects in the tubing or catheter and
crusting at the meatus occurs. It is not necessary to notify the provider immediately. The
nurse should not flush the catheter tubing. The patient should be encouraged to consume
fluids that increase urine acidity to prevent urinary tract infection; however, it will not
help clear the catheter tubing of sediment.
PTS:1DIF:ModerateREF:p. 1031
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
16. The surgeon orders hourly urine output measurement for a patient after
abdominal surgery. The patients urine output has been greater than 60 mL/hour for the
past 2 hours. Suddenly the patients urine output drops to almost nothing. What should the
nurse do first?
1)
Irrigate the catheter with 30 mL of sterile solution.
2)
Replace the patients indwelling urinary catheter.
3)
Infuse 500 mL of normal saline solution IV over 1 hour.
4)
Notify the surgeon immediately.
ANS: 1
If the patients urinary output suddenly ceases, the nurse should irrigate the urinary catheter
to assess whether the catheter is blocked. If no blockage is detected, the nurse should
notify the surgeon. The surgeon may request that the catheter be changed if irrigation does
not help or if the tubing is not kinked. However, the nurse should not change a catheter in
the immediate postoperative period without consulting with the surgeon. The surgeon may
prescribe an IV fluid bolus if the patient is suspected to have a deficient fluid volume.
PTS:1DIFifficultREF:p. 1058
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis
17. A patient is admitted with high BUN and creatinine levels, low blood pH,
and elevated serum potassium level. Based on these laboratory findings the nurse
suspects which diagnosis?
1)
Cystitis
2)
Renal calculi
3)
Enuresis
4)
Renal failure
ANS: 4
Elevated BUN, creatinine, and serum potassium levels and low blood pH are signs of renal
failure. Cystitis is an infection of the bladder and would not result in abnormal renal
function. Renal calculi typically produce blood in the urine but do not lead to marked renal
dysfunction and failure. Enuresis is involuntary urination, particularly common in
children, and does not produce renal dysfunction. The cause of enuresis is often emotional,
developmental, or trauma related.
PTS:1DIFifficultREF:p. 1023
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
18. A mother tells the nurse at an annual well-child checkup that her 6-year-old
son occasionally wets himself. Which response by the nurse is appropriate?
1)
Explain that occasional wetting is normal in children of this age.
2)
Tell the mother to restrict her childs activities to avoid wetting.
3)
Suggest time out to reinforce the importance of staying dry.
4)
Inform the mother that medication is commonly used to control wetting.
ANS: 1
The nurse should explain that occasional wetting is normal in children during the early
school years. The mother should handle the situation calmly and avoid punishing the
child. Medications are occasionally prescribed for nocturnal enuresis when the child is
older and not sleeping at home, but not for occasional daytime wetting.
PTS:1DIF:ModerateREF:dm 1038-1039
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
19. Which task can the nurse safely delegate to the nursing assistive
personnel? 1)
Palpating the bladder of a patient who is unable to void
2)
Administering a continuous bladder irrigation
3)
Providing indwelling urinary catheter care
4)
Obtaining the patients history and physical assessment
ANS: 3
The nurse can safely delegate indwelling urinary catheter care to nursing assistive
personnel who are adequately trained to do so. Palpating the bladder, administering
continuous bladder irrigation, and obtaining the patients history and physical assessment
involve the critical thinking skills of a professional nurse.
PTS:1DIF:Moderate
REF: p. 1048, 1058; not directly stated in text
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
20. Which action should the nurse take when beginning bladder training
using scheduled voiding?
1)
Offer the patient a bedpan every 2 hours while she is awake.
2)
Increase the voiding interval by 30 to 60 minutes each week.
3)
Frequently ask the patient if she has the urge to void.
4)
Increase the frequency between voiding even if urine leakage occurs.
ANS: 1
The nurse should offer the patient the bedpan or assist the patient to the bathroom every 2
hours while she is awake. You would encourage the patient to get up once during the
night to void, but awakening the patient every 2 hours would lead to fatigue. If the patient
adheres to the schedule, the voiding interval should be increased by 15 to 30 minutes
each week. Simply asking the patient about the urge to void does not help to manage
bladder emptying.
PTS:1DIF:ModerateREF:p. 1033
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
21. A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of
congestive heart failure. The patient is at risk for which electrolyte imbalance associated
with use of this drug?
1)
Hypocalcemia
2)
Hypokalemia
3)
Hypomagnesemia
4)
Hypophosphatemia
ANS: 2
Furosemide is a loop diuretic, which causes potassium to pass into the urine. This drug
increases the risk for hypokalemia (low potassium); it does not cause hypocalcemia (low
calcium in the blood), hypomagnesemia (low blood magnesium), or hypophosphatemia
(low blood phosphorous).
PTS:1DIF:ModerateREF:p. 1016, not stated directly in the text and requires critical
thinking
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:
Comprehension
22. Which daily urine output is within normal limits for a newborn weighing
8 pounds?
1)
288 mL
2)
180 mL
3)
36 mL
4)
18 mL
ANS: 2
A newborn weighing 8 pounds (3.6 kg) should produce 15 to 60 mL of urine per kilogram
per day. If the newborn produces 50 mL/kg/day and weighs 3.6 kg, he will produce a total
of 180 mL in 24 hours. The other options are not within normal limits and require further
assessment.
PTS:1DIFifficultREF:p. 1015
KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis
23. The nurse is teaching an older female patient how to manage urge
incontinence at home. What is the first-line approach to reducing involuntary leakage of
urine?
1)
Insertion of a pessary
2)
Intermittent self-catheterization
3)
Bladder training 4)
Anticholinergic medication
ANS: 3
The goal of bladder training is to enable the patient to hold increasingly greater volumes
of urine in the bladder and to increase the interval between voiding. This involves patient
teaching, scheduled voiding, and self-monitoring using a voiding diary. In addition to
teaching the mechanisms of urination, teach distraction and relaxation strategies to help
inhibit the urge to void. Other techniques include deep breathing and guided imagery. A
pessary is an incontinence device that is inserted into the vagina to reduce organ
prolapse or pressure on the bladder. Clean, intermittent self-catheterization is a good
option for managing incontinence that is resistant to conservative measure, such as
bladder training, Kegel exercises, lifestyle modification, and medication. Anticholinergic
medication can be highly effective for improving urinary incontinence. However, more
conservative measures, such as timed voiding and Kegel exercises, are recommended first.
PTS:1DIF:ModerateREF:p. 1033
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
24. What is the best technique for obtaining a sterile urine specimen from
an indwelling urinary catheter?
1)
Use antiseptic wipes to cleanse the meatus prior to obtaining the sample.
2)
Briefly disconnect the catheter from the drainage tube to obtain the sample.
3)
Withdraw urine through the port using a needleless access device.
4)
Obtain the urine specimen directly from the collection bag.
ANS: 3
To obtain a specimen from an indwelling catheter, insert the needleless access device with
a 20- or 30-mL syringe into the specimen port, and aspirate to withdraw the amount of
urine you need. Wiping the meatus with an antiseptic material helps to minimize
contamination for a clean-catch voided specimen, not a sample collected from a closed
system such as an indwelling catheter system. Never disconnect the catheter from the
drainage tube to obtain a sample. Interrupting the system creates a portal of entry for
pathogens, thereby increasing the risk of contamination. Do not take the specimen from
the collection bag because that urine may be several hours old.
PTS: 1 DIF: Moderate REF: p. 1024
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which of the following is/are an appropriate goal(s) for a patient with
urinary incontinence? Choose all that apply.
1)
Increase the intake of citrus fruits.
2)
Maintain daily oral fluids to 8 to 10 servings per day.
3)
Limit daily caffeine intake to less than 100 mg.
4)
Engage in high-impact, aerobic exercise.
ANS: 2, 3
The nurse should encourage lifestyle changes such as limiting caffeine intake to fewer
than 100 mg per day; limiting intake of alcohol, artificial sweeteners, spicy foods, and
citrus fruit; and maintaining daily oral fluid intake to 8 to 10 servings per day. Highimpact exercise can be associated with stress incontinence for those with weakened
pelvic muscles that support the bladder and urethra.
Chapter 27 Sensation, Perception, & Cognition
Identify the choice that best completes the statement or answers the question.
1. The nurse checks a patients pupils using a penlight. Which receptors is the
nurse stimulating?
1)
Chemoreceptors
2)
Photoreceptors
3)
Proprioceptors
4)
Mechanoreceptors
ANS: 2
Photoreceptors located in the retina of the eyes detect visible light. Proprioceptors in the
skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an
individual to sense the position of the body in space. Chemoreceptors are located in the
taste buds and epithelium of the nasal cavity. They play a role in taste and smell.
Thermoreceptors in the skin detect variations in temperature. Mechanoreceptors in the
skin and hair follicles detect touch, pressure, and vibration.
PTS:1DIF:EasyREF:p. 1068
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
2. Which structure within the brain is responsible for consciousness and
alertness? 1)
Reticular activating system
2)
Cerebellum
3)
Thalamus
4)
Hypothalamus
ANS: 1
The reticular activating system, located in the brainstem, controls consciousness and
alertness. The cerebellum maintains muscle tone, coordinates muscle movement, and
controls balance. The thalamus is a relay system for sensory stimuli. The hypothalamus
controls body temperature.
PTS:1DIF:EasyREF:p. 1068
KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall
3. The nurse has been teaching a parent about stimuli to develop her infants
auditory nervous system. Which behavior by a parent toward the child provides evidence
that learning occurred?
1)
Cuddling
2)
Speaking
3)
Feeding
4)
Soothing
ANS: 2
Exposure to voices, music, and ambient sound helps develop the infants auditory nervous
system. Cuddling, feeding, and soothing provide comfort and pleasure and teach the infant
about his external environment.
PTS:1DIF:EasyREF:p. 1069
KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Recall
4. A patient complains to the nurse that since taking a medication he has suffered
from excessively dry mouth. What term should the nurse use to document this complaint?
1)
Exophthalmos
2)
Anosmia
3)
Insomnia
4)
Xerostomia
ANS: 4
The nurse should document excessively dry mouth as xerostomia. Exophthalmos is
abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosmia is
losing the sense of smell. Insomnia is inability to sleep.
PTS:1DIF:ModerateREF:p. 1072
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
5. Which nursing diagnosis has the highest priority for a patient with
impaired tactile perception?
1)
Self-Care Deficit: Dressing and Grooming
2)
Impaired Adjustment
3)
Risk for Injury 4)
Activity Intolerance
ANS: 3
The patient with impaired tactile perception is unable to perceive touch, pressure, heat,
cold, or pain, placing him at risk for injury. Self-Care Deficit, Impaired Adjustment, and
Activity Intolerance are also likely to be appropriate for this patient but are not as high a
priority as Risk for Injury. Risk for Injury is directly related to safety, which must always
be a priority.
PTS: 1 DIF: Moderate REF: p. 1072
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
6. A patient with Parkinsons disease is at risk for which
complication? 1)
Impaired kinesthesia 2)
Macular degeneration
3)
Seizures
4)
Xerostomia
ANS: 1
Patients with Parkinsons disease are at risk for impaired kinesthesia, placing them at risk
for falling. Drooling, not excessive dry mouth (xerostomia), is common with Parkinsons
disease. Seizures and macular degeneration are not associated with Parkinsons disease.
PTS:1DIF:ModerateREF:dm 1074-1075
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
7. The nurse is caring for a patient with dementia who becomes agitated
every evening. Which intervention by the nurse is best for calming this patient?
1)
Encouraging family members to visit only during the day
2)
Applying wrist restraints during periods of agitation
3)
Playing soft, calming music during the evening
4)
Administering lorazepam (a tranquilizer)
ANS: 3
Soft, calming music is sometimes helpful for patients with dementia. Encouraging a family
member to sit with the patient might have a calming effect, but the option does not provide
for that during the evening when the patient is symptomatic. Applying bilateral wrist
restraints might further agitate the patient. Lorazepam will provide sedation but might
cause further confusion.
PTS:1DIF:ModerateREF:p. 1081
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis
8. Which intervention is appropriate for the patient with a nursing diagnosis
of Disturbed Sensory Perception: Gustatory?
1)
Limit oral hygiene to one time a day.
2)
Teach the patient to combine foods in each bite.
3)
Assess for sores or open areas in the mouth.
4)
Instruct the patient to avoid salt substitutes.
ANS: 3
The nurse should assess for sores or open areas in the mouth and provide frequent oral
hygiene. The nurse should also teach the patient to eat foods separately to allow the taste
of food to be distinguishable. Seasonings, salt substitutes, spices, or lemon may improve
the taste of foods, so the patient should not avoid them.
PTS:1DIF:ModerateREF:p. 1083
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
9. A patient diagnosed with macular degeneration asks the nurse to explain
his condition. Which statement by the nurse best describes macular degeneration?
1)
The portion of your eye called the macula, which is responsible for central vision, is
damaged.
2)
Your lens became cloudy, causing your blurred vision. This cloudiness will increase over
time.
3)
The pressure in the anterior cavity of your eye became elevated, shifting the position of
your lens.
4)
Theres an irregular curvature of your cornea, causing your blurred vision.
ANS: 1
Macular damage (degeneration) causes diminished central vision. Cataracts are caused by
a cloudy lens and result in blurred vision. Glaucoma is pressure in the anterior cavity of
the eye, which shifts the lens position. Astigmatism is irregular curvature of the cornea,
resulting in blurred vision.
PTS:1DIF:ModerateREF:p. 1072
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
10. A patient who sustained a head injury in a motor vehicle accident has damage
to the temporal lobe. This injury places the patient at risk for which type of hearing loss?
1)
Otosclerosis
2)
Conduction deafness 3)
Presbycusis
4)
Central deafness
ANS: 4
Central deafness results from damage to the auditory areas in the temporal lobes.
Otosclerosis is hardening of the bones of the middle ear, especially the stapes.
Conduction deafness results when one of the structures that transmits vibrations is
affected. Presbycusis is a progressive sensorineural loss associated with aging.
PTS:1DIF:ModerateREF:p. 1072
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application
11. A patient comes to the clinic complaining of a taste disturbance. Which
medication that the patient is currently prescribed is most likely responsible for this
disturbance?
1)
Furosemide, a diuretic
2)
Phenytoin, an anticonvulsant
3)
Glyburide, an antidiabetic
4)
Heparin, an anticoagulant
ANS: 2
Phenytoin is a medication that has a high incidence of associated taste disturbance.
Furosemide, glyburide, and heparin are not implicated in taste disturbances.
PTS:1DIF:ModerateREF:p. 1073
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
12. Which instruction should the nurse be certain to include when
providing discharge teaching for a patient who has a serious visual deficit?
1)
Install blinking lights to alert an incoming phone call.
2)
Have gas appliances inspected regularly to detect gas leaks.
3)
Wear properly fitting shoes and socks.
4)
Avoid using throw rugs on the floors.
ANS: 4
The nurse should instruct the visually impaired patient to avoid using throw rugs on the
floors at home. She should instruct the patient with a hearing deficit to install blinking
lights to alert him to an incoming phone call. She should instruct the patient with an
olfactory deficit to have gas appliances inspected regularly to detect leaks. The patient
with a tactile deficit should be instructed to use properly fitting shoes and socks.
PTS:1DIF:ModerateREF:p. 1084
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
13. The nurse must irrigate the ear of a 4-year-old child. How should the nurse
pull the pinna to straighten the childs ear canal?
1)
Up and back
2)
Straight back
3)
Down and back
4)
Straight upward
ANS: 3
The nurse should straighten the ear canal of a small child by pulling the pinna down and
back. To straighten the ear canal of an adult, the nurse should pull the pinna up and
outward.
PTS: 1 DIF: Moderate REF: p. 1086
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
14. Which step should the nurse take first when performing otic irrigation in
an adult?
1)
Warm the irrigation solution to room temperature.
2)
Position the patient so she is sitting with her head tilted away from the affected ear.
3)
Straighten the ear canal by pulling up and back on the pinna.
4)
Place the tip of the nozzle into the entrance of the ear canal.
ANS: 1
The nurse should warm the irrigation solution to room temperature first. Next, the nurse
should assist the patient into a sitting position, with the head tilted away from the affected
ear; straighten the ear canal by pulling up and back on the pinna; place the tip of the nozzle
into the entrance of the ear canal; and direct the stream of irrigating solution gently along
the top of the ear canal toward the back of the patients head. Then continue irrigating until
the canal is clean.
PTS: 1 DIF: Easy REF: p. 1086
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
15. Which essential oil might the nurse trained in aromatherapy use to uplift
and stimulate a patient?
1)
Lavender
2)
Roman chamomile
3)
Rosemary
4)
Ylang-ylang
ANS: 3
Rosemary is very stimulating and uplifting. Lavender, Roman chamomile, and Ylangylang are used to promote relaxation.
PTS:1DIF:ModerateREF:p. 1073
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
16. Which assessment finding is considered an age-related
change? 1)
Presbycusis
2)
Hyperopia
3)
Increased sensitivity to touch
4)
Increased sensitivity to taste
ANS: 1
Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia is the
ability to see distant objects well; it is not an age-related change. The ability to perceive
touch and taste diminishes with age; it does not increase.
PTS:1DIF:ModerateREF:p. 1069, 1072
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
17. After sustaining a stroke, the patient lacks attention to the right side of his
body. Which nursing diagnosis best describes the patients problem?
1)
Disturbed Sensory Perception
2)
Unilateral Neglect
3)
Risk for Peripheral Vascular Dysfunction
4)
Acute Confusion
ANS: 2
This patient lacks attention to the right side of his body after sustaining a stroke;
therefore, the most appropriate nursing diagnosis is Unilateral Neglect. The patient may
also have Disturbed Sensory Perception, Risk for Peripheral Vascular Dysfunction, and
Acute Confusion, but they are not the most appropriate for the defined problem.
PTS:1DIFifficultREF:p. 1079
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
18. A patient is admitted with an exacerbation of asthma. Which factor places
the patient at highest risk for sensory overload?
1)
Administering albuterol (a central nervous stimulant) as needed
2)
Administering a tranquilizer intravenously every 2 hours as prescribed
3)
Delivering oxygen at 6 L/min via nasal cannula
4)
Maintaining complete bedrest in a quiet, dimly lit room
ANS: 1
Medications that stimulate the central nervous system, such as albuterol, place the patient
at risk for sensory overload. A tranquilizer and a quiet darkened room may help the patient
to relax, thus preventing sensory overload. If the patients oxygen needs are met with
oxygen at 6 L/min via nasal cannula, the patient should not experience sensory overload
related to oxygen therapy alone.
PTS:1DIFifficultREF:p. 1071
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
19. A patient complains of an impaired sense of smell. Which cranial nerve
might have been affected?
1)
Trigeminal
2)
Glossopharyngeal
3)
Olfactory
4)
Vagus
ANS: 3
The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an
impaired sense of smell. The trigeminal nerve transmits stimuli from the face and head.
The glossopharyngeal nerve is responsible for taste. The vagus nerve is responsible for
sensations of the throat, larynx, and thoracic and abdominal viscera.
PTS: 1 DIF: Moderate REF: p. 1072
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
20. Which intervention is helpful when caring for a patient with impaired
vision? 1)
Suggest the patient use bright overhead lighting.
2)
Advise the patient to avoid wearing sunglasses when outdoors.
3)
Do not offer large-print books, as this may embarrass the patient.
4)
Place the patients eyeglasses within easy reach.
ANS: 4
The nurse should place the patients eyeglasses within easy reach and make sure that they
are clean and in good repair. The patient should have sufficient light but avoid bright light,
which might cause glare. The patient should be encouraged to wear sunglasses, visors, or
hats with brims when outdoors. A magnifying lens or large-print books may be helpful.
PTS:1DIF:ModerateREF:p. 1082
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
21. A patient tells the nurse that since taking a medication he has suffered from
excessively dry mouth. Which of the following assessments would be needed in order to
plan interventions for that symptom?
1)
Asking the patient if foods taste different now
2)
Checking the patients sense of smell
3)
Having the patient stand to check for balance
4)
Assessing for a history of seizures
ANS: 1
Many medications cause xerostomia (dry mouth), and xerostomia is the most common
cause of impaired taste. Impaired sense of smell also affects the sense of taste; however,
there is no reason to assume impaired smell in this patient. Balance is related the inner
ear and to kinesthetic sense, not to taste and xerostomia. Xerostomia would be related to
seizures only if a patient experienced dry mouth as an aura; this would be unusual. Even
if this were the case, the information would allow the nurse to plan care for seizures, but
not for the symptom of dry mouth.
PTS:1DIFifficultREF:p. 1072
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. For a particular patient, it has become essential to minimize the risk of
further damage to the auditory nerve. Which of the following medications may need to
be discontinued if the patient is taking them? Choose all that are correct.
1)
Furosemide, a diuretic
2)
Digoxin, a cardiotonic
3)
Famotidine, an antacid
4)
Aspirin, an analgesic
ANS: 1, 4
Aspirin and furosemide may cause ototoxicity, leading to auditory nerve impairment.
Digoxin and famotidine do not place the patient at risk for auditory nerve impairment.
PTS:1DIFifficultREF:p. 1070
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension
2. Which factors in a health history place a patient at risk for hearing loss?
Choose all that apply.
1)
Being an older adult
2)
Childhood chickenpox
3)
Frequent otitis media
4)
Diabetes mellitus
ANS: 1, 3
Having had frequent ear infections (otitis media) places a patient at risk for hearing loss
because of scarring that may have occurred. Older adults experience a generalized
decrease in the number of nerve conduction fibers and structural changes in the ear,
which cause hearing loss. Chickenpox and diabetes mellitus do not place the patient at
risk for hearing loss.
PTS: 1 DIF: Moderate REF: p. 1072
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
3. The nurse caring in the intensive care unit suspects that one of her patients
is experiencing sensory overload. Which findings(s) has/have aroused her suspicion?
Choose all that apply.
1)
Disorientation
2)
Restlessness
3)
Hallucinations
4)
Depression
ANS: 1, 2
The patient with sensory overload might exhibit disorientation, confusion, restlessness,
decreased ability to perform tasks, anxiety, muscle tension, and muscle tension. Sensory
deprivation causes irritability, confusion, depression, heart palpitations, hallucinations,
and delusions.
PTS:1DIF:ModerateREF:p. 1071
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
4. Which action(s) can the nurse take to prevent sensory overload? Choose all
that apply.
1)
Leave the television on to block out other noises.
2)
Minimize unnecessary light in the patients room.
3)
Plan care to provide uninterrupted periods of sleep.
4)
Speak calmly with a moderate voice volume.
ANS: 2, 3, 4
To prevent sensory overload, minimize unnecessary light, plan care to provide
uninterrupted periods of sleep, and speak to the patient in a moderate tone of voice using
a calm and confident manner. Television can be used to provide sensory stimuli, but not to
prevent sensory overload. When used, it should not be left on indiscriminately.
PTS:1DIF:ModerateREF:p. 1081
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
5. For an unconscious patient, which of the following interventions are necessary
to provide for patient safety? Choose all that apply.
1)
Talk to the patient as you provide care. 2)
Incorporate more touch in the plan of care.
3)
Give frequent eye care if blink reflex is absent.
4)
Keep the side rails up and bed in low position.
ANS: 3, 4
Safety measures are a priority for unconscious clients. Keep the bed in low position when
you are not at the bedside, and keep the side rails up. If the patients blink reflex is absent
or her eyes do not close totally, you may need to give frequent eye care to keep secretions
from collecting along the lid margins. The eyes may be patched to prevent corneal drying,
and lubricating eye drops may be ordered. It is important to talk to the patient because the
sense of hearing may still be intact. This provides some stimulation and may help with
reality orientation. Providing touch will also help prevent sensory deficit; however, it is not
a safety measure.
Chapter 28 Pain
Identify the choice that best completes the statement or answers the question.
1. A patient suddenly develops right lower-quadrant pain, nausea, vomiting,
and rebound tenderness. How should the nurse classify this patients pain?
1)
Acute
2)
Chronic
3)
Intractable
4)
Neuropathic
ANS: 1
Acute pain typically has a short duration and a rapid onset. Chronic pain lasts longer than
6 months and interferes with daily activities. Intractable pain is chronic and highly
resistant to relief. Neuropathic pain is a type of chronic pain that occurs from injury to one
or more nerves.
PTS:1DIF:EasyREF:p. 1092
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
2. How should the nurse classify pain that a patient with lung cancer
is experiencing?
1)
Radiating
2)
Deep somatic
3)
Visceral
4)
Referred
ANS: 3
Visceral pain is commonly experienced in the abdominal cavity, cranium, or thorax.
Lung cancer produces visceral pain. Radiating pain starts at the source and extends to
other locations. Deep somatic pain is typically caused by fracture, sprain, arthritis, and
bone cancer. Referred pain occurs in an area distant from the original site.
PTS:1DIF:ModerateREF:p. 1091
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
3. A patient who underwent a left above-the-knee amputation complains of pain
in his left foot. The nurse should document this finding as what type of pain?
1)
Psychogenic
2)
Phantom
3)
Referred
4)
Radiating
ANS: 2
The nurse should document this finding as phantom pain. Phantom pain is pain that is
perceived to originate in an area that has been amputated. Psychogenic pain refers to pain
experienced by a person which does not match the symptoms or the apparent source of
pain. It is thought to arise from psychological factors and is disproportional to the painful
stimuli. Referred pain occurs in an area distant from the original site. Radiating pain starts
at the source but extends to other locations.
PTS:1DIF:EasyREF:p. 1091
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
4. A patient who sustained a leg laceration in an industrial accident is brought to the
emergency department. The area around the laceration is red, swollen, and tender. Which
substance is responsible for causing this response?
1)
Histamine
2)
Prostaglandin
3)
Bradykinin
4)
Serotonin
ANS: 3
Tissue damage causes the release of the substances histamine, bradykinin, and
prostaglandin. Bradykinin triggers the release of inflammatory chemicals that cause the
injured area to become red, swollen, and tender. Serotonin is a neurotransmitter and is not
involved in the inflammatory response.
PTS:1DIFifficultREF:p. 1092
KEY: Nursing process: NA | Client need: PHSI | Cognitive level: Application
5. In which process do peripheral nerves carry the pain message to the dorsal
horn of the spinal cord?
1)
Transduction
2)
Transmission
3)
Perception
4)
Modulation
ANS: 2
Peripheral nerves carry the pain message to the dorsal horn of the spinal cord during a
process known as transmission. In a process called transduction, specialized nociceptors
convert potentially damaging mechanical, thermal, and chemical stimuli into electrical
activity that leads to the experience of pain. Perception involves the recognition of pain
by the frontal cortex of the brain. During modulation, pain signals can be facilitated or
inhibited, and the perception of pain can be changed.
PTS:1DIFifficultREF:p. 1092
KEY:Nursing process: NA | Client need: PHSI | Cognitive level: Recall
6. A patient reports that he uses music therapy to help control his chronic pain.
Music therapy works by prompting the release of endogenous opioids during which stage
of the pain process?
1)
Perception
2)
Transduction
3)
Transmission
4)
Modulation
ANS: 4
Music therapy can prompt the release of endogenous opioids during the modulation stage,
which is the stage of the pain process where the perception of pain changes. It is not during
the perception (recognizing the pain sensation), transmission (relaying the pain message),
or transduction (converting potentially damaging stimuli into electrical activity leading to
pain sensation).
PTS:1DIF:ModerateREF:dm 1093, 1100; synthesis of information required
KEY:Nursing process: Planning | Client need: PHSI | Cognitive level: Recall
7. The nurse is assessing an intubated patient who returned from coronary artery
bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is
experiencing pain?
1)
Blood pressure 160/82 mm Hg
2)
Temperature 100.6F
3)
Heart rate 80 beats/min
4)
Oxygen saturation 95%
ANS: 1
This patient has an elevation in blood pressure which is a physiological finding
associated with pain. The patient has a mild temperature elevation, which is a common
response to surgery. Heart rate and oxygen saturation are within normal limits.
PTS: 1 DIF: Moderate REF: dm 1095-1096
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
8. A patient who sustained rib fractures in a motor vehicle accident is complaining
that his pain medication is ineffective. Inadequate pain control places this patient at risk
for which complication?
1)
Metabolic alkalosis
2)
Pneumothorax
3)
Pneumonia
4)
Hemothorax
ANS: 3
Pain associated with rib fractures causes splinting. Splinting often causes the patient to
breathe shallowly and avoid deep coughing to expel sputum, which can lead to
pneumonia. Rib fractures can also lead to complications such as pneumothorax and
hemothorax; however, they do not result from inadequate pain control. Respiratory
acidosis, not metabolic alkalosis, may result from the shallow breaths caused by pain and
restricted chest wall movement with splinting.
PTS:1DIF:ModerateREF:p. 1096
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
9. When should the nurse assess
pain? 1)
Whenever a full set of vital signs is taken
2)
During the admission interview
3)
Every 4 hours for the first 2 days after surgery
4)
Only when the patient complains of pain
ANS: 1
The nurse should assess pain whenever a full set of vital signs is checked. Moreover, the
nurse should assess pain on admission of a patient to the facility, even when pain is not
the chief complaint. Patients may have chronic pain that has no association with their
reason for seeking care. Pain should be assessed more frequently than every 4 hours in the
immediate postoperative period. Pain should be reassessed after any treatment is given to
evaluate effectiveness of the treatment. Some patients may not complain of pain unless
they are specifically asked whether they are in pain. Pain rating scales help to quantify the
intensity of pain for the nurse providing analgesia.
PTS: 1 DIF: Moderate REF: dm 1096-1098
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
10. Which nursing diagnosis is most appropriate for the patient who returns
from the postanesthesia care unit after undergoing right hemicolectomy surgery for
colon cancer?
1)
Acute pain secondary to surgery
2)
Acute pain (abdominal) secondary to surgery for colon cancer
3)
Chronic pain secondary to cancer diagnosis
4)
Chronic pain (abdominal) secondary to abdominal surgery
ANS: 2
The nurse should identify a diagnosis by specifying the location of the pain and any
precipitating or etiological factors. This patient is experiencing acute abdominal pain that
is related to his surgery for colon cancer; therefore, a nursing diagnosis that specifies the
surgery is the most appropriate diagnosis for this patient. In addition, options listing
chronic pain are incorrect because the pain is acute, not chronic.
PTS: 1 DIF: Moderate REF: p. 1100
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application
11. Which drug might the primary care provider prescribe to help facilitate
pain management in a client with chronic pain?
1)
Selective serotonin reuptake inhibitor
2)
Selective norepinephrine reuptake inhibitor
3)
Narcotic analgesic 4)
Anti-emetic
ANS: 1
The control of depression greatly facilitates pain management, especially for patients
experiencing chronic pain. Therefore, the physician may prescribe a selective serotonin
uptake inhibitor (antidepressant), such as paroxetine (Paxil), as part of the treatment plan.
Selective norepinephrine reuptake inhibitors, such as Atomoxetine (Strattera), are
commonly used for attention deficit-hyperactivity disorder. If a narcotic, such as
oxycodone (OxyContin), is used for a long time, it may become habit forming (causing
mental or physical dependence). Physical dependence may lead to withdrawal side effects
when you stop taking the medicine. This is not the first-line therapy for chronic pain. An
anti-emetic, such as ondansetron (Zofran), is used to control for nausea and vomiting,
which can occur with some analgesic medication. However, the prescriber would more
likely change the medication to something the patient tolerates better rather than order an
anti-emetic to control the side effect.
PTS:1DIFifficultREF:p. 1103; higher-order item, can be inferred from text
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
12. The nurse administers acetaminophen 325 mg and codeine 30 mg orally to a
patient complaining of a severe headache. When should the nurse reassess the patients
pain?
1)
15 minutes after administration
2)
60 minutes after administration
3)
90 minutes after administration
4)
Immediately before the next dose is due
ANS: 2
The nurse should reassess pain in the patient who received an oral pain medication 30 to
60 minutes after administration. The nurse should reassess the patient receiving IV
medications 10 to 15 minutes after administration. The nurse should not wait until just
before the patient can receive another dose. The patient may require additional pain
medication before the next dose is due.
PTS:1DIF:ModerateREF:p. 1100
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application
13. After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, the
patient states that his pain is 8 out of 10 on the numerical pain scale. Which action
should the nurse take?
1)
Use nonpharmacological therapy while waiting 3 more hours before the next dose.
2)
Administer an additional 800 mg oral dose of ibuprofen right away.
3)
Do nothing because the patients facial expression indicates he is comfortable.
4)
Notify the prescriber that the current pain management plan is ineffective.
ANS: 4
The nurse should notify the prescriber that the current pain management plan is
ineffective. The nurse should not delay treatment for 3 hours when the next dose of
medication is due. The nurse cannot administer an extra dose of ibuprofen without a
prescribers order to do so. Ibuprofen 800 mg is a maximum dose for most individuals.
The nurse should not assume that the patient is not in pain simply because he appears
comfortable; pain is what the patient states it is.
PTS:1DIF:ModerateREF:dm 1110-1111
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
14. The nurse is teaching a client who sustained an ankle injury about
cold application. Which instruction should the nurse include in the teaching
plan?
1)
Place the cold pack directly on the skin over the ankle.
2)
Apply the cold pack to the ankle for 30 minutes at a time.
3)
Check the skin frequently for extreme redness.
4)
Keep the cold pack in place for at least 24 hours.
ANS: 3
The nurse should instruct the patient to cover the cold pack with a washcloth, towel, or
fitted sheet before applying it to the ankle to prevent tissue damage. A cold pack should
be applied intermittently for the first 24 hours, leaving it in place for no longer than 15
minutes at a time. The patient should check the skin frequently and discontinue the
treatment immediately if redness or other signs of tissue irritation occur.
PTS:1DIF:ModerateREF:p. 1101
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
15. The nurse plays music for a child with leukemia who is experiencing
pain. Which pain management technique is this nurse using?
1)
Distraction
2)
Guided imagery 3)
Sequential muscle relaxation
4)
Hypnosis
ANS: 1
Music is a form of distraction that has been shown to reduce pain and anxiety by allowing
the patient to focus on something other than pain. Guided imagery uses auditory and
imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient
sits and tenses muscles for 15 seconds and then relaxes the muscles while breathing out.
This relaxation technique has also been effective for relieving pain.
Hypnosis involves the induction of a deeply relaxed state.
PTS:1DIF:EasyREF:dm 1101-1102
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
16. The nurse uses his hands to direct energy fields surrounding the patients body.
After this intervention, the patient states that his pain has lessened. How should the nurse
document the intervention?
1)
Tactile distraction was performed and appeared effective in reducing pain.
2)
Guided imagery was effective to relax the patient and reduce the pain.
3)
Therapeutic touch was performed; patient verbalized lessening of pain after treatment.
4)
Sequential muscle relaxation was performed; patient states pain is less.
ANS: 3
Therapeutic touch focuses on the use of hands to direct energy fields surrounding the
body. The nurse should document use of therapeutic touch and its effectiveness in the
progress notes after performing the procedure. Tactile distraction involves activities such
as massage, hugging a favorite toy, holding a loved one, or stroking a pet. Guided
imagery uses auditory and imaginary processes to help the patient to relax. In sequential
muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the
muscle while breathing out. This relaxation technique is often effective for relieving pain.
PTS:1DIF:ModerateREF:p. 1102
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
17. A patient prescribed a nonsteroidal anti-inflammatory drug (NSAID),
naproxen (Aleve, Naprosyn), for treatment of arthritis complains of stomach upset. What
should the nurse instruct the patient to do?
1)
Notify the prescriber immediately.
2)
Take the medication with food.
3)
Take the medication with 8 ounces of water.
4)
Take the medication before bedtime.
ANS: 2
The nurse should instruct the patient to take the medication with food to lessen gastric
irritation. Taking the medication with 8 ounces of water will not decrease gastric irritation.
Taking the medication just before bedtime may cause gastric reflux, increasing gastric
irritation. Although indigestion is an unwanted side effect of naproxen, it is not an
emergency that requires the prescriber to be notified immediately. However, prior to
giving naproxen, be sure the patient has not had ulcers, stomach bleeding, or severe
kidney or liver problems. If so, the patient is not a candidate for treatment with naproxen.
PTS:1DIF:ModerateREF:p. 1103
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
18. A patient is prescribed morphine sulfate 4 mg intravenously for
postoperative pain. Which action should the nurse take before administering the
medication?
1)
Monitor the patients respiratory status.
2)
Auscultate the patients heart sounds.
3)
Check blood pressure in supine and sitting positions.
4)
Monitor the patient for psychological drug dependence.
ANS: 1
The nurse should assess the patients respiratory status and level of alertness before
administering the medication because respiratory depression can be a life-threatening
effect. It is not necessary to auscultate heart sounds or to check blood pressure while the
patient lies down (supine position) and sits up. Psychological dependence occurs rarely
even after long-term prescribed use of morphine. Therefore, it is not necessary to
routinely monitor a patient who is receiving morphine for acute postoperative pain for
psychological drug dependence.
PTS:1DIF:ModerateREF:p. 1104
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
19. A client reports taking acetaminophen (Tylenol) to control osteoarthritis.
Which instruction should the nurse give the patient requiring long-term acetaminophen
use?
1)
Caution the patient against combining acetaminophen with alcohol.
2)
Explain that acetaminophen increases the risk for bleeding.
3)
Advise taking acetaminophen with meals to prevent gastric irritation.
4)
Explain that physical dependence may occur with long-term oral use.
ANS: 1
Even in recommended doses, acetaminophen can cause hepatotoxicity in those who
consume alcohol. Therefore, the nurse should caution the patient against combining
acetaminophen with alcohol. Aspirin, not acetaminophen, increases the risk for bleeding
because it inhibits platelet aggregation. Nonsteroidal anti-inflammatory drugs (NSAIDs),
not acetaminophen, cause gastric irritation and should be taken with meals. Opioid
analgesics, not acetaminophen, can cause physical dependence.
PTS:1DIF:ModerateREF:p. 1103
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
20. Which side effects associated with opioid use may improve after taking a
few doses of the drug?
1)
Constipation
2)
Drowsiness
3)
Dry mouth
4)
Difficulty with urination
ANS: 2
Drowsiness as well as nausea are side effects of opioid therapy that commonly improve
after a few doses are administered. Other side effects include constipation, vomiting, dry
mouth, and difficulty with urination. These side effects do not typically lessen with use.
PTS:1DIF:ModerateREF:p. 1104
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension
21. A patient develops a respiratory rate 6 breaths/minute after receiving
IV hydromorphone (Dilaudid) 2 mg. Which medication should the nurse
anticipate administering to this patient after notifying the prescriber of this side
effect?
1)
Physostigmine (Antilirium)
2)
Flumazenil (Romazicon)
3)
Naloxone (Narcan)
4)
Protamine sulfate
ANS: 3
The nurse should anticipate administering naloxone to reverse the respiratory depression
associated with opioid use. Flumazenil reverses the central nervous system depressant
effects of benzodiazepines. Physostigmine reverses the effects of anticholinergic drugs.
Protamine sulfate is the antidote for heparin.
PTS:1DIF:ModerateREF:p. 1104
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
22. Which pain management task can be safely delegated to nursing
assistive personnel?
1)
Assessing the quality and intensity of the patients pain
2)
Evaluating the effectiveness of pain medication
3)
Providing a therapeutic back massage
4)
Administering oral dose of acetaminophen
ANS: 3
The nurse can safely delegate providing a back massage for the patient in pain. However,
the nurse should never delegate the responsibility of assessing the patients pain,
monitoring the patients response to pain management strategies, administering
medications (including over-the-counter preparations), or evaluating the pain management
plan.
PTS:1DIF:ModerateREF:p. 1100
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
23. Which expected outcome is best for the patient with a nursing diagnosis of
Acute Pain related to movement and secondary to surgical resection of a ruptured spleen
and possible inadequate analgesia?
1)
The patient will verbalize a reduction in pain after receiving pain medication and
repositioning.
2)
The patient will rest quietly when undisturbed.
3)
On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during
ambulation.
4)
The patient will receive pain medication every 2 hours as prescribed.
ANS: 3
A low pain rating is the best expected outcome for the patient with a nursing diagnosis of
Acute Pain secondary to surgical resection of a ruptured spleen and possible inadequate
analgesia because it is specific and measurable. The patient verbalizing reduced pain is not
specific enough. The nurse needs to know how much pain relief is achieved. A numeric
score gives a clearer indication of the effectiveness of analgesia. The patient might have
experienced a reduction in pain, but his pain level might still be intolerable. Saying the
patients pain is relieved because he is resting quietly does not address the pain relief while
he is awake. Some patients will sleep in an attempt to cope with pain, so this outcome
could lead to inaccurate evaluation. Providing pain medication is a nursing intervention,
not an expected outcome.
PTS:1DIFifficultREF:p. 1100
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis
24. A patient had a bowel resection 5 days ago. Which request by the patient
might alert the nurse that the patient has a history of substance abuse?
1)
Oral pain medication once every 6 to 8 hours
2)
Patient-controlled analgesic 3)
Oral pain medications instead of the IM form
4)
Only nonpharmacological pain measures
ANS: 2
The patient underwent surgery 5 days ago; if there are no complications, it is unlikely that
he would require frequent dosing of analgesic. The nurse should recognize this behavior as
a possible indicator of current substance abuse or addiction. Requesting oral pain
medications every 6 to 8 hours is a typical behavior for a patient 5 days after surgery.
Requesting an oral form of the drug does not indicate substance abuse.
PTS:1DIF:EasyREF:dm 1109-1110
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
25. A patient with Raynauds disease receives no symptomatic relief with
diltiazem (Cardizem). Which surgical intervention might be a treatment option for this
patient to help provide symptomatic relief?
1)
Cordotomy
2)
Rhizotomy
3)
Neurectomy
4)
Sympathectomy
ANS: 4
Sympathectomy severs the pathways to the sympathetic nervous system. The procedure
improves vascular blood supply and eliminates vasospasm. It is effective for treatment of
pain associated with vascular disorders, such as Raynauds disease. Cordotomy interrupts
pain and temperature sensation below the tract that is severed. This procedure is
commonly performed to relieve trunk and leg pain. Rhizotomy interrupts the anterior or
posterior nerve route located between the ganglion and the cord. It is commonly used to
treat head and neck pain. Neurectomy is used to eliminate intractable localized pain. The
pathways of peripheral or cranial nerves are interrupted to block pain transmission.
PTS:1DIF:ModerateREF:p. 1108
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Recall
26. Which action should the nurse take first when the patient has a score of 4 on
the sedation rating scale?
1)
Stimulate the patient.
2)
Prepare to administer naloxone (Narcan).
3)
Administer a dose of pain medication.
4)
Notify the physician immediately.
ANS: 1
If the patients score on the sedation rating scale is equal to or greater than 4, the nurse
should first stimulate the patient. He should next notify the physician. The nurse should
consider administering naloxone, as prescribed, if the patients respiratory rate is less than 8
breaths/minute; if respirations are shallow with marginal or falling oxygen saturation; or if
the patient is unresponsive to stimulation. Before the patient receives another dose of pain
medication, the dose should most likely be reduced and other potential causes of sedation
should be investigated.
PTS:1DIFifficultREF:p. 1106
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
27. A patient with a history of mitral valve replacement, hypertension, and type 2
diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg.
Which factor contraindicates the use of epidural analgesia in this patient?
1)
Anticoagulant therapy
2)
Diabetes mellitus
3)
Hypertension
4)
Embolectomy
ANS: 1
Patients who undergo mitral valve replacement typically require long-term anticoagulant
therapy. Anticoagulant therapy is a contraindication for epidural analgesia use because of
the risk for spinal hematoma and uncontrolled bleeding. Diabetes and hypertension are not
contraindications for epidural analgesia. Epidural analgesia is commonly used after
embolectomy because certain anesthetic agents, such as bupivacaine, help prevent
vasospasm.
PTS:1DIFifficultREF:p. 1108
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
28. After undergoing dural puncture while receiving epidural pain medication,
a patient complains of a headache. Which action can help alleviate the patients pain?
1)
Encourage the client to ambulate to promote flow of spinal fluid.
2)
Offer caffeinated beverages to constrict blood vessels in his head.
3)
Encourage coughing and deep breathing to increase CSF pressure.
4)
Restrict oral fluid intake to prevent excess spinal pressure.
ANS: 2
Treatment for a headache that occurs as a result of dural puncture consists of bedrest,
analgesics as prescribed, and liberal hydration. Caffeine and a dark, quiet environment
may also be helpful. Headaches will be more severe when the patient is sitting upright or
ambulating. Fluid volume deficit will also aggravate a spinal headache after epidural
anesthesia.
PTS:1DIFifficultREF:p. 1108
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
29. An older adult receiving hospice care has dementia as a result of metastasis to
the brain. His bone cancer has progressed to an advanced stage. Why might the client fail
to request pain medication as needed? The client:
1)
Experiences less pain than in earlier stages of cancer.
2)
Cannot communicate the character of his pain effectively.
3)
Recalls pain at a later time than when it occurs.
4)
Relies on caregiver to provide pain relief without asking.
ANS: 2
There is no evidence to suggest that patients with dementia and other forms of cognitive
impairment do not experience pain. It is most likely that they cannot effectively
communicate the intensity or quality of pain and are therefore at risk for underassessment
of pain and inadequate pain relief. Be aware of behavioral cues indicating pain rather than
relying on verbal report. Failure to request pain medication is not likely a result of
hesitation to ask for it out of habit or reliance on others; rather, it is likely due to inability
to effectively express to the caregiver that analgesia is needed.
PTS:1DIF:ModerateREF:p. 1095
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis
30. What is typically the most reliable indicator of
pain? 1)
Patients self-report
2)
Past medical history
3)
Description by caregiver(s)
4)
Behavioral cues
ANS: 1
The patients self-report is the most reliable indicator of pain. A patients facial expression,
vocalization, posture or position, or other behaviors do not always accurately indicate the
intensity or quality of a patients experience of pain. The patient might be trying to hide
signs of pain in order to be brave or strong. Sociocultural factors can influence a patients
nonverbal expression of pain. Caregivers might not appreciate the extent of pain because
pain is an individualized experience. Perception of pain might be heightened if other
medical conditions coexist, although this perception is also influenced by other factors,
such as past experience with pain and the success or failure of the treatment to produce
relief. Emotions, cognitive impairment, developmental stage, communication skills, and
mental health disorders, such as depression or anxiety, can influence the perception of
pain.
PTS:1DIF:ModerateREF:p. 1096
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. A 73-year-old patient admitted after a stroke has expressive aphasia. Which
pain intensity scale(s) would be appropriate to use with this patient? Choose all that
apply.
1)
Visual analog
2)
Numerical rating
3)
Wong-Baker face rating 4)
Simple descriptor
ANS: 1, 3
The Wong-Baker face-rating scale uses simple illustrations of faces to depict various
levels of pain. The scale was developed for children but has proved effective for adults
with communication and cognitive impairments. The visual analog requires patients to
point to a location on a line that reflects their pain level. Some patients have difficulty
with the abstract nature of this scale. When using the numerical rating scale, the patient
must choose a number from 0 to 10 to denote his pain level. This scale is sometimes
difficult for clients with cognitive impairments, such as expressive aphasia; however, it
would be appropriate to try it if the face-rating scale is not available. Patients commonly
find the simple descriptor scale difficult to understand. This scale uses a list of adjectives
that describe pain intensity.
PTS: 1 DIF: Moderate REF: dm 1097-1098
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
2. A patient diagnosed with lung cancer who is receiving morphine (MS
Contin) complains of constipation. Which instruction(s) by the nurse might help
relieve the patients constipation? Choose all that apply.
1)
Be sure the amount of fruit, vegetables, and fiber in your diet is adequate.
2)
Drink at least eight 8-ounce glasses of water each day.
3)
Avoid using stool softeners because they may become habit forming. 4)
Increase your exercise routine to include 1 hour of exercise a day.
ANS: 1, 2
The nurse should instruct the patient to be sure the amount of fruit, vegetables,
and fiber in his diet is adequate, and increase fluid intake to eight, 8-ounce glasses of
water per day. Stool softeners may also be used. The patient should also be encouraged to
increase exercise; even walking a short distance may be helpful. It is not necessary to
increase exercise to 1 hour of exercise a day. The patient may be physically able to walk
only short distances.
Chapter 29 Activity & Mobility
Identify the choice that best completes the statement or answers the question.
1. A 15-year-old patient complains of left ankle pain after being tackled while
playing football. He asks the nurse what tests he needs to have to determine if he has a
strain or a fracture. How should the nurse reply?
1)
You dont need an x-ray; I can tell by the way your ankle looks and feels whether you
have a strain or fracture.
2)
Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of
the joint to be certain.
3)
We will need to get a venous Doppler study to make sure that there is not a fracture.
4)
First, we need to get an MRI to diagnose your injury as a fracture instead of strain or
sprain.
ANS: 2
Signs and symptoms associated with a sprain, strain, or fracture are the same. An x-ray
allows the medical provider to visually observe for any breaks in a bone. An x-ray is a
more practical than an MRI to diagnose a fracture. A venous or arterial Doppler is used to
detect blood flow.
PTS: 1 DIF: Easy REF: p. 1136
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
2. The nurse planning the care for a frail, malnourished, immobile
patient recognizes which of the following as the best treatment to protect the
patients integument?
1)
Offering the patient six small meals a day
2)
Assisting the patient to sit in a chair three times a day
3)
Turning the patient at least every 2 hours
4)
Administering fluid boluses as directed by the healthcare provider
ANS: 3
External pressure from lying or sitting in one position compresses capillaries and
obstructs blood flow to the skin. Immobile patients confined to a bed should be turned at
least every 2 hours to protect their skin and relieve pressure.
PTS:1DIF:EasyREF:p. 1137
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension
3. What action is most important in limiting the nurses risk of back
injuries? 1)
Use good body mechanics at all times.
2)
Work with another nurse or an aide when lifting and turning patients.
3)
Avoid manual lifting by using assistive devices as often as possible.
4)
Develop a lift team at the clinical site.
ANS: 3
Back injuries are the leading cause of injury among nurses. Good body mechanics and
teamwork limit the risk of injury. However, the American Nurses Associations
(ANA) Handle with Care program advocates the regular use of assistive devices as well
as avoiding manual lifting.
PTS:1DIFifficultREF:p. 1128
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
4. The nurse is helping the patient to perform leg exercises after surgery to
prevent thrombophlebitis. Which type of muscle is the patient using for these exercises?
1)
Skeletal
2)
Smooth
3)
Cardiac
4)
Slow-twitch fibers
ANS: 1
Skeletal muscle moves the bones with ligaments. Smooth muscle is found in the digestive
tract and other hollow structures, such as the blood vessels and bladder. Cardiac muscle
contracts spontaneously and is blood ejected out of the heart. Slow-twitch fibers are a
subtype of skeletal muscle cell. Slow-twitch fibers (type I), or red muscle, have a rich
blood supply and are rich in mitochondria (the powerhouse of the cell) to give the muscle
more oxygen and energy to sustain aerobic activity. The fast-twitch fibers (type II skeletal
muscle type) are known as white muscle. These fibers increase the speed of muscle
contraction.
PTS:1DIF:EasyREF:p. 1120
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
5. A nurse is caring for a 25-year-old male quadriplegic patient. Which of the
following treatments would the nurse perform to decrease the risk of joint contracture and
promote joint mobility?
1)
Active ROM
2)
Turning the patient every 2 hours
3)
Passive ROM
4)
Administering glucosamine supplements
ANS: 3
Passive ROM involves moving the joints through their ROM when the patient is unable
to do so for himself. Passive ROM promotes joint mobility. Active ROM would not be
possible for a quadriplegic patient. Turning the patient every 2 hours prevents skin
breakdown but does not promote mobility or prevent contracture. Glucosamine is a
building block for the formation and repair of cartilage. However, there is inconclusive,
scientific evidence regarding the benefit of this substance to improve joint function.
PTS:1DIF:Moderate
REF: dm 1122, 1151; higher-order item, answer can be derived from text
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
6. A nurse is assessing a 74-year-old male patient for an exercise program to be
offered at the local hospital. During the evaluation, the nurse notes the following vital
signs: P = 72, RR = 16, BP = 132/70. After 3 minutes of moderate-intensity running on
the treadmill, the patient becomes short of breath and states, I have to stop. I cant do this
anymore. The nurse measures his vital signs again: P = 152, RR = 40, BP = 172/98. She
instructs him to rest. Vital signs return to baseline after 15 minutes. The nurse should
recognize his symptoms as associated with which of the following?
1)
Anxiety
2)
Orthostatic hypotension
3)
Limited activity tolerance
4)
Respiratory distress
ANS: 3
To assess for activity tolerance, assess and record vital signs before and after exercise. A
rapid change from baseline vital signs or a slow return to baseline indicates limited
activity tolerance. Anxiety might primarily exhibit signs of difficulty getting enough air
and elevated heart rate and systolic blood pressure. Vitals would resolve when anxiety is
reduced and not after exercise. Orthostatic hypotension is a temporary lowering of blood
pressure when suddenly standing up. It is not a finding related to exercise.
PTS:1DIF:ModerateREF:p. 1138
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
7. What is the correct method for turning an adult patient who recently sustained
a spinal cord injury?
1)
Ask the patient to assist with the turn by holding the side rails of the bed.
2)
Place a draw sheet under the patient to assist with turning.
3)
Request help from another nurse to perform the logrolling technique.
4)
Use a mechanical lift for safe turning and protecting the nurses back.
ANS: 3
The patients spine should be maintained in straight alignment. Logrolling moves the
patients body as a unit and maintains the patients spine in straight alignment. Holding on
to the side rail or using a draw sheet or mechanical lift will not keep the spine in
alignment.
PTS: 1 DIF: Difficult REF: p. 1148
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
8. An older patient with newly diagnosed osteoporosis asks the nurse to explain
her health problem. Which of the following is the correct description of osteoporosis?
1)
Loss of bone density that increases the risk of fracture 2)
Degenerative joint disease that produces pain and decreased function
3)
Chronic inflammatory joint disease that must be treated with steroids
4)
Acute infection in the bone that must be treated with antibiotics
ANS: 1
Osteoporosis is a decrease in total bone density. The internal structure of the bone
diminishes, and the bone collapses in on itself. Women experience a rapid decline in bone
mass after menopause. Osteoarthritis is a degenerative joint disease. Osteomyelitis is a
serious infection in the bone.
PTS:1DIF:EasyREF:p. 1135
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
9. When caring for a patient with osteoporosis, which of the following
is the most important action to take to minimize progression of the disease?
1)
Take a calcium supplement twice a day.
2)
Start a weight-bearing exercise program.
3)
Avoid strenuous activity that puts stress on the bones.
4)
Schedule regular healthcare checkups.
ANS: 2
Osteoporosis causes bones to become porous and weak. Starting a weight-bearing exercise
program is the most important aid in promoting bone strength and decreasing the rate of
bone loss. Calcium supplementation helps maintain bone density.
PTS:1DIF:ModerateREF:p. 1135
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
10. Which course of action taken by her patient with osteoporosis would allow
the nurse to know that her teaching was effective?
1)
Taking a calcium supplement every day and increasing her phosphorous intake
2)
Participating in an aerobic barbell strength class at the gym three times a week
3)
Using a wheelchair to reduce the risk of spontaneous fractures to her legs and feet
4)
Seeking healthcare by scheduling a follow-up examination with bone density testing
ANS: 2
Active participation in a weight-bearing and weight-lifting program demonstrates not
only understanding of the treatment of osteoporosis but commitment to an action plan to
reduce bone loss that comes with osteoporosis. Calcium supplementation is also part of
the treatment for osteoporosis. However, high phosphorous intake lowers calcium levels
and would not be appropriate for a client with osteoporosis. Restricting weight-bearing
activity to a wheelchair will actually lower bone density. Although follow-up care is
appropriate for a client with osteoporosis, it does not indicate commitment to a daily
treatment plan.
PTS:1DIF:EasyREF:p. 1135
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis
11. Which of the following is true of synarthroses? Joints
are: 1)
Freely movable. 2)
Capable of only limited movement.
3)
Immovable.
4)
Painful with movement. ANS:
3
Synarthroses joints are immovable joints. The sutures between the cranial bones are
considered synarthroses joints. Although these joints have some flexibility in youth to
allow for growth, they gradually become rigid and immovable with age. There is no pain
associated with synarthroses.
PTS:1DIF:ModerateREF:p. 1120
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
12. A man has been admitted to the hospital unit with a medical diagnosis of
chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen at
2 L/min via nasal cannula. Which positioning technique will best assist him with his
breathing?
1)
Fowlers position
2)
Sims position
3)
Lateral recumbent position 4)
Lateral position
ANS: 1
Fowlers position is a semi-sitting position in which the head of the bed is elevated 45 to
60 degrees. This position promotes respiratory function by lowering the diaphragm and
allowing the greatest chest expansion. Sims position is a side-lying position where the
patient is on his left side with left leg extended and right leg flexed. This position is
commonly used for rectal examination. Lateral recumbent position is another term
describing Sims position. Lateral position simply means side lying.
PTS:1DIF:EasyREF:p. 1146
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
13. A nurse has been asked to design an exercise program with the goal of
increasing a clients muscular strength and endurance. Which exercise program would
specifically focus on meeting that goal?
1)
Flexibility training
2)
Resistance training
3)
Aerobic conditioning
4)
Anaerobic conditioning
ANS: 2
Resistance training involves movement against resistance, which increases muscular
strength and endurance. Most commonly, resistance training refers to weight lifting and
isotonic movement. When exercising for strength, the amount of resistance is increased
with each exercise. When exercising for endurance, the number of repetitions is increased
with each exercise. Flexibility training will not increase muscular strength. Aerobic and
anaerobic conditioning may have some benefit on strength and endurance, but their
primary focus is cardiovascular conditioning.
PTS:1DIF:ModerateREF:p. 1129
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Analysis
14. In order to achieve balance, body mass must be distributed around which
point? 1)
Center of body alignment
2)
Center of balance
3)
Center of gravity
4)
Base of support
ANS: 3
Balance is achieved when the body is in alignment. To be balanced, a persons line of
gravity must pass through his center of gravity, and the center of gravity must be close to
his base of support. The center of gravity is the point around which mass is distributed.
PTS:1DIF:EasyREF:p. 1121
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension
15. A frail 78-year-old man is admitted to the hospital after a fall at home
resulted in a left hip fracture. After surgery, he is to begin ambulating with a walker but
must avoid weight-bearing on his left lower leg. What is the best intervention to help
him use his walker?
1)
Aerobic exercise with deep breathing
2)
Quadriceps and gluteal repetitions
3)
Isometric toning of lower legs
4)
Arm resistance training
ANS: 4
Arm strength is necessary for ambulating with a walker and other assistive devices. Upper
body resistance training increases muscles strength and tone, which will aid him in using
the walker more easily. Toning the lower body through exercise of the quadriceps and
gluteal muscles, although important for regaining strength in general after surgery, does
not aid in using a walker. Aerobic exercise with deep breathing produces the greatest
benefit to cardiovascular health but does little to improve the upper body strength needed
for ambulating with an assistive device.
PTS:1DIF:Moderate
REF: dm 1152-1156; synthesis of information required; not a direct response to the item
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
16. Identify the most appropriate nursing diagnosis for promoting the safety of a
frail, elderly patient after hip replacement surgery who also has a history of emphysema.
1)
Impaired Mobility related to weakness
2)
Ineffective Breathing Pattern related to disease process
3)
Activity Intolerance related to injury
4)
Risk for Injury related to medical condition
ANS: 4
The patients medical condition places him at an increased Risk for Injury: He is at risk
for falls and for further injury to his hip. The patient does have Impaired Mobility;
however, his Impaired Mobility puts him at Risk for Injury. A diagnosis of Impaired
Mobility would focus the outcomes on improving his mobility rather than protecting him
from further injury. We have no data other than a diagnosis of emphysema to indicate
that he is experiencing Ineffective Breathing Pattern. He is experiencing Activity
Intolerance, but this is not his primary safety risk. A diagnosis of Activity Intolerance
would focus the goals on increasing his endurance and conserving his energy.
PTS:1DIF:ModerateREF:p. 1140
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Synthesis
17. What would be the most appropriate goal for a frail, elderly patient with
a nursing diagnosis of Risk for Injury after hip surgery?
1)
Remain free from injury or falls throughout hospital stay.
2)
Increase activity tolerance by discharge from hospital.
3)
Demonstrate effective breathing when ambulating.
4)
Increase mobility by discharge from hospital.
ANS: 1
Remaining free from injury or falls is a measurable goal, and it is directly related to the
patients nursing diagnosis, Risk for Injury. Increasing activity tolerance and mobility by
the time of discharge is not specific and measurable. Additionally, these outcomes do not
relate to Risk for Injury. A goal of effective breathing for a frail, elderly patient after hip
surgery does not relate to Risk for Injury.
PTS:1DIF:EasyREF:p. 1141
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
18. A 16-year-old was hospitalized 3 weeks ago. He has been confined to bed
throughout his hospital stay because of a crushed pelvis. His parents tell the nurse, Our
son is just staring off into space; he wont talk to us. We are worried because he has not
even listened to his iPod, watched television, or played his video games for 2 days. That
is so unlike him. What is the best response the nurse can make?
1)
I will inform his doctor and see if we can get your son started on an antidepressant
medication.
2)
He is at a critical time in his life; teens are often moody, and being in the hospital with an
injury will only make that worse.
3)
Your son had a major injury; and his immobility might be causing him to feel isolated
and depressed.
4)
He is bored because he has been in the hospital for 3 weeks; Ill try to find something new
for him to do.
ANS: 3
Being immobile, whether in the hospital or home, leads to isolation and mood changes.
Patients who are in bed for long periods can suffer from psychological changes such as
depression, anxiety, hostility, sleep disturbances, and changes in their ability to perform
self-care activities.
PTS:1DIF:ModerateREF:p. 1137
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
19. A healthy, 32-year-old man wants to start a fitness program to increase his
muscle tone and muscle strength. What advice should the nurse offer him? The United
States Department of Health and Human Services recommends:
1)
That exercising even once a week is beneficial.
2)
30 minutes or more of moderate-intensity physical activity three times a week.
3)
1 hour, three times a week of moderate-intensity physical activity.
4)
150 to 300 minutes or more of moderate-intensity physical activity per week.
ANS: 4
Exercise involves physical activity and increases muscle tone and strength. The U.S.
Department of Health and Human Services recommends 150 to 300 minutes or more of
moderate- or vigorous-intensity physical activity per week.
PTS:1DIF:ModerateREF:p. 1130
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:
Comprehension
20. A patient fractured her right ulna 8 weeks ago and has just had her cast
removed. The orthopedic surgeon prescribes isometric exercises for the right arm. Which
of the following exercises comply with the surgeons orders?
1)
Place a 5-pound dumbbell in the right hand and squeeze; hold the squeeze position for 6
to 8 seconds, and repeat 5 to 10 times.
2)
Grasping the right wrist with the left hand, move the right arm up, down, and side to side;
hold each position for 6 to 8 seconds, and repeat 5 to 10 times.
3)
Grasping the right wrist with the left hand, pull the right arm across the body; hold this
position for 6 to 8 seconds, and repeat 5 to 10 times.
4)
Press the right hand against a wall; hold this position for 6 to 8 seconds, and repeat 5 to
10 times.
ANS: 4
Isometric exercise involves muscle contraction without motion. Isometric exercises are
useful for developing strength. This type of exercise is appropriate for the patient who
has had an extremity confined to a cast because muscle atrophy occurs when the muscle
is not used. Performing repetitions light weight increases strength but this would stress
the healing fracture at this point in the rehabilitation. Pulling an arm across the body
improves flexibility but does not benefit the ulna while healing.
PTS:1DIFifficultREF:p. 1128
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
21. A woman with a high-risk pregnancy with triplets is in preterm labor; she is
on strict bedrest for 5 days. During this time she has not had a bowel movement,
although normally, passes stool daily. She describes feeling bloated and uncomfortable.
What information should the nurse give the patient when explaining constipation?
1)
Immobility often causes constipation.
2)
A stool softener daily will relieve the problem.
3)
Use of a bedpan results in bloating and constipation.
4)
A low-fiber diet will resolve the problem.
ANS: 1
Immobility slows peristalsis, which leads to constipation, gas, and difficulty evacuating
stools from the rectum. Increasing fiber in the diet often prevents constipation. A stool
softener may be ordered if other measures are unsuccessful. Some people do find use of a
bedpan difficult.
PTS:1DIF:EasyREF:p. 1137
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
22. A patient is on strict bedrest for 5 days. During this time she has not had a
bowel movement, although she normally passes stool daily. She describes feeling bloated
and uncomfortable. A nursing diagnosis that would best address a patient who is on
bedrest is Constipation related to:
1)
Change in previous pattern. 2)
Immobility.
3)
Dietary intake.
4)
Change in environment.
ANS: 2
Immobility slows peristalsis, which leads to constipation, gas, and difficulty evacuating
stools from the rectum. Based on the scenario, this nursing diagnosis would specifically
address the patients condition.
PTS:1DIF:Moderate
REF:p. 1137; higher-order item with implied answer
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
23. A 32-year-old with a high spinal cord injury has been admitted to the hospital
for antibiotic therapy to treat pneumonia. He lives independently and has developed
strong upper-body strength to maximize his independence. Which transfer device should
be used when transferring him from the bed to his wheelchair?
1)
Mechanical lift
2)
Transfer belt
3)
Draw sheet
4)
Transfer board
ANS: 4
A transfer board is used by patients with longstanding mobility problems; it offers them
the greatest amount of independence while ensuring safety. Patients using a transfer
board should have sufficient upper-body strength to perform the transfer safely. A
mechanical lift could be used, but it does not promote independence. A transfer belt is
used for clients who are able to stand. A draw sheet is useful for moving a patient in bed
rather than from bed to wheelchair.
PTS:1DIF:EasyREF:p. 1149
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Comprehension
24. An 82-year-old patient is unsteady on her feet when walking about the
room. She reports feeling a little sore but has no complaints of weakness. What is the
appropriate piece of equipment to use when helping her ambulate?
1)
Crutches
2)
Transfer belt
3)
Cane
4)
Walker
ANS: 2
Crutches are commonly used when the patient has an injured lower extremity. A cane or
walker is generally used for the patient with a lower extremity injury or weakness. The
most appropriate equipment to use would be a transfer belt. A transfer belt allows the
patient the greatest amount of independence while ensuring safety.
PTS:1DIF:EasyREF:dm 1149-1150
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
25. The nurse is helping an 82-year-old patient to ambulate in the hallway.
Suddenly she states, I feel so light-headed and weak, as her knees begin to buckle. The
nurses best action at this time would be to:
1)
Assist the patient to slide down his leg as he guides her to a seated or lying position.
2)
Grab her under the arms and hold her up as he calls for assistance.
3)
Immediately release the transfer device and place a wheelchair behind the patient to
prevent a fall.
4)
Instruct the patient to grab the rail in the hallway while he calls for assistance.
ANS: 1
If a patient becomes weak or begins to fall when walking, do not attempt to hold the
patient up. Instead, protect the patient as you guide her to a seated or lying position.
Create a wide base of support, and project forward the hip closest to the patient. Assist
the patient to slide down your leg as you call for help. Protect the patients head as her
body descends.
PTS:1DIF:ModerateREF:p. 1152
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
26. According to the U.S. Department of Health and Human Services 2008
Physical Activity Guidelines for Americans, which of the following statements about the
benefits of physical activity is correct?
1)
The risks of physical activity outweigh the health benefits.
2)
Physical activity in excess of recommendations for age is harmful.
3)
Combining aerobic and muscle-strengthening activities promotes better health.
4)
Lesser amounts of activity provide little to no health benefits.
ANS: 3
The combination of aerobic and bone- and muscle-strengthening physical activities leads
to health benefits for people of all ethnic groups and ages. Physical activity is safe for
almost everyone, and the health benefits of physical activity far outweigh the risks.
Additional health benefits are provided by increasing to 300 minutes a week of moderateintensity aerobic physical activity, or 150 minutes a week of vigorous-intensity physical
activity, or an equivalent combination of both. For all individuals, some activity is better
than none.
PTS:1DIF:EasyREF:p. 1130
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
27. When encouraging a fitness program for older adults, what must the
nurse consider?
1)
Older adults should engage in 75 to 150 minutes of moderate-intensity physical activity
per week.
2)
More than 150 minutes of moderate-intensity physical activity can be harmful to bones.
3)
Structured fitness programs achieve greater health benefits for older adults.
4)
Older adults at risk for falling should do activities that maintain or improve balance.
ANS: 4
Older adults should do exercises that maintain or improve balance if they are at risk of
falling. Older adults should follow the adult guidelines, which are for 150 minutes per
week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical
activity, or an equivalent combination of moderate- and vigorous-intensity aerobic
physical activity. Aerobic activity should be performed in periods of at least 10 minutes,
preferably spread throughout the week. If this is not possible because of limiting chronic
conditions, older adults should be as physically active as their abilities allow. They should
avoid inactivity. Structured calisthenics programs are no more beneficial for achieving
health benefits than other forms of moderate- and vigorous-intensity physical activity.
Structured fitness programs can become boring for some individuals. A varied routine
often improves compliance and consistency of exercise.
PTS: 1 DIF: Easy REF: dm 1131-1132
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which of the following body systems must interact to produce mobility
and locomotion? Choose all that apply.
1)
Digestive system
2)
Muscles
3)
Skeleton
4)
Nervous system
ANS: 2, 3, 4
Activity and exercise require bodily movement (mobility) and locomotion (self-powered
movement from one place to another). Mobility depends on the successful interaction
among the skeleton, the muscles, and the nervous system.
PTS:1DIF:EasyREF:p. 1119
KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
2. Which of the following patients would you expect to be at risk for
decreased activity? Choose all that apply.
1)
Older adult who walks at the mall for physical activity
2)
Someone living in a skilled nursing facility
3)
Healthy adult who works as a computer programmer
4)
Obese child who enjoys video games
ANS: 2, 3, 4
The person who lives in a skilled nursing facility might be sedentary because of
advancing age and other age-associated medical problems that lead to inactivity. With
obesity, movement becomes more difficult and strain on joints increases. A sedentary
lifestyle, whether adult or child, contributes to obesity; activities, such as computer work
and video games, are sedentary and require little physical activity. Physical activity
doesnt have to be a structured fitness class but can also be walking, even walking in a
mall or neighborhood, just as long as the intensity is moderately vigorous.
PTS: 1 DIF: Moderate REF: p. 1119
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension
3. A patient has started a fitness program. What program features illustrate that
he has started a well-rounded program?
1)
Flexibility
2)
Isometric exercises
3)
Resistance training
4)
Aerobic conditioning
ANS: 1, 3, 4
Flexibility training helps warm up the muscles and prevents injury during
exercise. Resistance training increases muscular strength and endurance. Aerobic
conditioning affects fitness and body composition. Isometric exercise is an active form of
physical activity using opposing resistance where the joints dont move and muscles dont
lengthen. Isometrics are done in static positions, rather than moving through a range of
motion.
PTS:1DIF:ModerateREF:dm 1129-1130
KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Comprehension
4. The nurse is instructing a patient about the need to replace fluid before, during,
and after exercise in order to avoid dehydration. She should teach the patient to determine
the amount of fluid to consume on the basis of:
1)
Duration of exercise.
2)
Environmental temperature. 3)
Level of fitness.
4)
Degree of thirst.
ANS: 1, 2
Lost fluids must be replaced to decrease the risk of dehydration, regardless of level of
fitness. During intense exercise, the body can lose 2 liters of fluid for every hour of
exercise. Elevated environmental temperatures also increase the amount of fluid lost
through sweating. When athletes drink according to thirst, the risk that they will overdrink and so develop exercise-associated hyponatremia is minimized (Noakes, 2007). On
the other hand, exercise can suppress thirst, making it an unreliable signal to replace fluids
lost with exercise.
PTS:1DIF:Easy
REF:p. 1133; answer can be derived from the text
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
5. Which of the following actions represent proper body mechanics for nurses
providing care as well as teaching patients about safe body movements? Choose all that
apply.
1)
Stand with the body in alignment and erect posture.
2)
Bend at the waist to lift heavy objects from the floor.
3)
Use a wide base of support with your feet at shoulder width.
4)
Keep objects close to your body when carrying them.
ANS: 1, 3, 4
Proper body mechanics involves good body alignment, erect posture, and a wide base of
support. To prevent back injury resulting from reaching and straining muscles, carry
objects close to the trunk. Bending at the waist to lift objects uses the back muscles and
increases the risk of injury. Instead, squat to lower your center of gravity, and use your
leg muscles for lifting.
Chapter 30 Sexual Health
Identify the choice that best completes the statement or answers the question.
1. Which of the following is the most important information to collect at a
womens health examination for a 52-year-old woman?
1)
Age at first sexual encounter
2)
History of PMS
3)
Birth control method used
4)
Date of last menstrual period
ANS: 4
A 52-year-old woman may be experiencing erratic periods of perimenopause. The date of
her last menstrual period will help determine her perimenopausal status and guide the
discussion of physical, emotional, and sexual changes that commonly occur during a
period of declining estrogen production. The nurse will need to determine her menstrual
status, which also includes the length and heaviness of flow, the regularity of her cycle,
and any change in symptoms associated with menstruation. The nurse will also need to
assess for birth control requirements in a heterosexual or bisexual woman.
PTS: 1 DIF: Moderate REF: dm 1186-1187; application item, not directly stated in text
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
2. An 18-year-old high school senior comes to the local family planning clinic
requesting birth control pills. When discussing sexual health with the adolescent girl,
your first nursing priority would be to do which of the following?
1)
Urge the teen to practice healthful sexual behaviors.
2)
Inform her about the risk of pregnancy and STIs.
3)
Assess the teens knowledge of sexuality and reproduction.
4)
Provide detailed information about birth control pills.
ANS: 3
You cannot assume that adolescents or young adults have adequate sexual knowledge,
and it is difficult for most people to admit a lack of knowledge to a professional.
Therefore, when discussing sexual health with a client, the nurse must first assess the
clients knowledge and understanding of reproduction and sexuality.
PTS: 1 DIF: Difficult REF: p. 1177
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis
3. Which is the first stage of sexual
arousal? 1)
Desire
2)
Excitement
3)
Stimulation
4)
Orgasm
ANS: 1
The sexual response cycle is the sequence of physiological events that occurs when a
person becomes sexually aroused. A theorist named Basson identified five stages of
physiological events that occur when a person becomes sexually aroused: desire,
excitement, plateau, orgasm, and resolution. Desire precedes all other stages of the cycle,
but sexual response does not necessarily proceed beyond desire.
PTS:1DIF:ModerateREF:dm 1178-1179
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall
4. A 65-year-old widow is being given an annual physical exam. She states she
has been dating a widowed man for 9 months and that the relationship is fulfilling in
most areas. However, she is unable to have sexual relations because she feels she is
cheating on her husband, who died 5 years ago. Her partner is very understanding,
although her inability to have sexual relations is becoming a strain on their relationship.
What is an appropriate nursing diagnosis for this woman?
1)
Sexual Dysfunction related to conflicted sexual orientation
2)
Ineffective Sexuality Patterns related to values conflicts
3)
Ineffective Sexuality Patterns related to impaired relationship with partner
4)
Sexual Dysfunction related to fear of the unknown
ANS: 2
The nursing diagnosis Ineffective Sexuality Patterns is used when the patient expresses
concerns about her own sexuality, whereas Sexual Dysfunction is used when there is an
actual change in sexual function that the patient views as unsatisfying, unrewarding, or
inadequate. In this situation, the patient still views herself as being committed to her
deceased husband, causing a conflict in values.
PTS:1DIFifficultREF:p. 1188
KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis
5. You are caring for a 35-year-old man who tells you that he feels distress about
being a male, and ever since he was a young child has thought of himself as a female. He
describes the isolation he feels and concern about fitting in socially and at work because
of these recurrent thoughts. How would you respond to your patient?
1)
Provide information about support groups and other community resources for transsexual
people.
2)
Reassure him that he is normal, saying there are more people than we know who feel this
way.
3)
Share with him that you personally have had thoughts like this but have coped with these
thoughts.
4)
Suggest your patient seek mental healthcare for medication to help him deal with his
anxiety.
ANS: 1
Those experiencing a sexual identity disorder, such as transsexualism, typically feel
overwhelming cultural disapproval and isolation. The lifelong stresses associated with
being transsexual penetrate nearly every aspect of life: medically, socially, and
emotionally. Competent and responsive healthcare is essential, and nurses can be an
especially valuable source of information and support during a time of isolation and
emotional inner conflict. Reassuring the patient he is normal discounts his feelings and
conveys insensitivity on the part of the nurse as well as a lack of willingness to listen
openly. Genuine support and active listening are important for the transsexual person
who is struggling with his gender identity. Interjecting your own experiences trivializes
the patients experience. The nurses first action is to offer information rather than imply
that the patient has a mental health issue requiring anti-anxiety agents.
PTS:1DIF:ModerateREF:p. 1174
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
6. Based on a nursing diagnosis of Ineffective Sexuality Patterns related to
values conflicts, what would be the most effective nursing intervention for a patient?
1)
Educate the patient about sexual orientation and function.
2)
Encourage the patient to discuss relationship problems with her partner.
3)
Advise the patient to discuss her value conflict with a counselor.
4)
Instruct the patient on effective methods to identify fears.
ANS: 3
Effective nursing interventions address the etiology of the identified nursing diagnoses.
This patient is experiencing a values conflict. Therefore, interventions must address this
concern rather than issues, such as fears and relationship problems. The partner might not
be the most suitable person for the patient to talk to because she would be too close to the
matter; a counselor is trained to discuss sexuality and values conflicts in a professional and
objective manner.
PTS:1DIF:ModerateREF:p. 1189
KEY: Nursing process: Interventions | Client need: Health Promotion | Cognitive level:
Application
7. What do shared touching, celibacy, masturbation, and developing
intimate relationships have in common? They are all:
1)
Forms of sexuality or sexual orientation.
2)
Cues to use in formulating a nursing diagnosis.
3)
Important in the development of sexual identity.
4)
Forms of sexual expression.
ANS: 4
People express their sexuality and gain satisfaction in many ways. Developing intimate
relationships, fantasies and erotic dreams, masturbation, shared touching, oralgenital
stimulation, anal stimulation or intercourse, sexual intercourse, and celibacy are all forms of
sexual expressioneven a lack of activity is an expression of sexuality.
PTS:1DIF:ModerateREF:dm 1181-1182
KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Analysis
8. In order to discuss a clients sexual health needs in a comfortable and
competent manner, it is most important for a nurse to be able to:
1)
Recognize and set aside personal biases or experiences related to sexuality.
2)
Perform an accurate and comprehensive physical assessment.
3)
Collect an accurate and comprehensive sexual history.
4)
Acquire theoretical knowledge of sexual health concerns.
ANS: 1
In many cultures, people have been socialized to avoid talking openly about sexuality. As
a nurse, you will find that you must discuss a variety of issues that are vital for a clients
optimal wellness. Some of these discussions may include sexual concerns, dysfunctions,
infections, or behaviors. As you reflect on the issues of human sexuality, you will be
challenged to confront your own biases related to sexuality and to set those aside as you
work with your clients. Although theoretical knowledge is important, you will be able to
use it fully only if you can identify and set aside your own biases.
PTS:1DIF:EasyREF:p. 1172
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:
Comprehension
9. Which of the following statements by a teenage client would indicate that
your teaching about detection of STIs has been effective?
1)
A healthcare provider can tell if you have an STI just by looking at your genitals.
2)
The doctor has to do surgery to biopsy the tissue to find out if a person has an STI.
3)
A healthcare provider can tell if you have an STI by getting a detailed sexual history.
4)
A genital swab culture can be done at the office or clinic to determine if a person has an
STI.
ANS: 4
Many STIs have few or no symptoms. To find out if a patient has an STI, you must
obtain a swab culture of secretions. For a man, a culture is obtained from the urethra. For
a woman, secretions are swabbed near the cervix.
PTS:1DIF:ModerateREF:p. 1183
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
10. When evaluating the treatment plan for a patient with erectile dysfunction
(ED), you would deem the treatment successful if the patient made the following
statement:
1)
I feel very good about the treatment; I am now comfortable with my sexual orientation.
2)
I am happy with the treatment as I can now maintain an erection through orgasm.
3)
Now I can communicate my sexual needs to my partner without embarrassment. 4)
I now know how to prevent further sexually transmitted infections.
ANS: 2
Men with erectile dysfunction have persistent or recurring inability to achieve or maintain
an erection sufficient for satisfactory sexual performance. When the patient is maintaining
penile erection through orgasm, this is an indication the interventions were successful. ED
is not related to sexual orientation or exposure to STIs. Comfort with communicating
about sexual needs is helpful for sexual satisfaction but is not the cause of ED.
PTS:1DIF:ModerateREF:p. 1185
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
11. When providing care for a client with concerns about his sexual orientation,
you use the PLISSIT model. You recognize that the first step you must take is to:
1)
Provide information about sexual orientation and common alterations.
2)
Plan time to discuss concerns with the client in a private, comfortable setting.
3)
Permit the client to speak openly by communicating an open, accepting attitude.
4)
Provide referrals to the client so he can identify resources to assist him in the future.
ANS: 3
The PLISSIT model was developed as a guideline for sex therapy. Although basic nursing
education does not prepare you to provide sex therapy, the first three PLISSIT steps have
been adapted to address sexual knowledge deficits that you are qualified to treat. The first
step, P, is to provide permission. Permission means that you communicate an open,
accepting attitude so the client feels free to ask questions and express concerns and
feelings.
PTS:1DIFifficultREF:p. 1196
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension
12. A 24-year-old woman comes to the clinic to be evaluated for sexually
transmitted infections. She states she has no symptoms, but her boyfriend is complaining
of a thin, clear discharge and mild discomfort with urination. His doctor advised him that
his partner should be treated because this problem may affect her future fertility. What
disorder should be assessed for?
1)
Chlamydia
2)
Trichomoniasis
3)
Genital herpes
4)
Human papillomavirus
ANS: 1
The male partner exhibits symptoms of chlamydia. Women are frequently asymptomatic
for chlamydia. As a result, the infection may go untreated and affect future fertility.
Trichomoniasis is asymptomatic in men, but women experience a frothy, odorous vaginal
discharge. Small blisters on the genitals may be seen with genital herpes. Human
papillomavirus produces genital warts.
PTS:1DIFifficultREF:p. 1183
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
13. When in the reproductive cycle is there marked growth of ovarian material
and regrowth of the endometrium, ending with the release of the ovum?
1)
Menstrual phase
2)
Follicular phase
3)
Luteal phase
4)
Fertilization
ANS: 2
The luteal phase occurs after the menstrual phase. At this time, the endometrial lining
builds back up after being shed with menstruation. Ovarian follicles mature until the ovum
is released. The luteal phase occurs after ovulation. In this phase, if fertilization does not
occur, progesterone drops and menses begins again. Fertilization occurs at the time of
ovulation at which a sperm joins with the mature egg and the endometrium is ripe to
support the embryo.
PTS:1DIF:ModerateREF:p. 1172
KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Normal physiological changes in womens sexual responses that occur with
aging include which of the following? Choose all that apply.
1)
Delayed nipple erection
2)
Increased vaginal expansion
3)
Reduced vaginal lubrication
4)
Reduced labial separation and swelling
ANS: 1, 3, 4
As women age, normal physiological responses in sexual behavior include delayed nipple
erection, reduced vaginal lubrication, and reduced labial separation and swelling. Vaginal
expansion is reduced rather than increased because of decreased estrogen and progesterone
levels.
PTS:1DIF:ModerateREF:p. 1179
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis
2. A 2-year-old boy has come to the well-child clinic with his mother for a
checkup. When the nurse asks his mother if she has any concerns, she says, I dont know
why he wont quit touching his privates all the time. I have tried sitting him in a chair,
smacking his hand, and telling him no, but he continues to do this. I just dont know how to
make him stop. How would you best respond to her concerns? Choose all that apply.
1)
Give him a little time, and hell grow out of it. Hes just too young to understand right
now.
2)
How often do you punish him by giving him a time-out or by using physical discipline?
3)
Physical punishment is not the best way to modify a childs behavior.
4)
It isnt unusual for him to fondle his genitals, as this is part of his exploration of his body.
ANS: 2, 3, 4
The first two years of life are highly sensual as infants are nursed, stroked, bathed, and
massaged, and they develop their first attachment experience through bonding with the
mother. It is not unusual for infants and preschoolers to fondle their genitals and enjoy
being nude. This is part of their exploration of their bodies, and parents should not
overreact. Although health teaching about normal sexual development of toddlers is
important, this mothers comments are a red flag to appropriate discipline. Her
exaggerated response using physical reprimands to a 2-year-old child bears further
exploration about other potential for physical harm or abuse within the home. The nurse
has a responsibility to assess risk to the child for an abusive situation and counsel the
mother about alternate methods of dealing with the behavior.
PTS:1DIF:ModerateREF:p. 1175
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
3. What are common reasons victims of abuse might not report an incident of
sexual assault? Choose all that apply.
1)
Fear that her abuser would be angry if she reported it and would hurt her again 2)
Belief that she was to blame for starting a fight with the abuser
3)
Idea that the legal system couldnt prosecute the abuser for the crime
4)
Desire to have the incident behind her, as if it never happened in the first place
ANS: 1, 2, 3, 4
Reasons for not reporting rape include fear of the assailant, fear of consequences to the
assailant, knowledge of the low conviction rate for rapists, the desire to avoid a trial,
shame and embarrassment, past sexual history, self-blame, and wanting to move on and
not face possible consequences involving pregnancy and sexually transmitted infection.
PTS:1DIF:ModerateREF:p. 1184
KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application
4. Which of the following are considered sexual response cycle disorders?
Choose all that apply.
1)
Arousal disorder
2)
Date rape
3)
Orgasmic disorder
4)
Low libido
ANS: 1, 3, 4
Low libido, arousal disorder, and orgasmic disorder all affect the sexual response cycle.
These disorders affect desire, arousal, excitement, and orgasm. Rape occurs when there is
nonconsensual vaginal, anal, or oral penetration. It occurs through force, by the threat of
bodily harm, or when the victim is incapable of giving consent. Date rape is forced,
unwanted sexual intercourse by an acquaintance when the assault occurs during an agreedupon social encounter.
PTS:1DIF:EasyREF:dm 1184-1185
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Comprehension
5. When caring for a woman who was sexually assaulted, what is your best
approach for collecting information surrounding the event? Choose all that apply.
1)
Use a calm, reassuring voice when asking questions of your patient.
2)
Ask only close family members to describe events related to the incident.
3)
Provide privacy by asking questions behind a closed curtain.
4)
Document the details using the patients own words.
ANS: 1, 4
Use a calm, professional approach as you collect sexual data from your patients. This will
not only help them to feel more comfortable and confident, but will also yield more honest
and complete information. Your patient might have difficulty discussing the events relating
to the assault; however, this is a private matter and not a topic to discuss with family
members, regardless of the apparent closeness of the relationship. When asking personal
questions, provide privacy and be sensitive to your clients cues. A curtain is not secure
enough because conversation easily could be overheard. Clear, unambiguous
documentation is extremely important because of the criminal nature of sexual crime.
Using the patients own words is a way for the nurse to avoid misinterpreting the facts as
well as keep from introducing bias or drawing conclusions about the event.
PTS:1DIF:ModerateREF:p. 1184; not directly stated in text
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
6. You are caring for a 32-year-old woman who has been sexually assaulted.
What nursing interventions are initially most important for this client?
1)
Help her to communicate effectively with police about the attack.
2)
Obtain permission from your client to test for pregnancy and STIs.
3)
Refer your client to a sexual assault support group.
4)
Promote and model empathy and support for her family members.
ANS: 2, 3
A victim of rape has experienced psychological and physiological trauma. Sexual assault
is a risk factor for sexually transmitted infection (STI). Testing for STIs and pregnancy is
a necessary component of the physical care of a victim of sexual violence. Referral to a
local sexual assault support group is critical when planning care. A sexual assault nurse
examiner (SANE), who is a registered nurse, can assist the client through the physical
examination, police interview, and disclosure to family members, all of which are
important activities.
Chapter 31 Sleep & Rest
Identify the choice that best completes the statement or answers the question.
1. A person who is deprived of REM sleep for several nights in succession
will usually experience:
1)
Extended NREM sleep.
2)
Paradoxical sleep.
3)
REM rebound.
4)
Insomnia.
ANS: 3
A person who is deprived of REM sleep for several nights will usually experience REM
rebound. The person will spend a greater amount of time in REM sleep on successive
nights, generally keeping the total amount of REM sleep constant over time.
PTS:1DIF:ModerateREF:p. 1205
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
2. A patient states that many of his friends told him to ask for Valium or Ativan to
help him sleep while hospitalized. The nurse knows that nonbenzodiazepines (such as
Ambien) are often preferred over benzodiazepines (Ativan or Valium). Why is this?
1)
Benzodiazepines are eliminated from the body faster than are nonbenzodiazepines, so
they do not provide a full night of sleep.
2)
Nonbenzodiazepines cause daytime sleepiness, allowing people to rest throughout the
day.
3)
Benzodiazepines produce daytime sleepiness and alter the sleep cycle.
4)
Nonbenzodiazepines remain in the body longer than do benzodiazepines.
ANS: 3
Nonbenzodiazepines (such as Ambien) have a short half-life, which means that they are
eliminated from the body quickly and do not cause daytime sleepiness. Ativan is a longacting benzodiazepine and remains in the body longer than Ambien, often causing
daytime sleepiness.
PTS: 1 DIF: Moderate REF: p. 1215
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis
3. Which of the following factors has the greatest positive effect on sleep
quality? 1)
Sleeping hours in synchrony with the persons circadian rhythm 2)
Sleeping in a quiet environment
3)
Spending additional time in stage IV of the sleep cycle
4)
Napping frequently during the day hours
ANS: 1
A circadian rhythm is a biorhythm based on the daynight pattern in a 24-hour cycle. Sleep
quality is best when the time at which the person goes to sleep and awakens is in
synchrony with his circadian rhythm. Not all people require a quiet environment for
sleep. Time spent in stage IV of the sleep cycle is affected by the total time spent asleep.
Napping on and off throughout the day might disrupt the natural circadian rhythm with
uninterrupted periods of sleep that cycle through the various stages of the sleep cycle.
PTS:1DIF:ModerateREF:p. 1204
KEY: Nursing process: N/A| Client need: HPM | Cognitive level: Analysis
4. Which is a major factor regulating
sleep? 1)
Electrical impulses transmitted to the cerebellum
2)
Level of sympathetic nervous system stimulation
3)
Amount of sleep a person has become accustomed to
4)
Amount of light received through the eyes
ANS: 4
The circadian rhythm is a biorhythm based on the daynight pattern in a 24-hour cycle. A
persons circadian rhythm is regulated by a cluster of cells in the hypothalamus of the
brainstem that respond to changing levels of light. A major factor in regulating sleep is
the amount of light received through the eyesnot the typical amount of sleep the person
has within a 24-hour period. The autonomic nervous system (rather than central nervous
system) controls the involuntary processes of the body, such as sleep, digestion, immune
function, and so on.
PTS:1DIF:ModerateREF:p. 1204
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension
5. Which of the following is the main difference between sleep and
rest? 1)
In sleep, the body may respond to external stimuli.
2)
Short periods of sleep do not restore the body as much as do short periods of rest.
3)
Sleep is characterized by an altered level of consciousness.
4)
The metabolism slows less during sleep than during rest.
ANS: 3
During rest, the mind remains active and conscious; sleep is characterized by altered
consciousness. Sleep is a cyclic state of decreased motor activity and perception. A
sleeping person is unaware of the environment and does respond selectively to certain
external stimuli. However, at rest, the body is disturbed by all external stimuli; sleep
restores the body more than does rest. The metabolism decreases more during sleep than
during rest.
PTS:1DIF:EasyREF:p. 1202
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Analysis
6. A patient tells you that she has trouble falling asleep at night, even though she is
very tired. A review of symptoms reveals no physical problems and she takes no
medication. She has recently quit smoking, is trying to eat healthier foods, and has started
a moderate-intensity exercise program. Her sleep history reveals no changes in bedtime
routine, stress level, or environment. Based on this information, the most appropriate
nursing diagnosis would be Disturbed Sleep Pattern related to:
1)
Increased exercise.
2)
Nicotine withdrawal.
3)
Caffeine intake.
4)
Environmental changes.
ANS: 2
Based on the information given, the patient is not experiencing significant stress or
change in sleep routine or environment, which commonly lead to insomnia. People who
use nicotine tend to have more difficulty falling asleep and are more easily aroused than
those who are nicotine free. People who stop smoking often experience temporary sleep
disturbances during the withdrawal period.
PTS:1DIF:ModerateREF:p. 1208
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
7. Which patient teaching would be most therapeutic for someone with
sleep disturbance?
1)
Give yourself at least 60 minutes to fall asleep.
2)
Avoid eating carbohydrates before going to sleep.
3)
Catch up on sleep by napping or sleeping in when possible.
4)
Do not go to bed feeling upset about a conflict.
ANS: 4
Intense emotion before bedtime can interfere with rest and sleep. Lying awake longer
than 30 minutes is counterproductive. Eating a small amount of a complex carbohydrate
can aid in falling asleep. Avoid simple sugars because sucrose can lead to a short-term
energy boost instead of relaxation. Taking naps during the day and sleeping late on some
mornings can actually exacerbate a sleep disturbance. Its better to establish a consistent
routine for wake and sleep. The extra sleep during the day can interfere with the bodys
readiness for sleep at night.
PTS:1DIF:EasyREF:dm 1207-1208
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
8. The expected outcome (goal) for a patient with Disturbed Sleep Pattern is
that she will:
1)
Limit exercise to 1 hour per day early in the day.
2)
Consume only one caffeinated beverage per day.
3)
Demonstrate effective guided imagery to aid relaxation.
4)
Verbalize that she is sleeping better and feels less fatigued.
ANS: 4
The patient would verbalize that she is sleeping better and feels less fatigued. The
expected outcome (goal) is based on the nursing diagnosis, and its achievement should
reflect resolution of the problem. The other options are outcomes that demonstrate only
that the patient took certain actions. They would not, if achieved, demonstrate that the
problem of Disturbed Sleep Pattern had been resolved.
PTS:1DIF:ModerateREF:p. 1213
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis
9. When making rounds on the night shift, the nurse observes her patient to be in
deep sleep. His muscles are very relaxed. When he arouses as the nurse changes the IV
tubing, he is confused. What stage of sleep was the patient most likely experiencing? 1)
Stage V
2)
Stage IV
3)
Stage III
4)
REM
ANS: 2
Stage IV is the deepest sleep. In this stage, the delta waves are highest in amplitude, slowest
in frequency, and highly synchronized. The body, mind, and muscles are very relaxed. It is
difficult to awaken someone in stage IV sleep; if awakened, the person may appear confused
and react slowly. During this stage, the body releases human growth hormone, which is
essential for repair and renewal of brain and other cells.
PTS:1DIF:EasyREF:p. 1206
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
10. What is the purpose of using a sleep
diary? 1)
Identify sleeprest patterns over a 1-year period.
2)
Note the trend in sleepwakefulness patterns over a 2-week period.
3)
Note typical sleep habits and most common daily routines.
4)
Examine the patterns of sleep during the night and naps during the day.
ANS: 2
A sleep diary provides specific information about the patients sleepwakefulness patterns
over a certain period of time. It allows identification of trends in sleepwakefulness
patterns and associates specific behaviors interfering with sleep. The diary is typically
kept for 14 days.
PTS: 1 DIF: Moderate REF: p. 1212
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
11. Patterns of waking behavior that appear during sleep are known
as: 1)
Parasomnias.
2)
Dyssomnias.
3)
Insomnia.
4)
Hypersomnia.
ANS: 1
Parasomnias are patterns of waking behavior that appear during sleep. Sleepwalking,
sleep talking, and bruxism are parasomnias.
PTS: 1 DIF: Easy REF: p. 1208
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension
12. A 6-year-old boy is admitted to the hospital for a surgical procedure associated
with a hospital stay. When the nurse asks his mother about the boys sleep patterns, she
says, Sometimes he will get out of bed, walk into the kitchen, and get the cereal out of the
cabinet. Then he just turns around and goes back to bed. The nurse explains that he is
sleepwalking. The best nursing diagnosis for Tad would be:
1)
Risk for Insomnia related to sleepwalking.
2)
Risk for Fatigue related to sleepwalking.
3)
Disturbed Sleep Pattern related to dyssomnia.
4)
Risk for Injury related to sleepwalking.
ANS: 4
Sleepwalking occurs during stages III and IV of NREM sleep. The sleeper leaves the bed
and walks about with little awareness of surroundings. He may perform what appear to be
conscious motor activities but does not wake up and has no memory of the event on
awakening. The boy is at high risk for injury when sleepwalking because of his lack of
awareness of his surroundings. Insomnia is a medical diagnosis rather than a nursing
diagnosis. Certainly his sleep pattern is disturbed; however, there is little in the way of
independent actions that the nurse could take for either the problem or etiology of this
diagnosis, so it would not be useful. The boy does not awaken while sleepwalking and is
not likely to experience fatigue from the event.
PTS:1DIF:ModerateREF:p. 1213
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
13. The primary focus of your interventions for a 6-year-old child who
sleepwalks would be to:
1)
Maintain patient safety during episodes of somnambulation.
2)
Administer and teach about medications to suppress stage IV sleep.
3)
Encourage the child to verbalize feelings regarding sleep pattern.
4)
Provide a quiet environment for nighttime sleep.
ANS: 1
Sleepwalking places the patient at Risk for Injury because of his lack of awareness of the
surroundings. The nurses primary intervention would be to protect the patient from injury
(e.g., falls) while sleepwalking, also called somnambulation. Because the child is only 6
years old, administering and teaching about medications and having him verbalize feelings
would not be useful. Providing a quiet environment would likely be ineffective and
certainly not the focus of interventions.
PTS:1DIF:ModerateREF:p. 1211
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
14. From what stage of sleep are people typically most difficult to
arouse? 1)
NREM, alpha waves 2)
NREM, sleep spindles
3)
NREM, delta waves
4)
REM
ANS: 3
Contrary to previous beliefs, stages III and IV of NREM (delta wave) are the deepest
stages of sleepnot REM. It is difficult to awaken someone in stage IV slow wave NREM
sleep, and if she is awakened, the person may appear confused and react slowly. Stage I
NREM is a light sleep from which the sleeper can easily be awakened. Stage II (sleep
spindles) is also light sleep; the sleeper in this stage is easily roused. REM sleep is the
stage at which most dream activity occurs, as well as more spontaneous awakenings.
PTS:1DIF:ModerateREF:p. 1205
KEY:Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
15. During which of the following developmental stages does a person tend to
need the most hours of sleep?
1)
Toddler
2)
Adolescence
3)
Middle adulthood
4)
Older adulthood
ANS: 1
Toddlers (ages 1 to 3 years) require 12 to 14 hours of sleep in a 24-hour period.
Adolescents (ages 12 to 18 years) usually need 8 to 9 hours in a 24-hour period. Middleaged adults (ages 40 to 65 years) typically require 7 hours in a 24-hour period. Older
adults (age 65 years and older) often need 5 to 7 hours of sleep in a 24-hour period.
PTS:1DIF:EasyREF:p. 1204
KEY:Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Select the factors known to affect sleep. Choose all that
apply. 1)
Age
2)
Environment
3)
Lifestyle
4)
State of health
5)
Ethnicity
ANS: 1, 2, 3, 4
Age, environment, lifestyle, and state of health are factors affecting sleep. Many older
adults sleep less but require more rest. Alcohol, caffeine, nicotine use, and diet are
examples of lifestyle factors that affect sleep. When a person is ill, she may sleep more or
find that she cannot sleep because of pain or other factors associated with illness.
Changes in environment also affect sleep.
PTS:1DIF:EasyREF:dm 1207-1208
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Comprehension
2. A mother expresses concern that her 7-year-old has episodes of nocturnal
enuresis approximately 3 to 4 times per week. The nurses best response would be which
of the following? Choose all that apply.
1)
Your daughters bladder is still developing at this point in her life.
2)
Be patient; most children outgrow enuresis.
3)
Wake your daughter every 4 hours to use the bathroom.
4)
You might consider purchasing protective pads for the bed.
5)
Try a bed alarm to wake her when she starts wetting the bed at night.
ANS: 2, 4
Enuresis is nighttime incontinence past the stage at which toilet training has been well
established. Most incidents occur during NREM sleep when the child is difficult to
arouse. As the great majority of children outgrow enuresis, the best strategy is patience.
In the meantime, protecting the mattress from moisture and odor will help reduce
frustration and embarrassment. A bed alarm can be used for older children (typically
older than age 10 or 12) who are resistant to other behavioral strategies.
PTS:1DIF:ModerateREF:p. 1211
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
3. The patient is diagnosed with obstructive sleep apnea. Identify the symptoms
you would expect the client to exhibit. Choose all that apply.
1)
Bruxism
2)
Enuresis
3)
Daytime fatigue
4)
Snoring
5)
Drooling
ANS: 3, 4
Obstructive sleep apnea is caused by partial airway occlusion (usually by the tongue or
palate) during sleep. The patient experiences interrupted sleep as he arouses frequently to
clear the airway. As a result, the patient has episodes of snoring and daytime fatigue.
Chapter 32 Skin Integrity & Wound Healing
Identify the choice that best completes the statement or answers the question.
1. What is the function of the stratum
corneum? 1)
Provides insulation for temperature regulation
2)
Provides strength and elasticity to the skin
3)
Protects the body against the entry of pathogens
4)
Continually produces new skin cells
ANS: 3
The stratum corneum is the outermost layer of the epidermis and is composed of
numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts
water loss, prevents entry of fluids into the body, and protects the body against the entry of
pathogens and chemicals. The subcutaneous layer is composed of adipose and connective
tissue that provide insulation, protection, and an energy reserve (adipose). The dermis is
composed of irregular fibrous connective tissue that provides strength and elasticity to the
skin. The stratum germinativum is the innermost layer of the skin that produces new cells,
pushing older cells toward the skin surface.
PTS:1DIF:ModerateREF:p. 1223
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
2. Skin integrity and wound healing are compromised in the client who takes
blood pressure medications because antihypertensives:
1)
Can cause cellular toxicity.
2)
Increase the risk of ischemia. 3)
Delay wound healing.
4)
Predispose to hematoma formation.
ANS: 2
Blood pressure medications decrease the amount of pressure required to occlude blood
flow to an area, creating a risk for ischemia. Chemotherapeutic agents delay wound
healing because of their cellular toxicity. Anticoagulants can lead to extravasation of
blood into subcutaneous tissue, predisposing to hematoma formation with minimal
pressure or injury.
PTS:1DIFifficultREF:p. 1224
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
3. What is the primary difference between acute and chronic wounds?
Chronic wounds:
1)
Are full-thickness wounds, but acute wounds are superficial. 2)
Result from pressure, but acute wounds result from surgery.
3)
Are usually infected, whereas acute wounds are contaminated.
4)
Exceed the typical healing time, but acute wounds heal readily.
ANS: 4
The length of time for healing is the determining factor when classifying a wound as acute
or chronic. Acute wounds are expected to be of short duration. Wounds that exceed the
anticipated length of recovery are classified as chronic wounds.
PTS:1DIF:EasyREF:p. 1225
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
4. A patient with quadriplegia presents to the outpatient clinic with an ischial
wound that extends through the epidermis into the dermis. When documenting the depth
of the wound, how would the nurse classify it?
1)
Partial-thickness wound
2)
Penetrating wound
3)
Superficial wound
4)
Full-thickness wound
ANS: 1
Partial-thickness wounds extend through the epidermis into the dermis. Superficial
wounds involve only the epidermal layer of skin. Full-thickness wounds extend into the
subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to indicate
that the wound includes internal organs.
PTS:1DIF:EasyREF:dm 1226-1227
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
5. A patient underwent abdominal surgery for a ruptured appendix. The surgeon did
not surgically close the wound. The wound healing process described in this situation is:
1)
Primary intention healing.
2)
Secondary intention healing.
3)
Tertiary intention healing.
4)
Approximation healing.
ANS: 2
Secondary intention healing occurs when a wound is left open, and it heals from the inner
layer to the surface by filling in with beefy red granulation tissue. Primary intention
healing occurs when a wound is surgically closed. Tertiary intention healing occurs when a
wound that was previously left open to heal by secondary intention is closed by joining the
margins of granulation tissue. Approximation is another word for the joining of wound
edges.
PTS:1DIF:ModerateREF:p. 1227
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
6. When teaching a patient about the healing process of an open wound
after surgery, which of the following points would the nurse make?
1)
The patient will need to take antibiotics until the wound is completely healed.
2)
Because the patients wound was left open, the wound will likely become infected.
3)
The patient will have more scar tissue formation than for a wound closed at surgery.
4)
The patient should expect to remain hospitalized until complete wound healing occurs.
ANS: 3
Because the wound edges are not approximated, more scar tissue will form. Although open
wounds are more prone to infection, this is not an expected outcome, and antibiotics would
not necessarily be needed. A patient with an open wound should not expect an extended
hospital stay if wound care can be provided in the home or an outpatient setting.
PTS:1DIFifficultREF:p. 1227
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
7. What is the primary goal that the nurse should establish for a patient with an
open wound?
1)
The wound will remain free of infection throughout the healing process.
2)
Client completes antibiotic treatment as ordered.
3)
The wound will remain free of scar tissue at healing.
4)
Client increases caloric intake throughout the healing process.
ANS: 1
Wounds healing by secondary intention are more prone to infection; therefore, the
primary goal would be to prevent infection. Antibiotics may not be necessary, and the
nurse can expect the formation of scar tissue in this particular situation. There is no
evidence presented that the patient needs to increase caloric intake.
PTS:1DIF:ModerateREF:p. 1227
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Synthesis
8. While assessing a new wound, the nurse notes red, watery drainage. What type
of drainage will the nurse document this as?
1)
Sanguineous
2)
Serosanguineous
3)
Serous
4)
Purosanguineous
ANS: 2
Serosanguineous drainage, a combination of bloody and serous drainage, is most
commonly seen with new wounds. Serous drainage is straw colored, and sanguineous
drainage is bloody. Purosanguineous drainage is pus that is red tinged.
PTS:1DIF:EasyREF:p. 1229
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
9. Three days after a patient had abdominal surgery, the nurse notes a 4-cm
periwound erythema and swelling at the distal end of the incision. The area is tender and
warm to the touch. Staples are intact along the incision, and there is no obvious drainage.
Heart rate is 96 beats/min and oral temperature is 100.8F (38.2C). The nurse would
suspect that the patient has what kind of complication?
1)
Infection at the incisional site 2)
Dehiscence of the wound
3)
Hematoma under the skin
4)
Formation of granulation tissue
ANS: 1
Infection is a complication of wound healing that causes warmth, pain, inflammation of
the affected area, and changes in vital signs (i.e., elevated pulse and temperature).
Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of
internal organs through the rupture. A hematoma is a collection of blood that forms under
the skin. It is usually tender or painful to the touch and is usually swollen. Granulation
tissue is new connective tissue and tiny blood vessels that form on the surfaces of a
wound during the healing process. It is beefy red in appearance but would not be warm or
tender to the touch.
PTS:1DIF:ModerateREF:p. 1229
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
10. Which of the following describes the difference between dehiscence
and evisceration?
1)
With dehiscence, there is a separation of one or more layers of wound tissue; evisceration
involves the protrusion of internal viscera from the incision site.
2)
Dehiscence is an urgent complication that requires surgery as soon as possible;
evisceration is not as urgent.
3)
Dehiscence involves the protrusion of internal viscera from the incision site; with
evisceration, there is a separation of one or more layers of wound tissue.
4)
Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to
dermal tissue.
ANS: 1
With dehiscence there is a separation of one or more layers of wound tissue, whereas
evisceration involves the protrusion of internal viscera from the incision site. Evisceration
is an urgent complication usually requiring immediate surgical intervention.
PTS:1DIF:ModerateREF:dm 1229-1230
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
11. The nurse will know that the plan of care for the diabetic client with
severe peripheral neuropathy is effective if the client:
1)
begins an aggressive exercise program.
2)
follows a diet plan of 1,200 calories per day.
3)
is fitted for deep-depth diabetic footwear.
4)
remains free of foot wounds.
ANS: 4
Diabetic clients experiencing difficulty with blood sugar control are prone to the
development of peripheral neuropathy, which results in decreased sensation in the feet and
lower extremities. Decreased sensation in the feet places the client at increased risk for
development of wounds or pressure ulcers in the feet. The nurse will know his plan of care
is effective when the clients feet remain free of wounds. An aggressive exercise program
would not be appropriate for a client with severely diminished sensation in the feet.
Similarly, a 1,200-calorie diet would be inadequate for most clients. Being fitted for
diabetic footwear is an intervention rather than a goal.
PTS:1DIFifficultREF:p. 1232; higher-order item implied from text
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Synthesis
12. Pressure ulcers are directly caused by which of the following conditions at
the site?
1)
Compromised blood flow
2)
Edema
3)
Shearing forces 4)
Inadequate venous return
ANS: 1
Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area,
resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and
shear are extrinsic factors affecting skin integrity, which increases the risk of a client
developing a pressure ulcer but is not the direct cause. Inadequate arterial blood
flow to an area due to pressure causes the development of a pressure ulcer. Edema leads
to compromised skin and tissue integrity, which is more prone to pressure injury.
PTS: 1 DIF: Difficult REF: p. 1230
KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension
13. A patient hospitalized in a long-term rehabilitation facility is immobile and
requires mechanical ventilation with a tracheostomy. She has a pressure area on her
coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the
nurse identify this as?
1)
Stage II pressure ulcer
2)
Stage III pressure ulcer
3)
Stage IV pressure ulcer
4)
Unstageable pressure ulcer
ANS: 4
An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in
eschar cannot be classified using a staging method because it is impossible to determine
the depth.
PTS: 1 DIF: Moderate REF: p. 1234
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
14. A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and
now the ulcer appears to be a shallow crater involving only partial skin loss. What would
the nurse now classify the pressure ulcer as?
1)
Stage I pressure ulcer, healing
2)
Stage II pressure ulcer, healing
3)
Stage III pressure ulcer, healing
4)
Stage IV pressure ulcer, healing
ANS: 4
Reverse staging is not done because as the ulcer heals with granulation tissue and
becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced.
Pressure ulcers maintain their original staging classification throughout the healing
process but are accompanied by the modifier healing.
PTS: 1 DIF: Moderate REF: p. 1232
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
15. A patient has underlying cardiac disease and requires careful monitoring of
his fluid balance. He also has a draining wound. Which of the following methods for
evaluating his wound drainage would be most appropriate for assessing fluid loss?
1)
Draw a circle around the area of drainage on a dressing.
2)
Classify drainage as less or more than the previous drainage.
3)
Weigh the patient at the same time each day on the same scale.
4)
Weigh dressings before they are applied and after they are removed.
ANS: 4
By weighing the dressing before it is applied and after it is removed, the nurse can
accurately determine the amount of drainage. Weighing the patient daily would evaluate
his overall fluid balance but is not sensitive to fluid loss through the wound. Marking a
circle around the wound is useful for determining the extent of drainage seeping out of a
wound, but it does not provide information how much fluid is draining.
PTS:1DIF:ModerateREF:p. 1238
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Synthesis
16. A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her
left side. During the assessment, the nurse discovers a stage I pressure area on the
patients left heel. What is the initial treatment for this pressure ulcer?
1)
Antibiotic therapy for 2 weeks
2)
Normal saline irrigation of the ulcer daily
3)
Dbridement to the left heel
4)
Elevation of the left heel off the bed
ANS: 4
Pressure ulcers are caused by pressure to an area that restricts blood flow, causing
ischemia to underlying tissue. The primary treatment is to relieve the pressure, thus
improving blood flow. Elevating the patients left heel off the bed would relieve pressure
to this area.
PTS:1DIF:ModerateREF:p. 1231
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
17. Why is the information obtained from a swab culture of a wound
limited? 1)
A positive culture does not necessarily indicate infection, because chronic wounds are
often colonized with bacteria.
2)
A negative culture may not indicate infection, because chronic wounds are often
colonized with bacteria.
3)
Most wound infections are viral, so the swab culture would not be indicative of a wound
infection.
4)
A swab culture result does not include bacterial sensitivity information necessary to
provide treatment.
ANS: 1
The information obtained from a swab culture is limited because a positive culture may
not indicate infection. Chronic wounds are often colonized with bacteria, but this does
not require antibiotic treatment. A needle aspiration of the wound would provide more
definitive information about whether the wound is infected or not and can be performed
by a registered nurse. However, the most accurate wound information is obtained by
tissue biopsy performed by a specially trained provider.
PTS:1DIF:ModerateREF:p. 1242
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
18. For the client with a stage IV pressure ulcer, what would an applicable
patient goal/outcome be?
1)
Client will maintain intact skin throughout hospitalization.
2)
Client will limit pressure to wound site throughout treatment course.
3)
Wound will close with no evidence of infection within 6 weeks.
4)
Wound will improve prior to discharge as evidenced by a decrease in drainage.
ANS: 3
The goal for any wound is for healing to take place with no complications (such as
infection). Intact skin throughout hospitalization is not realistic with a stage IV pressure
ulcer. Limiting pressure to a wound site is incorrect because total pressure relief must be
provided to the area. Improved wound drainage before discharge is not a realistic
expectation for a stage IV pressure ulcer.
PTS:1DIFifficultREF:p. 1234
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Synthesis
19. A man was involved in a motor vehicle accident yesterday. He is to be sedated
for over 2 weeks while breathing with the assistance of a mechanical ventilator. Which of
the following would be an appropriate nursing diagnosis for him at this time?
1)
Risk for Infection related to subcutaneous injuries
2)
Risk for Impaired Skin Integrity related to immobility
3)
Impaired Tissue Integrity related to ventilator dependency
4)
Impaired Skin Integrity related to ventilator dependency
ANS: 2
This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated
state. Thus, he is unable to turn himself to relieve pressure. There is no mention of
subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries.
Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is
no supporting evidence for these nursing diagnoses.
PTS:1DIF:ModerateREF:dm 1235-1237
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
20. What intervention would be most appropriate for a wound with a beefy
red wound bed?
1)
Mechanical dbridement
2)
Autolytic dbridement
3)
Dressing to keep the wound moist and clean
4)
Removal of devitalized tissue and a sterile dressing
ANS: 3
A red wound indicates active healing, and the best treatment is gentle cleansing and a
dressing that will ensure a clean, moist wound environment. Dbridement is not necessary
in this situation because there is no devitalized tissue present.
PTS: 1 DIF: Moderate REF: p. 1228
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
21. A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered
with dry, yellow slough that tightly adheres to the wound. What is the best treatment the
nurse could recommend for treating this wound?
1)
Dry gauze dressing changed twice daily
2)
Nonadherent dressing with daily wound care
3)
Hydrocolloid dressing changed as needed
4)
Wet-to-dry dressings changed three times a day
ANS: 3
A hydrocolloid dressing would conform to this area and form a protective layer against
friction and bacterial invasion. It would also promote autolytic dbridement of the slough
and absorb the exudate from the autolysis. Dry gauze and nonadherent dressing (e.g.,
Telfa) would cover the wound but would not aid in removing the slough. A wet-to-dry
dressing is a form of mechanical dbridement. It would aid in removing the slough but is
nonselective; therefore, it could cause damage to healthy tissue as well.
PTS:1DIFifficultREF:dm 1233, 1251, 1277; synthesis required
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
22. The nurse would know care for a stage II pressure ulcer is achieving the
desired goal when:
1)
The ulcer is completely healed with minimal scarring.
2)
The patient reports no pain at the site.
3)
A minimal amount of drainage is noted.
4)
The wound bed contains 100% granulated tissue.
ANS: 4
A healing wound contains granulating tissue. Although pain and drainage are indicators
of inflammation, infection, and bleeding, no pain or drainage at the wound site does not
indicate proper healing is occurring. A wound can heal leaving a scar.
PTS:1DIFifficult
REF: p. 1227; higher-order item, answer can be derived from text
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
23. Your patient has a deep wound on the right hip, with tunneling at the 8 oclock
position extending 5 cm. The wound is draining large amounts of serosanguineous fluid
and contains 100% red beefy tissue in the wound bed. Of the following, which would be
an appropriate dressing choice?
1)
Alginate dressing
2)
Dry gauze dressing
3)
Hydrogel
4)
Hydrocolloid dressing
ANS: 1
Alginates are highly absorbent and are appropriate for wounds with moderate to large
amounts of drainage. They are ideal for wounds with tunneling, as they will conform to fill
the tunnel. Gauze and hydrocolloids have limited absorptive ability. Gauze could adhere to
the wound bed and cause trauma when removed. A hydrogel would increase the drainage,
with the potential of macerating surrounding skin.
PTS:1DIF:ModerateREF:p. 1250
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
24. Of the following, which is the best choice for performing wound
irrigation? 1)
Water jet irrigation
2)
35-cc syringe with a 19-gauge angiocatheter
3)
5-cc syringe with a 23-gauge needle
4)
Bulb syringe
ANS: 2
A 35-cc syringe with a 19-gauge angiocatheter is the best choice for irrigation because it
will deliver the irrigation solution at approximately 8 psi. The water jet irrigation unit and
5-cc syringe with a 23-gauge needle would deliver the solution above the recommended
pressure range of 4 to 15 psi. A bulb syringe is not an appropriate choice because there is
an increased risk of aspirating drainage from the wound.
PTS: 1 DIF: Moderate REF: p. 1246
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
25. Your patient has multiple open wounds that require treatment. When
performing dressing changes, you should:
1)
Remove all of the soiled dressings before beginning wound treatment.
2)
Cleanse wounds from most contaminated to least contaminated.
3)
Treat wounds on the patients side first, then the front and back of the patient.
4)
Irrigate wounds from least contaminated to most contaminated.
ANS: 4
To avoid the possibility of cross-contamination, the wound with the least amount of
contamination should be treated first, progressing to the wound with the most
contamination.
PTS:1DIF:ModerateREF:p. 1249
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Synthesis
26. A patient had abdominal surgery. The incision has been closed by primary
intention, and the staples are intact. To provide more support to the incision site and
decrease the risk of dehiscence, it would be appropriate to apply which of the following?
1)
Steri-Strips
2)
Abdominal binder
3)
T-binder
4)
Paper tape
ANS: 2
An abdominal binder provides added support to an incision site and decreases the risk of
wound dehiscence. A T-binder is used in the perineal area. Steri-Strips and paper tape would
not be needed for an approximated incision that has intact staples, sutures, or surgical glue.
PTS:1DIF:EasyREF:p. 1253
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
27. A patient has an area of nonblanchable erythema on his coccyx. The nurse
has determined this to be a stage I pressure ulcer. What would be the most
important treatment for this patient?
1)
Transparent film dressing
2)
Sheet hydrogel 3)
Frequent turn schedule
4)
Enzymatic dbridement
ANS: 3
The patient should be placed on a turn schedule to relieve the pressure. If pressure is not
relieved, the wound will worsen. A stage I wound is not open, so a dressing is not
warranted. Enzymatic dbridement is used to remove slough or eschar in an open wound.
A transparent film dressing would protect the area. However, the primary treatment is to
relieve the source of pressure.
PTS:1DIF:ModerateREF:p. 1244
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
28. When applying heat or cold therapy to a wound, what should the nurse
do? 1)
Leave the therapy on each area no longer than 15 minutes.
2)
Leave the therapy on each area no longer than 30 minutes.
3)
When using heat, ensure the temperature is at least 135F (57.2C) before applying it.
4)
When using cold, ensure the temperature is less than 32F (0C) before applying it.
ANS: 1
Apply heat or cold therapies intermittently, leaving them on for no more than 15 minutes
at a time in an area. This helps prevent tissue injury and also makes the therapy more
effective by preventing rebound phenomenon. Temperatures should be kept between 59F
and 113F (15C and 45C), depending on the type of therapy chosen and what is
comfortable to the patient. Temperatures colder or warmer than those recommended can
damage tissue.
PTS:1DIF:EasyREF:p. 1254
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
29. A patient has a contaminated right hip wound that requires dressing changes
twice daily. The surgeon informs the nurse that when the wound heals a little more he will
suture it closed. The nurse recognizes that the surgeon is using which form of wound
healing?
1)
Primary intention
2)
Regenerative healing
3)
Secondary intention
4)
Tertiary intention
ANS: 4
Tertiary intention is a technique used when a wound is clean contaminated or dirty
(potentially infected). Initially, the wound is allowed to heal by secondary intention, and
when there is no evidence of edema, infection, or foreign matter, granulating tissue is
brought together and the wound edges are sutured closed.
PTS:1DIF:ModerateREF:p. 1227
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
30. What is a common characteristic of aging
skin? 1)
Increased permeability to moisture 2)
Diminished sweat gland activity
3)
Reduced oxygen-free radicals
4)
Overproduction of elastin
ANS: 2
Aging skin tends to be drier. Sweat gland activity is diminished. The skins connective
tissue, collagen, and elastin are reduced, which means the skin loses firmness and so
wrinkles. Skin aging also occurs with exposure to oxygen-free radicals that are waste
products from chemical reactions in the body as well as with exposure to certain food and
environmental sources. An infants skin is thinner and more permeable to moisture in the
environment.
PTS:1DIF:ModerateREF:p. 1224
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
31. Which client does the nurse recognize as being at greatest risk for
pressure ulcers?
1)
Infant with skin excoriations in the diaper region
2)
Young adult with diabetes in skeletal traction
3)
Middle-aged adult with quadriplegia
4)
Older adult requiring use of assistive device for ambulation
ANS: 3
The client at greatest risk for pressure sores is the one with a lack of sensory perception at
the site (e.g., quadriplegia). The infant with disruption to the skin from diaper rash is at
risk for skin infection but not for a pressure sore. The young adult with diabetes is at
increased risk for delayed wound healing but not likely for a pressure sore because he
would shift weight in bed and respond to discomfort of pressure on a bony site. The older
adult is normally at risk for pressure injury, but when mobile, even with an assistive
device, the risk is minimal.
PTS:1DIF:ModerateREF:p. 1224
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
32. The nurse working in the emergency department is preparing heat therapy for
one of the patients in the unit. Which one is it most likely to be? Choose all that apply.
1)
Is actively bleeding
2)
Has swollen, tender insect bite
3)
Has just sprained her ankle
4)
Has lower back pain
ANS: 4
Heat therapy is used to relieve stiffness and discomfort commonly associated with
musculoskeletal soreness. Heat causes dilation of the blood vessels and improves delivery
of oxygen and nutrients to the tissues. It promotes relaxation and is used to aid in the
healing process. Applying heat promotes vasodilation and reduces blood thickness
(viscosity) and leaky capillaries, all of which would be harmful to the patient who is
actively bleeding. It can lead to a drop in blood pressure. Heat should not be applied to a
site with inflammation (insect bite or acute joint injury with swelling) because it can
increase edema to the site. A good application for heat therapy is to promote comfort and
relaxation to the patient experiencing back pain.
PTS:1DIF:ModerateREF:p. 1254
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Select the process(es) that occur(s) during the inflammatory phase of
wound healing. Choose all that apply.
1)
Granulation
2)
Hemostasis
3)
Epithelialization
4)
Inflammation
ANS: 2, 4
During the inflammatory phase of wound healing, hemostasis and inflammation occur.
After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site
and aggregate to stop bleeding. Together, this results in hemostasis. Inflammation follows
as a defense against infection at the wound site.
PTS: 1 DIF: Moderate REF: p. 1228
KEY:Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
2. What are two risk assessment tools used in the United States to evaluate
a patients risk for pressure ulcers? Choose all that apply.
1)
Pressure ulcer healing chart
2)
PUSH tool
3)
Braden scale
4)
Norton scale
ANS: 3, 4
The Braden scale is a tool used to predict the risk of developing a pressure sore.
Evaluation is based on six areas (indicators): sensory perception, moisture, activity,
mobility, nutrition, and friction or shear. The Norton scale is another tool used to assess the
risk for pressure ulcers based on the patients physical condition, mental state, activity,
mobility, and incontinence. These are the two most used risk assessment tools in the
United States. Both of these tools are used to identify persons at high risk of pressure ulcer
development. The PUSH tool provides a comprehensive means of reporting the
progression of a pressure ulcer. Surface area, exudate, and type of wound tissue are scored
and totaled. The Pressure Ulcer Healing Chart is part of the PUSH tool, which is used to
monitor the progression of a pressure ulcer.
PTS: 1 DIF: Moderate REF: p. 1235
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
3. Which of the following are examples of nonselective mechanical
dbridement methods? Choose all that apply.
1)
Wet-to-dry dressings
2)
Sharp dbridement
3)
Whirlpool
4)
Pulsed lavage
ANS: 1, 3, 4
Wet-to-dry dressings, sharp dbridement, and pulsed lavage are all forms of mechanical
dbridement. They are nonselective forms, which means that healthy tissue as well as
devitalized tissue can be removed with their use. Sharp dbridement is a selective form of
dbridement. With sharp dbridement, only devitalized tissue is removed.
PTS:1DIF:ModerateREF:p. 1248
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
4. Why is an accurate description of the location of a wound important? Choose
all that apply.
1)
Influences the rate of healing
2)
Determines the appropriate treatment choice
3)
Will affect the frequency of dressing changes
4)
Affects patient movement and mobility
ANS: 1, 4
Wounds in highly vascular areas heal more rapidly than wounds in less vascular regions.
Wounds that can be stabilized also heal more readily than those in areas of stress.
Treatment choices and frequency of dressing changes will be dependent on the condition
of the wound, not the location.
Chapter 33 Oxygenation
Identify the choice that best completes the statement or answers the question.
1. The nurse is providing care to a pregnant woman in preterm labor. The patient
is 32 weeks pregnant. Initially, the patient states, Ive gained 30 pounds. That should be
enough for the baby. Everything will be OK if I deliver now. After teaching the patient
about fetal development, the nurse will know her teaching is effective if the patient makes
which of the following statements?
1)
The babys lungs are well developed now, but he will be at increased risk for SIDS if I
deliver early.
2)
We should try to stop this labor now because the baby will be born with sleep apnea if I
deliver this early.
3)
If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that
can be life threatening.
4)
Thanks for reassuring me; I was pretty sure there isnt much risk to the baby this far along
in my pregnancy.
ANS: 3
Premature infants (younger than 33 weeks gestation) are born before the alveolar
surfactant system is fully developed. Therefore, they are at high risk for respiratory
distress syndrome (RDS). RDS is characterized by widespread atelectasis (collapse of
alveoli), usually related to a deficiency of surfactant that keeps air sacs open.
PTS:1DIF:ModerateREF:p. 1297
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
2. The nurse is caring for a patient who is experiencing dyspnea. Which of
the following positions would be most effective if incorporated into the patients
care? 1)
Supine
2)
Head of bed elevated 80
3)
Head of bed elevated 30
4)
Lying on left side
ANS: 2
Position affects ventilation. An upright or elevated position pulls abdominal organs
down, thus allowing maximum diaphragm excursion and lung expansion.
PTS:1DIF:EasyREF:p. 1303
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
3. While a patient is receiving hygiene care, her chest tube becomes
disconnected from the water-seal chest drainage system (CDU). Which action should
the nurse
take immediately? 1)
Clamp the chest tube close to the insertion site.
2)
Set up a new drainage system, and connect it to the chest tube.
3)
Have the patient take and hold a deep breath while the nurse reconnects the tube to the
CDU.
4)
Place the disconnected end nearest the patient into a bottle of sterile water.
ANS: 4
Recollapse of the lung can occur because of loss of negative pressure within the system.
This is commonly caused by air leaks, disconnections, or cracks in the bottles or
chambers. If any of these occur, the nurse should immediately place the disconnected end
nearest the patient into a bottle of sterile water or saline to a depth of 2 cm to serve as an
emergency water seal until a new system can be connected. Do not clamp the chest tube
because this can rapidly lead to a tension pneumothorax. A new drainage system should
be set up to decrease the risk of infection, but the immediate action is to place the
disconnected end into a bottle of sterile water.
PTS:1DIF:ModerateREF:p. 1322
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis
4. The nurse administers an antitussive/expectorant cough preparation to a
patient with bronchitis. Which of the following responses indicates to the nurse that the
medication is effective?
1)
The amount of sputum the patient expectorates decreases with each dose administered.
2)
Cough is completely suppressed, and she is able to sleep through the night.
3)
Dry, unproductive cough is reduced, but her voluntary coughing is more productive.
4)
Involuntary coughing produces large amounts of thick yellow sputum.
ANS: 3
Antitussives are cough suppressants that reduce the frequency of an involuntary, dry,
nonproductive cough. Antitussives are useful for adults when coughing is unproductive
and frequent, leading to throat irritation or interrupted sleep. Expectorants help make
coughing more productive. The goal of an antitussive/expectorant combination is to
reduce the frequency of dry, unproductive coughing while making voluntary coughing
more productive.
PTS:1DIFifficultREF:p. 1310
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
5. The nurse is admitting to the medical-surgical unit an older adult woman with a
diagnosis of pulmonary hypertension and right-sided heart failure. The patient is
complaining of shortness of breath, and the nurse observes conversational dyspnea. What
is the first action the nurse should take?
1)
Review and implement the primary care providers prescriptions for treatments.
2)
Perform a quick physical examination of breathing, circulation, and oxygenation.
3)
Gather a thorough medical history, including current symptoms, from the family.
4)
Administer oxygen to the patient through a nasal cannula.
ANS: 2
The first action the nurse should take is to make a quick assessment of the adequacy of
breathing, circulation, and oxygenation in order to determine the type of immediate
intervention required. The nurses assessment should include simple questions about
current symptoms. A more thorough medical history can be gathered once the patients
oxygenation needs are addressed. Following a quick assessment, the nurse should then
review and implement physicians orders. Administering oxygen is not appropriate
without knowing what treatments the primary care provider has prescribed.
PTS:1DIF:ModerateREF:dm 1301-1302
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
6. You are caring for a young adult patient with an intracranial hemorrhage
secondary to a closed head injury. During your assessment, you notice that the patients
respirations follow a cycle progressively increasing in depth, then progressively
decreasing in depth, followed by a period of apnea. Which of the following appropriately
describes this respiratory pattern?
1)
Biots breathing 2)
Kussmauls respirations
3)
Sleep apnea
4)
Cheyne-Stokes respirations
ANS: 4
This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with
damage to the medullary respiratory center or high intracranial pressure due to brain
injury.
PTS:1DIF:EasyREF:p. 1303
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
7. You are admitting a 54-year-old patient with chronic obstructive pulmonary
disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate
oxygen delivery method for this patient?
1)
Nonrebreather mask
2)
Nasal cannula
3)
Partial rebreather mask
4)
Venturi mask
ANS: 4
The Venturi mask is capable of delivering 24% to 50% FIO2. The cone-shaped adapter at
the base of the mask allows a precise FIO2 to be delivered. This is very useful for patients
with chronic lung disease. Rebreather masks are used when high concentrations of oxygen
are required. A nasal cannula administers oxygen in liters per minute and does not allow
administration of a precise FIO2.
PTS:1DIFifficultREF:p. 1335
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
8. Which of the following provide the most reliable data about the effectiveness
of airway suctioning?
1)
The amount, color, consistency, and odor of secretions
2)
The patients tolerance for the procedure
3)
Breath sounds, vital signs, and pulse oximetry before and after suctioning
4)
The number of suctioning passes required to clear secretions
ANS: 3
Breath sounds, vital signs, and oxygen saturation levels before and after suctioning
provide data about the effectiveness of suctioning. Information about the amount and
appearance of secretions provides data about the likelihood of airway infection and/or
inflammation. Data about the patients tolerance of suctioning provide information about
the patients overall condition. The number of suctioning passes required to clear the
secretions provides information about the amount of secretions present.
PTS: 1 DIF: Moderate REF: p. 1351
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
9. What is the rationale for wrapping petroleum gauze around a chest tube
insertion site?
1)
Prevents air from leaking around the site
2)
Prevents infection at the insertion site
3)
Absorbs drainage from the insertion site
4)
Protects the tube from becoming dislodged
ANS: 1
Petroleum gauze creates a seal around the insertion site. Collapse of the lung can occur if
there is a leak around the insertion site that causes loss of negative pressure within the
system. Air leaks are one common cause of loss of negative pressure.
PTS:1DIF:EasyREF:p. 1322
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
10. You are caring for an adult patient with a tracheostomy who is being
mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113, and
respiratory rate is 30. The patient is very restless. His respirations are labored, and you
hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the
most appropriate action to take?
1)
Call the respiratory therapist to check the ventilator settings.
2)
Provide endotracheal suctioning.
3)
Provide tracheostomy care.
4)
Notify the physician of the patients signs of fluid overload.
ANS: 2
Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds
during respiration, auscultation of adventitious breath sounds, and restlessness are signs
that indicate the need for suctioning. Airways are suctioned to remove secretions and
maintain patency. The patients symptoms should subside once the airway is cleared.
PTS: 1 DIF: Moderate REF: p. 1318, 1342
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
11. Chest percussion and postural drainage would be an appropriate intervention
for which of the following conditions?
1)
Congestive heart failure
2)
Pulmonary edema
3)
Pneumonia
4)
Pulmonary embolus
ANS: 3
Chest physiotherapy moves secretions to the large, central airways for expectoration or
suctioning. This treatment is not effective for conditions that do not involve the
development of airway secretions, including congestive heart failure, pulmonary edema,
and pulmonary embolus.
PTS:1DIF:ModerateREF:p. 1313
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
12. Which of the following blood levels normally provides the primary stimulus
for breathing?
1)
pH
2)
Oxygen
3)
Bicarbonate
4)
Carbon dioxide
ANS: 4
Carbon dioxide (CO2) level provides the primary stimulus to breathe. High CO2 levels
stimulate breathing to eliminate the excess CO2. A secondary, although important, drive
to breathe is hypoxemia. Low blood O2 levels stimulate breathing to bring more oxygen
into the lungs.
PTS:1DIF:ModerateREF:p. 1296
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
13. A 62-year-old man with emphysema says, My doctor wants me to quit
smoking. Its too late now, though; I already have lung problems. Which of the following
would be the best response to his statement?
1)
You should quit so your family does not get sick from exposure to secondhand smoke.
2)
You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in
your home.
3)
Once you stop smoking, your body will begin to repair some of the damage to your lungs. 4)
You should ask your primary care provider for a prescription for a nicotine patch to help
you quit.
ANS: 3
The nurses response should focus on correcting the patients misinformation rather than
on convincing him to stop smoking. Once a person stops smoking, the body begins to
repair the damage. During the first few days, the person will cough more as the cilia
begin to clear the airways. Then the coughing subsides, and breathing becomes easier.
Even long-time smokers can benefit from smoking cessation. The suggestions that the
patients family will become ill and that oxygen is a fire hazard appear to be scare tactics,
which can be seen as coercive, and would not be effective in motivating the patient to
stop smoking. Although asking the primary care provider for a prescription may help the
patient to stop smoking, it does not address his incorrect belief that it is too late for him to
do so.
PTS:1DIF:ModerateREF:p. 1299
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
14. The nurse administers intravenous morphine sulfate to a patient for pain
control. She will need to monitor her patient for which of the following adverse effects?
1)
Decreased heart rate
2)
Muscle weakness
3)
Decreased urine output
4)
Respiratory depression
ANS: 4
Opioids are potent respiratory depressants. Patients receiving opioids should be
monitored for decreased rate and depth of respirations.
PTS:1DIF:ModerateREF:dm 1299, 1305; critical-thinking and synthesis required
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension
15. When using sterile technique to perform tracheostomy care of a
new tracheostomy, which of the following is correct?
1)
You will need a single pair of sterile gloves.
2)
Place the patient in semi-Fowlers position, if possible.
3)
Clean the stoma under the faceplate with hydrogen peroxide.
4)
Cut a slit in sterile 4 4 gauze halfway through to make a dressing.
ANS: 2
Semi-Fowlers position promotes lung expansion and prevents back strain for the nurse.
You will need two pairs of sterile gloves: one pair for dressing removal, and a clean pair
for the rest of the procedure. You should clean the stoma under the faceplate with sterile
saline. Never cut a 4 4 gauze for the dressing because lint and fibers from the cut edge
could enter the trachea and cause respiratory distress.
PTS: 1 DIF: Easy REF: p. 1338
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
16. A patient has just had a chest tube inserted to dry-seal suction drainage.
Which of the following is a correct nursing intervention for maintenance?
1)
Keep the head of the bed flat for 6 hours.
2)
Immobilize the patients arm on the affected side.
3)
Keep the drainage system lower than the insertion site.
4)
Drain condensation into the humidifier when it collects in the tubing.
ANS: 3
The drainage system must be below the insertion site to prevent fluid flowing back into
the pleural cavity and compromising the patients respiratory status. Maintain patient in
semirecumbent position (head of bed elevated 30 to 45 degrees), not flat. This is
extremely important to promote lung expansion, reduce gastric reflux, and prevent
ventilator-associated pneumonia (VAP), if the person is being mechanically ventilated.
Patients being mechanically ventilated are at high risk for developing VAP, which is
associated with high mortality rates. Mouth rinses and mouthwashes are a part of the
recommended routine for preventing VAP. They also provide comfort and preserve
integrity of the mucous membranes. Encourage the patient to move the arm on the
affected side; if he cannot, perform passive range-of-motion. You should check the
ventilator tubing frequently for condensation, and drain the fluid into a collection device
or waste receptacle because condensation in the ventilator tubing can cause resistance to
airflow. Moreover, the patient can aspirate it if it backflows down into the endotracheal
tube. The fluid should not be drained into the humidifier because the patients secretions
may have contaminated it.
PTS: 1 DIF: Difficult REF: p. 1353
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. The nurse is counseling a 17-year-old girl on smoking cessation. The nurse
should include which of the following helpful tips in her education? Choose all that
apply.
1)
Keep healthy snacks or gum available to chew instead of smoking a cigarette.
2)
Dont tell your friends and family you are trying to quit, until you feel confident that youll
be successful.
3)
Plan a time to quit when you will not have many other demands or stressors in your life.
4)
Reward yourself with an activity you enjoy when you quit smoking.
ANS: 1, 3, 4
People who are trying to quit smoking often are more successful when they are
accountable to other people who are encouraging and supportive. Having something to
chew (e.g., carrot sticks, gum, nuts, or seeds) can distract from the desire to smoke a
cigarette. Setting a date to stop smoking and choosing a time of low stress are two
strategies that help people be more successful with smoking cessation. Self-reward for
meeting goals is a form of positive reinforcement.
PTS:1DIF:ModerateREF:p. 1311, ESG Self-Care: Smoking Cessation Tips
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:
Comprehension
2. A patient has a history of COPD. His pulse oximetry reading is 97%. What
other findings would indicate adequate tissue and organ oxygenation? Choose all that
apply.
1)
Normal urine output
2)
Strong peripheral pulses 3)
Clear breath sounds bilaterally
4)
Normal muscle strength
ANS: 1, 2, 4
To determine adequacy of tissue oxygenation, assess respiration, circulation, and tissue/
organ function. Good peripheral circulation is characterized by strong peripheral pulses.
Impaired tissue oxygenation to the kidneys would result in abnormal kidney function
(e.g., poor urine output). Hypoxic limb tissue would result in abnormal muscle
functioning (e.g., muscle weakness and pain with exercise). Adequacy of tissue
oxygenation cannot be determined by assessing pulmonary ventilation alone; circulation
must also be assessed.
PTS:1DIFifficult
REF: p. 1300; higher-order item, some of answer implied in text
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
3. The nurse is teaching a patient about her chest drainage system. Which of
the following should the nurse include in the teaching? Choose all that apply.
1)
Perform frequent coughing and deep-breathing exercises.
2)
Sit up in a chair but do not walk while the drainage system is in place.
3)
Get out of bed without assistance as much as possible.
4)
Immediately notify the nurse if she experiences increased shortness of breath.
ANS: 1, 4
Patients should regularly perform coughing and deep-breathing exercises to promote lung
reexpansion. Also to promote lung reexpansion, the nurse should encourage the patient to
be as active as her condition permits, rather than telling her not to walk. Chest drainage
systems are bulky, but patients with disposable systems can still get out of bed and
ambulate. However, the patient will need assistance from one or two staff members to
protect and monitor the system and to monitor her responses to activity; she should not get
out of bed on her own. If a patient with a chest drainage system becomes acutely short of
breath, the patient should immediately notify the nurse so the nurse can check for
occlusion of the system, which can result in a tension pneumothorax.
PTS:1DIF:ModerateREF:dm 1313, 1358
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
4. When providing safety education to the mother of a toddler, you would inform
the mother that, based on the childs developmental stage, he is at high risk for which of
the following factors that influence oxygenation? Choose all that apply.
1)
Frequent, serious respiratory infections
2)
Airway obstruction from aspiration of small objects
3)
Drowning in small amounts of water around the home
4)
Development of asthma
ANS: 2, 3
As a toddlers respiratory and immune systems mature, the risk for frequent and serious
infections is less than in infanthood. Most children recover from upper respiratory
infections without difficulty. Toddlers airways are relatively short and small and may be
easily obstructed, and they often put objects in their mouth as part of exploring their
environment, thus increasing their risk for aspiration and airway obstruction. In addition,
toddlers are at high risk for drowning in very small amounts of water around the home (e.g.,
in a bucket of water or toilet bowl). The risk for developing asthma is not significantly
influenced by the childs developmental stage.
PTS:1DIF:ModerateREF:p. 1297
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level:
Comprehension
5. Obesity is associated with higher risk for which of the following conditions
that affect the pulmonary and cardiovascular systems? Choose all that apply.
1)
Reduced alveolar-capillary gas exchange
2)
Lower respiratory tract infections
3)
Sleep apnea
4)
Hypertension
ANS: 2, 3, 4
Obesity causes multiple health problems, many of which affect the lungs, heart, and
circulation. Large abdominal fat stores press upward on the diaphragm, preventing full
chest expansion and leading to hypoventilation and dyspnea on exertion. The risk for
respiratory infection increases because lower lung segments are poorly ventilated, and
secretions are not removed effectively. When an obese person lies down, chest expansion
is limited even more. Excess neck girth and fat stores in the upper airway often lead to
obstructive sleep apnea. Obesity also increases the risk of developing atherosclerosis and
hypertension. Obesity does not cause reduced alveolar-capillary gas exchange.
PTS: 1 DIF: Easy REF: p. 1299
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension
6. Which of the following is/are accurate about nasotracheal suctioning? Choose
all that apply.
1)
Apply suction for no longer than 10-15 sec during a single pass.
2)
Apply suction while inserting and removing the catheter.
3)
Reapply oxygen between suctioning passes for ventilator patients.
4)
Gently rotate the suction catheter as you remove it.
ANS: 1, 4
Limiting suctioning to 10 seconds or less and reapplying oxygen between suctioning
passes prevent hypoxia. Suction should be applied only while withdrawing the catheter,
using a continuous rotating motion to prevent trauma to the airway. Endotracheal
suctioning is used when the patient is being mechanically ventilated, and most ventilator
patients have in-line suctioning, so there is no need to reapply oxygen.
PTS: 1 DIF: Moderate REF: p. 1347
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
7. Which of the following factors influence normal lung volumes and
capacities? Choose all that apply.
1)
Age
2)
Race
3)
Body size
4)
Activity level
ANS: 1, 3, 4
Normal lung volumes and capacities vary with body size, age, and exercise level.
Volumes and capacities are higher in men, in large people, and in athletes. Race does not
influence normal lung volumes and capacities.
PTS:1DIF:EasyREF:p. 1305
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
8. Of the following interventions, which is/are likely to reduce the risk
of postoperative atelectasis? Choose all that apply.
1)
Administer bronchodilators.
2)
Apply low-flow oxygen.
3)
Encourage coughing and deep breathing.
4)
Administer pain medication.
ANS: 3, 4
Pain alters the rate and depth of respirations. Often, patients in pain breathe shallowly,
which puts them at risk for atelectasis. Regularly assess all patients for pain. Once you
have medicated the patient, reassess breath sounds, and encourage the patient to cough and
breathe deeply. This will help to open air sacs and mobilize secretions in the airways. PTS:
1 DIF: Moderate REF: dm 1303, 1313 ; critical-thinking item that requires synthesis of
information
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Synthesis
Completion
Complete each statement.
is the movement of air into and out of the lungs through the act of breathing.
1.
refers to the exchange of gases (oxygen and carbon dioxide) in the lungs.
ANS: Ventilation; Respiration
Pulmonary ventilation (breathing) is the movement of air into and out of the lungs.
Oxygenation of the blood, and ultimately of organs and tissues, depends on adequate
ventilation. Respiration refers to gas exchangethat is, the oxygenation of blood and
elimination of carbon dioxide in the lungs. Although the plural form respirations is used
to mean breaths when taking vital signs, this is a misnomer: You cannot measure gas
exchange by counting breaths per minute.
PTS:1DIF:EasyREF:p. 1295
KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension
production, which
2.Prolonged use of high oxygen concentrations reduces
leads to alveolar collapse and reduced lung elasticity.
ANS: surfactant
Oxygen toxicity can develop when oxygen concentrations of more than 50% are
administered for longer than 48 to 72 hours.
PTS:1DIF:ModerateREF:p. 1314
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall
3.The amount of air moved into and out of the lungs with each normal breath is known as
. Normally, this volume is around
mL.
the
ANS: tidal volume; 500
PTS:1DIF:EasyREF:p. 1306
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension
True or False
1. A positive TB skin test indicates that a patient has active tuberculosis.
ANS: F
Patients with positive TB skin tests must undergo further testing (chest x-ray and sputum
cultures) to determine whether they have merely been exposed to the tuberculosis bacillus
or whether they have active disease.
Chapter 34 Circulation
Identify the choice that best completes the statement or answers the question.
1. A patient diagnosed with hypertension is taking an angiotensin-converting
enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be
appropriate for the patient?
1)
BP will be lower than 135/85 mm Hg on all occasions.
2)
BP will be normal after 2 to 3 weeks on medication.
3)
Patient will not experience dizziness on rising.
4)
Urine output will increase to at least 50 mL/hr
ANS: 1
Goals must be clearly stated so that it is easy to evaluate if they have been met. BP . . .
lower than 135/85 mm Hg . . . is clearly stated and easily evaluated. In contrast, BP will
be normal . . . does not clearly state the desired endpoint. Freedom from dizziness on
rising is probably not achievable because ACE inhibitors are vasodilating agents, which
may cause vessel dilation and hypotension, especially when the patient arises from a
seated or lying position. Patients should be warned of this effect. The expected/desired
effect of the ACE inhibitor is to lower the blood pressure; the urine output is minimally
relevant in determining that outcome, if at all.
PTS: 1 DIF: Difficult REF: dm 1372-1373
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
2. You are preparing the nursing care plan for a middle-aged patient admitted to
the intensive care unit for an acute myocardial infarction (heart attack). His symptoms
include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of
the following nursing diagnoses is most appropriate?
1)
Decreased Cardiac Output
2)
Impaired Tissue Perfusion
3)
Impaired Cardiac Contractility
4)
Impaired Activity Tolerance
ANS: 1
The patients symptoms reflect altered cardiac preload, a component of cardiac output.
Acute myocardial infarction is often associated with decreased cardiac output as a result
of altered cardiac pumping ability. Although the other nursing diagnoses might be
associated with Decreased Cardiac Output, these diagnoses cannot be determined from
the symptoms presented. Additionally, Impaired Cardiac Contractility is not a NANDA-I
nursing diagnosis.
PTS: 1 DIF: Difficult REF: p. 1372
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
3. You are to connect a patient to a cardiac monitor. Which of the following
actions should you take to ensure an accurate electrocardiogram tracing?
1)
Select electrode placement sites over bony prominences.
2)
Apply the electrodes immediately after cleansing the skin, before the alcohol evaporates.
3)
Before applying the electrodes, rub the placement sites with gauze until the skin reddens.
4)
Ensure that the gel on the back of the electrodes is dry.
ANS: 3
Electrodes should be placed over soft tissues or close to bone in order to obtain accurate
waveforms. Sites over bony prominences, thick muscles, and skinfolds can produce
artifact; therefore, they should not be used. Alcohol removes skin oils that may prevent
the electrodes from adhering. However, the alcohol should be allowed to dry before the
electrodes are placed. Rubbing the skin with gauze or a washcloth removes dead skin
cells and promotes better electrical contact. A dry electrode will not conduct electrical
activity; gel should not be dry.
PTS: 1 DIF: Moderate REF: p. 1377
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
4. Chronic stress may lead directly to cardiovascular disease because of the
repeated release of which of the following?
1)
Histamine
2)
Catecholamines
3)
Cortisol
4)
Protease
ANS: 2
The stress response stimulates release of catecholamines from the sympathetic nervous
system. This results in increased heart rate and contractility, vasoconstriction, and
increased tendency of blood to clot. Cortisol is also released in the stress response, but it
is more indirectly related to development of cardiovascular disease through altered
glucose, fat, and protein metabolism.
PTS: 1 DIF: Moderate REF: p. 1365
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall
5. The nurse is teaching a pregnant woman about the increased oxygen demand that
develops during pregnancy. The nurse knows the patient comprehends the teaching when
she makes the following statement:
1)
I may need to drink more fluids in order to make more oxygen.
2)
I may need to take an iron supplement so that I am not anemic.
3)
I will need a multivitamin supplement for several months.
4)
I will need to eat more fruits and vegetables.
ANS: 2
During pregnancy, oxygen demand increases dramatically. To compensate, the mothers
blood volume increases by 30%. The woman requires additional iron to produce this blood
as well as to meet fetal requirements. Failure to meet these iron demands can result in
maternal anemia, reducing tissue oxygenation of the mother.
PTS: 1 DIF: Moderate REF: p. 1365-1366
KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application
6. Which part of the ECG tracing represents ventricular
repolarization? 1)
P wave 2)
QRS complex
3)
T wave
4)
U wave
ANS: 2
The QRS complex represents ventricular depolarization and leads to ventricular
contraction. The P wave represents the firing of the SA node and conduction of the
impulse through the atria. In the healthy heart, this leads to atrial contraction. The T
wave represents the return of the ventricles to an electrical resting state so they can be
stimulated again (ventricular repolarization). The atria also repolarize, but they do so
during the time of ventricular depolarization; thus, they are obscured by the QRS
complex and cannot be seen on the ECG complex. The U wave is not always seen on the
ECG but may be detected with electrolyte imbalance, such as hypokalemia or
hypercalcemia. U waves sometimes occur in response to certain medication (e.g.,
digitalis, epinephrine). Inverted U wave may occur with ischemia to the cardiac muscle.
1)
PTS: 1 DIF: Moderate REF: dm 1371-1372
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall
7. Three days ago a patient had cardiac surgery to bypass three occlusions of his
coronary arteries. Veins for the bypass were harvested from his right leg. He informs the
nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound
erythema and swelling at the distal end of the incision. Staples are intact along the
incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the
patient has what kind of complication?
1)
Deep vein thrombosis
2)
Dehiscence of the wound
3)
Internal bleeding
4)
Infection at the incisional site
ANS: 1
Deep vein thrombosis (DVT) is a clot in the veins that are deep under the muscles of the
leg. DVT can occur after surgery, after lengthy bedrest, or after trauma. Symptoms include
pain, warmth, redness, and swelling of the leg. Dorsiflexion of the foot (pulling toes
forward) and Pratts sign (squeezing calf to trigger pain) have not been found to be reliable
in diagnosing DVT. Dehiscence is the rupture of a suture line, whereas evisceration is the
protrusion of internal organs through the rupture. Internal bleeding is a wound-healing
complication associated with hematoma formation, pain, hypotension, and tachycardia.
Infection is a complication of wound healing that causes warmth, pain, inflammation of
the affected area, and changes in vital signs (i.e., elevated pulse and temperature).
PTS: 1 DIF: Moderate REF: dm 1367-1368
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Nursing interventions to reduce the risk of clot formation in the legs
include which of the following activities? Choose all that apply.
1)
Keep the patients hips and knees flexed while the patient is in bed.
2)
Apply compression devices (e.g., sequential compression devices).
3)
Turn the patient frequently or encourage frequent position changes. 4)
Promote adequate hydration by encouraging oral intake.
ANS: 2, 3, 4
A
Antiembolism stockings and SCDs are frequently used in perioperative patients to
promote venous return and prevent clot formation. Turn patients frequently; teach
patients to change positions frequently. This prevents vessel injury from prolonged
pressure in one position. Promote adequate hydration to keep the blood from becoming
viscous (thick). Viscous blood clots more readily.
PTS: 1 DIF: Difficult REF: p. 1373
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
2. Which of the following medications would you expect to be included in
the treatment of a patient with congestive heart failure? Choose all that apply.
1)
Nitrates
2)
Beta-adrenergic agents
3)
Diuretics
4)
Anticoagulants
ANS: 2, 3
Beta-adrenergic agents block stimulation of beta receptors in the heart, lungs, and blood
vessels and decrease heart rate, slow conduction through the AV node, and decrease
myocardial oxygen demand by reducing myocardial contractility. Diuretics increase
removal of sodium and water from the body through increased urine output. Diuretics
reduce the volume of circulating blood and prevent accumulation of fluid in the
pulmonary circulation.
PTS: 1 DIF: Moderate REF: dm 1373-1374
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
3. As the nurse caring for a patient who has suffered a myocardial infarction
that has damaged the sinoatrial (SA) node, you should plan to monitor for which of
the following potential complications? Choose all that apply.
1)
Decreased heart rate
2)
Increased heart rate
3)
Decreased cardiac output
4)
Decreased strength of ventricular contractions
ANS: 1, 3
Normally, the SA node is the primary pacemaker for the heart and initiates a rate of 60 to
100 beats per minute. If the SA node fails, the atrioventricular node can take over as the
pacemaker, but it generally triggers a slower heart rate. Cardiac output will decrease as a
result of the decrease in heart rate. Damage to the SA node interferes with the electrical
activity of the heart but does not directly affect the pumping action of the heart.
PTS: 1 DIF: Difficult REF: dm 1362-1363
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
4. Which outcome statement is related to Decreased Cardiac Output? Choose
all that apply.
1)
No dyspnea or shortness of breath with exertion
2)
Normal skin color
3)
Respiratory rate less than 16 breaths/min
4)
Brisk capillary refill
ANS: 1, 2, 4
Individualized goals/outcome statements depend on nursing diagnoses you identify for
the patient. However, for a patient with compromised cardiac output, you might plan
goals, such as no shortness of breath with exertion, brisk capillary refill in nailbeds, and
normal skin color with no pallor. Respiratory rate of less than 16 breaths/min is
hypoventilation and can lead to poor oxygenation and tissue acidosis.
PTS: 1 DIF: Moderate REF: p. 1367
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
5. Your client is a healthy, older adult who has come to the health clinic because
she reports not feeling like herself. When you are gathering data in your clients health
history, she tells you that she is feeling more fatigue when walking up stairs and doing
her normal household activities. What normal physiologic changes in the cardiovascular
system occur with aging? Choose all that apply.
1)
Cardiac contractile strength is reduced.
2)
Heart valves become more rigid.
3)
Peripheral vessels lose elasticity.
4)
Heart responds to increased oxygen demands.
ANS: 1, 2, 3
Cardiac efficiency gradually declines as the heart muscle loses contractile strength and
heart valves become thicker and more rigid. The peripheral vessels become less elastic,
which creates more resistance to ejection of blood from the heart. As a result of these
changes, the heart becomes less able to respond to increased oxygen demands, and it
needs longer recovery times after responding.
PTS: 1 DIF: Moderate REF: p. 1365
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
True or False
Complete each statement.
1.Nicotine increases the risk for thrombus (blood clot) formation.
ANS: T
Nicotine increases the risk for thrombus formation because of its constricting effects on
blood vessel walls.
PTS: 1 DIF: Easy REF: p. 1373
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension
2.A troponin level is a laboratory test performed to determine how well the cells, tissues,
and organs are supplied with oxygen.
ANS: F
Troponin is a serum evaluation used to detect myocardial infarction (MI). Levels of these
contractile proteins remain elevated for up to 7 days after MI. Organ function indirectly
evaluates the extent to which oxygen demands have been met in the cells, organs, and
tissues.
Chapter 35 Hydration & Homeostasis
Identify the choice that best completes the statement or answers the question.
1. Which body fluid lies in the spaces between the body
cells? 1)
Interstitial
2)
Intracellular
3)
Intravascular
4)
Transcellular
ANS: 1
Extracellular fluid lies outside the cells. It is composed of three types of fluid: interstitial,
intravascular, and transcellular. Interstitial fluid lies in the spaces between the body cells.
Intracellular fluid is contained within the cells. Intravascular fluid is the plasma within the
blood. Transcellular fluid includes specialized fluids, such as cerebrospinal, pleural,
peritoneal, and synovial; and digestive juices.
PTS:1DIF:EasyREF:p. 1383
KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall
2. Chloride, bicarbonate, phosphate, and sulfate are examples of what type
of charged particles and why?
1)
Cations, because they carry a positive charge
2)
Cations, because they carry a negative charge
3)
Anions, because they carry a positive charge
4)
Anions, because they carry a negative charge
ANS: 4
Anions are electrolytes that carry a negative charge; they include chloride, bicarbonate,
phosphate, and sulfate. Electrolytes that carry a positive charge are called cations.
Cations include sodium, potassium, calcium, and magnesium.
PTS:1DIF:ModerateREF:p. 1383
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension
3. A patient is brought to the emergency department (ED) by paramedics after a
person standing on the sidewalk saw him fall on a crowded street. He has a history of
alcoholism and is frequently brought to the ED. The nurse finds the patient to be
disoriented; he has periods of being calm mixed with episodes of being disruptive and
loud. His vital signs are the following: BP 138/84 mm Hg; pulse 135 beats/min, regular
and strong; respiratory rate 22 breaths/min; temperature 37.1C (98.1F). What electrolyte
imbalance might the nurse suspect?
1)
Hypomagnesemia
2)
Hypocalcemia
3)
Hyperkalemia
4)
Hypernatremia
ANS: 1
Hypomagnesemia is a frequent consequence of alcoholism. Signs and symptoms include
disorientation, mood changes, and tachycardia. Hypocalcemia, a low calcium level, is
associated with muscle spasms and tetany. Hyperkalemia, a high potassium level,
manifests as weakness, fatigue, and cardiac dysrhythmias. Hypernatremia, a high sodium
level, produces extreme thirst and agitation.
PTS:1DIFifficultREF:p. 1392
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
4. The passive process by which molecules of a solute move through a cell
membrane from an area of higher concentration to an area of lower concentration is
called which of the following?
1)
Osmosis
2)
Filtration
3)
Hydrostatic pressure
4)
Diffusion
ANS: 4
Diffusion is a passive process by which molecules move from an area of higher
concentration to an area of lower concentration. Osmosis is the movement of water across
a membrane from an area of a less-concentrated solution to an area of more-concentrated
solution. Filtration is the movement of water and smaller particles from an area of high
pressure to low pressure. Hydrostatic pressure is the force created by fluid within a closed
system.
PTS: 1 DIF: Moderate REF: p. 1384
KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall
5. A client is admitted to the emergency department (ED) in respiratory distress.
The results of his arterial blood gases are the following: pH = 7.30; PCO2 = 40; HCO3 =
19 mEq/L; PO2 = 80. The nurse interprets the findings as which of the following?
1)
Respiratory acidosis with normal oxygen levels
2)
Respiratory alkalosis with hypoxia
3)
Metabolic acidosis with normal oxygen levels
4)
Metabolic alkalosis with hypoxia
ANS: 3
The pH is acidotic. The HCO3 of 19 mEq/L is low and has moved in the same direction
as the pH, indicating a metabolic disorder. The PCO2 is within normal range with no
signs of compensation. The PO2 level is normal.
PTS: 1 DIF: Difficult REF: dm 1393-1395
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
6. A patient is admitted to the emergency department (ED) in respiratory distress.
The results of his first arterial blood gases were: pH = 7.30; PCO2 = 40; HCO3 = 19
mEq/L; PO2 = 80. The nurse evaluates the patients treatment plan by examining repeat
arterial blood gases (ABGs). The results are: pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/L.
The nurse concludes which of the following?
1)
Respiratory acidosis; the treatment plan is ineffective.
2)
Metabolic alkalosis; the treatment plan is effective.
3)
Partial compensation; the treatment plan is ineffective.
4)
Full compensation; the treatment plan is effective.
ANS: 4
Full compensation has occurred as the PCO2 has returned the pH to the normal range. This
change indicates that the treatment plan is effective. Partial compensation would be
indicated by changes in the PCO2, but the pH would still be outside the normal range.
The ABG is now complete compensation metabolic acidosis.
PTS: 1 DIF: Difficult REF: dm 1393-1395
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis
7. When a patient has metabolic acidosis, which body system influences the
acidbase imbalance to produce the compensatory changes in the arterial blood gases?
1)
Respiratory system
2)
Renal system
3)
Vascular system
4)
Neurological system
ANS: 1
In a metabolic problem, the respiratory system compensates. In a respiratory problem, the
renal system must compensate. The respiratory system compensates early in the disorder,
but it may take up to 3 days for the renal system to compensate fully.
PTS:1DIF:ModerateREF:p. 1394
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis
8. A patients arterial blood gas results are as follows: pH = 7.30; PCO2 = 40; HCO3
= 19 mEq/L; PO2 = 80. An appropriate nursing diagnosis for the patient is which of the
following?
1)
Impaired Gas Exchange
2)
Metabolic Acidosis
3)
Risk for Impaired Gas Exchange
4)
Risk for Acid-Base Imbalance
ANS: 1
An appropriate diagnosis is Impaired Gas Exchange. The arterial blood gas (ABG) results
provide the defining characteristics for Impaired Gas Exchange. The ABG results
demonstrate metabolic acidosis; however, this is not a nursing diagnosis. The patient has
an actual problem; therefore, the risk for nursing diagnoses are incorrect. Additionally,
there is no nursing diagnosis of AcidBase Imbalance or Risk for AcidBase Imbalance.
PTS:1DIF:ModerateREF:p. 1401
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
9. The nurse is caring for a patient with a medical diagnosis of hypernatremia.
The following prescriptions are written in the clients electronic health record. Which one
should the nurse question?
1)
Administer an IV of D5W at 125 mL/hr.
2)
Strict I&O monitoring. 3)
Restrict oral intake to 900 mL every 24 hr.
4)
Monitor serum electrolytes every 4 hr.
ANS: 3
Restricting the oral intake of a patient with hypernatremia (Na+ greater than 145 mEq/L)
would lead to further elevation in the serum sodium level. Infusing D5W IV fluid is
appropriate, as this solution does not contain sodium. Hydrating the patient with D5W
would reduce the serum sodium level. Strict I&O monitoring and laboratory evaluation of
electrolytes every 4 hr would ensure that the patient is safely rehydrated.
PTS:1DIFifficultREF:p. 1391
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
10. Which process requires energy to maintain the unique composition
of extracellular and intracellular compartments?
1)
Diffusion
2)
Osmosis
3)
Filtration
4)
Active transport
ANS: 4
Active transport occurs when molecules move across cell membranes from an area of low
concentration to an area of high concentration. Active transport requires energy
expenditure for the movement to occur against a concentration gradient. In the presence of
ATP, the sodiumpotassium pump actively moves sodium from the cell into the
extracellular fluid. Active transport is vital for maintaining the unique composition of both
the extracellular and intracellular compartments. Diffusion, osmosis, and filtration are
passive processes.
PTS: 1 DIF: Difficult REF: p. 1385
KEY:Nursing process: N/A | Client need: PHSI| Cognitive level: Comprehension
11. The nurse records a patients hourly urine output from an indwelling catheter
as follows:
0700: 36 mL
0800: 45 mL
0900: 85 mL
1000: 62 mL
1100: 50 mL
1200: 48 mL
1300: 94 mL
1400: 78 mL
1500: 60 mL
The nurse can conclude that the patients urine output should be described as which of the
following?
1)
Low
2)
Within normal limits
3)
High
4)
Inconclusive
ANS: 2
Urine accounts for the greatest amount of fluid loss. Normal urine output for an averagesized adult is approximately 1,500 mL in 24 hr. Urine output varies according to intake
and activity but should remain at least 30 to 50 mL per hour. The patients urine output is
within the normal range. This patient has an indwelling catheter, which will result in
continual flow of urine.
PTS:1DIF:ModerateREF:p. 1385
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis
12. Which of the following is the principal site for regulation of fluid
and electrolyte balance?
1)
Cardiac system 2)
Vascular system
3)
Pulmonary system 4)
Renal system
ANS: 4
A balance of fluid and electrolytes is essential to maintain homeostasis. Excesses or
deficits can lead to severe disorders. The kidneys are the principal regulator of fluid and
electrolyte balance and are the primary source of fluid output. Specific hormones (e.g.,
ADH, aldosterone) cause the kidneys to regulate the bodys fluid and electrolyte balance.
The heart and vascular system are involved in fluid balance but not in electrolyte balance
and not as dramatically in fluid balance as are the kidneysthat is, they do not actually
regulate electrolytes. The pulmonary system plays a major role in regulation of acidbase
balance.
PTS:1DIF:EasyREF:p. 1386
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension
13. Which electrolyte is the primary regulator of fluid
volume? 1)
Potassium
2)
Calcium
3)
Sodium
4)
Magnesium
ANS: 3
Sodium is the major cation in the extracellular fluid (ECF). Its primary function is to
regulate fluid volume. When sodium is reabsorbed in the kidney, water and potassium are
also reabsorbed, thereby maintaining ECF volume. Potassium is a key electrolyte in
cellular metabolism. Calcium is responsible for bone health and neuromuscular and
cardiac functions. It is also an essential factor in blood clotting. Magnesium is a mineral
used in more than 300 biochemical reactions in the body.
PTS:1DIF:EasyREF:p. 1386
KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall
14. An 82-year-old woman was brought to the emergency department by her
granddaughter. She is a widow and lives alone, although her granddaughter checks on her
daily. She has been vomiting for 2 days and has not been able to eat or drink anything
during this time. She has not urinated for 12 hours. Physical examination reveals the
following: T = 99.6F (37.6C) orally; P = 110 beats/min weak and thready; BP = 80/52 mm
Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The
patient states that she feels very weak. The following are her laboratory results:
Sodium 138
mEq/L
Potassium
3.7 mEq/L
Calcium
9.2 mg/dL
Magnesium
1.8 mg/dL
Chloride
99 mEq/L
BUN
29 mg/dL
The nurse recognizes that the patient is displaying symptoms associated with which of
the following?
1)
Hypovolemia
2)
Hypervolemia
3)
Hypernatremia
4)
Hyponatremia
ANS: 1
Hypovolemia may occur as a result of insufficient intake of fluid; bleeding; excessive loss
through urine, skin, or the gastrointestinal tract; insensible losses; or loss of fluid into a
third space. The first symptom of hypovolemia is thirst. Other symptoms are a rapid weak
pulse, a low blood pressure (although initially the blood pressure may rise), dry skin and
mucous membranes, decreased skin turgor, and decreased urine output.
Temperature increases because the body is less able to cool itself through perspiration. The
person with fluid volume deficit usually has elevated BUN (blood urea nitrogen) and
hematocrit levels. Hypervolemia involves excessive retention of sodium and water in the
extracellular fluid, and the vital sign changes are opposite those of a patient with
hypovolemia. Hypernatremia and hyponatremia are not applicable because the patients
sodium level is within normal range.
PTS:1DIFifficultREF:p. 1390
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
15. A patient has been vomiting for 2 days and has not been able to eat or drink
anything during this time. She has not urinated for 12 hours. Physical examination reveals
the following: T = 99.6F (37.6C) orally; P = 110 beats/min weak and thready; BP
= 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin
turgor. The patient states that she feels very weak. The following are her laboratory
results:
Sodium 138
mEq/L
Potassium
3.7 mEq/L
Calcium
9.2 mg/dL
Magnesium
1.8 mg/dL
Chloride 99
mEq/L
BUN
29 mg/dL
Which of the following is an appropriate nursing diagnosis for this patient?
1)
Impaired Gas Exchange related to ineffective breathing
2)
Excess Fluid Volume related to limited fluid output
3)
Deficient Fluid Volume related to abnormal fluid loss
4)
Electrolyte Imbalance related to decreased oral intake
ANS: 3
Vomiting has made this patient hypovolemic; therefore, she has deficient fluid volume.
There is no information to indicate that she has respiratory problems or Impaired Gas
Exchange. Her symptoms are not consistent with Excess Fluid Volume. Electrolyte
Imbalance is not a nursing diagnosis.
PTS:1DIFifficultREF:p. 1400
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
16. Which of the following is the most appropriate goal for a patient with
the nursing diagnosis of Deficient Fluid Volume?
1)
Electrolyte balance restored, as evidenced by improved levels of alertness and cognitive
orientation
2)
Electrolyte balance restored, as evidenced by sodium returning to normal range
3)
Patient demonstrates effective coughing and deep breathing techniques.
4)
Maintains fluid balance, as evidenced by moist mucous membranes and urinating every 4
hours
ANS: 4
Moist mucous membranes and urinating every 4 hours would demonstrate restoration of
fluid balance. Electrolyte imbalance does not necessarily occur with Deficient Fluid
Volume; if electrolyte imbalance were present, the nursing diagnosis would be different.
There is no evidence that this patient has a respiratory problem, so coughing and deep
breathing are irrelevant.
PTS:1DIF:ModerateREF:p. 1401
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
17. Which laboratory results on a clients health record should alert the nurse to
a potential problem?
1)
Na+ = 137 mEq/L
2)
K+ = 5.2 mEq/L 3)
Ca2+ = 9.2 mg/dL 4)
Mg2+ = 1.8 mg/dL
ANS: 2
A potassium level of 5.2 mEq/L indicates hyperkalemia. The other results are all within
normal ranges.
PTS:1DIF:ModerateREF:p. 1386
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension
18. A patients vital signs prior to a blood transfusion were: T = 97.6F (36.4C); P =
72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the
transfusion was begun, the patient began complaining of feeling itchy and hot. The nurse
discovered a rash on the patients trunk. Vital signs were: T = 100.8F (38.2C); P = 82 beats/
min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the
priority intervention?
1)
Administer an antihistamine (anti-allergenic) medication.
2)
Flush the blood tubing with D5W immediately.
3)
Prepare for emergency resuscitation.
4)
Stop the blood transfusion immediately.
ANS: 4
The nurse should suspect a transfusion reaction. When a transfusion reaction is suspected,
the infusion should be stopped immediately. The blood bag and tubing must be sent to the
laboratory for analysis. A new IV line of normal saline should be hung.
Diphenhydramine (an antihistamine) may be ordered once the physician has been notified
of the patients condition. There is no information indicating that the patient is in danger of
cardiovascular collapse or requires resuscitation.
PTS: 1 DIF: Moderate REF: p. 1417
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
19. A patient is receiving an IV infusion of lactated Ringers solution and 40 mEq
of KCl at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and
warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient
is complaining of pain at the site. The nurse would recognize these findings to be
consistent with which of the following?
1)
Infiltration
2)
Extravasation
3)
Hematoma
4)
Phlebitis
ANS: 4
Phlebitis is an inflammation of the vein. It may be caused by the infusion of solutions that
are irritating to the vein. Patients receiving IV solutions with potassium chloride are at a
higher risk for phlebitis, as it is irritating to the vein. The symptom of a palpable cord
along the vein distinguishes this as phlebitis. Infiltration presents as erythema, pain, and
swelling. However, there is no palpable cord with inflammation. Extravasation is
infiltration of a vesicant substance into the tissues. Differentiating symptoms include
blanching and coolness of the surrounding skin; the formation of blisters and subsequent
tissue sloughing and necrosis are later signs. A hematoma is a localized mass of blood
outside the blood vessel. This is generally seen when a vein is nicked during an
unsuccessful insertion of an IV line or when an IV line is discontinued without pressure
applied over the site.
PTS:1DIFifficultREF:p. 1412
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
20. The nurse assesses that her patients intravenous solution has infiltrated into
the tissues. What action should she take first?
1)
Aspirate, then inject 0.5 mL normal saline.
2)
Restart the IV line in a different vein.
3)
Stop the infusion immediately.
4)
Notify the primary care provider.
ANS: 3
The nurse should first stop the infusion to avoid further tissue trauma. Because the IV has
infiltrated, you must assume that the nurse has already checked the patency of the line by
aspirating. There is no point in injecting saline because doing so puts even more fluid in
the tissues. Injecting fluid to try to clear a clot from the catheter is not recommended
because of the possibility of causing an embolism. Once the infusion is stopped, the nurse
must assess whether the patient needs additional IV therapy. If so, a new IV line must be
restarted above the site of infiltration or in the opposite arm. The nurse may need to inform
the primary care provider if she is unable to find a new IV site or if she believes the patient
no longer needs an IV.
PTS:1DIF:ModerateREF:p. 1411
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
21. The physician has ordered a complete blood count for a 6-year-old child.
When the nurse enters the room, she finds the child sobbing uncontrollably. His mother
tells him to shut up and act your age. How should the nurse proceed?
1)
Request that the mother leave the room immediately.
2)
Request the help of a coworker to hold the child down.
3)
Inform the child that this wont hurt a bit.
4)
Calmly approach the child and tell him what is going to happen.
ANS: 4
Having blood drawn may be uncomfortable and frightening for a 6-year-old child. A
calm approach can alleviate some of the fear. Explain to the childs mother that the boys
behavior is normal. Informing the child that the blood draw will not hurt is wrong and
will make him distrustful of future interventions. The nurse may need the help of a
coworker, but she should first try a calm approach.
PTS: 1 DIF: Moderate REF: p. 1399; not found in text; critical thinking required KEY:
Nursing process: Interventions | Client need: PSI | Cognitive level: Application
22. A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be
infused over 2 hours. A microdrip infusion set is being used. What is the drip rate (drops/
min) that the nurse should monitor?
1)
60
2)
75
3)
125
4)
250
ANS: 3
Calculate the drip rate by multiplying the number of milliliters to be infused per hour
(hourly rate) by the drop factor in drops/mL, divided by 60 minutes. An infusion of 250
mL in 2 hours results in an hourly rate of 125 mL/hr.
125 (mL/hr) 60 (drops/mL) = 125 drops/min
60 min
PTS:1DIF:ModerateREF:p. 1410
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
23. The nurse examines the electrocardiogram (ECG) tracing of a client and
notes tall T waves. What electrolyte imbalance should the nurse suspect?
1)
Hypokalemia
2)
Hypophosphatemia
3)
Hyperkalemia
4)
Hypercalcemia
ANS: 3
Potassium levels affect the heart. A tall, peaked T wave on an ECG is associated with
hyperkalemia. A flat T wave is associated with hypokalemia. Phosphorous levels do not
trigger ECG changes.
PTS:1DIF:ModerateREF:p. 1391
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:
Comprehension
24. The nurse gathers the following data: BP = 150/94 mm Hg; neck veins
distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37C
(98.6F). What disorder should the nurse suspect?
1)
Hypovolemia
2)
Hypercalcemia
3)
Hyperkalemia
4)
Hypervolemia
ANS: 4
Hypervolemia results from retention of sodium and water. Blood pressure rises, the pulse
is bounding, and neck veins become distended due to increased intravascular volume.
PTS:1DIF:ModerateREF:p. 1390
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application
25. A patient has a continuous IV infusion at 60 mL/hr. The right hand IV has
infiltrated and the nurse has started a new IV on the left forearm. Which of the following
interventions should the nurse also perform?
1)
Elevate the patients left forearm.
2)
Schedule daily dressing changes to the new IV site.
3)
Change the administration set.
4)
Place the patient in Fowlers position.
ANS: 3
Reusing an IV set from a previous site increases the risk of contamination. IV dressings
are usually changed every 72 to 96 hours when the IV site is rotated. There is no reason
to elevate the patients left forearm or to place him in Fowlers position.
PTS:1DIF:EasyREF:p. 1414
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
26. When performing a central venous catheter dressing change, which of
the following steps is/are correct?
1)
Wear sterile gloves while removing and discarding the soiled dressing.
2)
Apply pressure on the catheter-hub junction when removing the soiled dressing.
3)
Place a sterile transparent dressing over the site and the catheter-hub junction.
4)
Have the patient wear a mask or turn his head away from the site.
ANS: 4
Aseptic technique should be used with approaching the insertion site. Therefore, both
nurse and patient should wear a mask. If the patient cannot wear a mask, have him turn his
head away from the insertion site during the procedure. Sterile gloves should be worn
when placing the new sterile dressing; however, procedure gloves are used to remove the
soiled dressing. The nurse should stabilize the catheter while removing the soiled dressing
but not apply pressure to the catheter-hub junction. The transparent dressing
should cover the hub of the catheter, but not the catheter-hub junction; this makes it too
difficult to remove without disturbing the integrity of the IV line or the site.
PTS: 1 DIF: Difficult REF: p. 1432
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. In a healthy adult, which of the following regulate(s) body fluids? Choose all
that apply.
1)
Hormone levels
2)
Fluid intake 3)
Oxygen saturation
4)
Kidney function
ANS: 1, 2, 4
A balance between fluid intake and output is essential to maintain homeostasis. Excesses
or deficits of intake can lead to severe disorders. The kidneys are the principal regulator of
fluid and electrolyte balance and are the primary source of fluid output. Specific hormones
(e.g., ADH, aldosterone) cause the kidneys to regulate the bodys fluid and electrolyte
balance. Oxygen saturation does not regulate fluids. It measures the saturation of oxygen
on hemoglobin and is influenced by the partial pressure of oxygen, alveolararterial
gradient lung disease, and the amount and type of hemoglobin (such as sickle cell
anemia).
PTS:1DIF:ModerateREF:dm 1385-1386
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension
2. A patient has been admitted to the nursing unit with a diagnosis of chronic
renal failure. She will be dialyzed for the first time the following morning. Which of the
following are appropriate nursing interventions for the patient? Choose all that apply.
1)
Encourage oral fluid intake as desired.
2)
Place the patient on strict I&O.
3)
Weigh the patient before and after dialysis. 4)
Maintain a total fluid restriction of 1,000 mL as prescribed.
ANS: 2, 3, 4
Fluids are restricted in patients with chronic renal failure because of decreased renal
function. Therefore, encouraging oral fluids would not be appropriate. Appropriate
nursing interventions for this patient include monitoring the intake and output, weighing
the patient before and after dialysis, following a strict renal diet, and monitoring
laboratory values.
PTS:1DIF:ModerateREF:p. 1391-1393, 1402; critical thinking required
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
3. Identify the mechanism(s) involved in acidbase balance. Choose all that
apply. 1)
Respiratory mechanisms 2)
Active transport mechanisms
3)
Renal mechanisms
4)
Buffer systems
ANS: 1, 3, 4
Acidbase balance is regulated by respiratory mechanisms, renal mechanisms, and buffer
systems. Acidbase regulation can be monitored by examining arterial blood gases,
especially blood pH. Buffer systems prevent wide swings in pH by absorbing or releasing
free hydrogen ions. The lungs (respiratory mechanisms) control the carbonic acid supply
via carbon dioxide. Conditions that cause retention of carbon dioxide, such as chronic
obstruction pulmonary disease, lower the pH, whereas tachypneic conditions, such as
hyperventilation syndrome, blow off carbon dioxide and increase the pH. The kidneys
(renal mechanisms) regulate the concentration of plasma bicarbonate. By reabsorbing or
excreting bicarbonate, the kidneys affect acidbase balance. Active transport involves the
movement of fluids and electrolytes in the body.
PTS:1DIF:ModerateREF:p. 1389
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension
4. Identify the appropriate intervention(s) for a patient with hypovolemia.
Choose all that apply.
1)
Teach deep-breathing techniques.
2)
Monitor I&O daily.
3)
Encourage fluid intake.
4)
Monitor electrolyte balance.
ANS: 2, 3, 4
Hypovolemia occurs when more fluid is lost than is taken into the body. Monitoring I&O
provides information to evaluate the status of the problem. Encouraging fluid intake helps
to correct the problem. It is good to monitor electrolytes because electrolyte imbalance can
occur with hypovolemia (although it may not occur at first). Deep-breathing
techniques do not address fluid balance; there is no evidence that the patient has a
respiratory disorder.
PTS:1DIF:EasyREF:p. 1390
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
5. A patients blood group is B. The nurse knows the patient can receive blood only
from donors with what group(s) of blood? Choose all that apply.
1) A
2) B
3) O
4 )
AB
ANS: 2, 3
Persons with blood group B can receive blood only from the blood groups B and O. Those
with blood group AB may receive AB, A, B, and O blood. Blood group A persons may
receive blood from A and O donors. Persons with blood group O may receive blood only
from O donors. Blood group AB persons are considered universal recipients, and blood
group O persons are considered universal donors.
PTS:1DIF:ModerateREF:p. 1416
KEY: Nursing process: Analysis/Diagnosis | Client need: SECE | Cognitive level:
Analysis
6. A nurse is caring for a patient with a peripheral IV line located in the right
forearm. The patient informs the nurse that the IV site is burning. Upon assessment the
nurse determines that the IV solution has infiltrated. What site(s) is/are appropriate to
consider when restarting the IV line? Choose all that apply.
1)
Left hand
2)
Right wrist
3)
Right antecubital area
4)
Right saphenous vein
ANS: 1, 3
When restarting an IV line after an infiltration, you must restart above the site of
infiltration. As a result, the right antecubital area is correct. The opposite extremity (e.g.,
left hand) may also be used. The right saphenous vein is incorrect because that vein is
located in the leg. The leg should be used as a last resort for an IV site. The primary care
provider should be notified if a leg is being considered as an IV site.
PTS:1DIFifficultREF:p. 1414
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
7. A patient has been diagnosed with hypovolemia. Which order(s) for
hydration should the nurse question? Choose all prescriptions that should be
questioned.
1)
0.9% (normal) saline at 100 mL/hr
2)
Lactated Ringers solution at 100 mL/hr
3)
Total parenteral nutrition solution at 100 mL/hr
4)
D5W solution at 100 mL/hr
ANS: 3, 4
Hypovolemia occurs when there is a proportional loss of water and electrolytes from the
ECF. Lactated Ringers and 0.9% (normal) saline are isotonic fluids that remain inside the
intravascular space, thus increasing volume. The D5W is a hypotonic solution that would
pull body water from the intravascular compartment into the interstitial fluid compartment.
Total parenteral nutrition is a hypertonic fluid used to provide nutrition for the patient who
cannot meet caloric needs by eating or enteral nutrition.
Chapter 36 Caring for the Surgical Patient
Identify the choice that best completes the statement or answers the question.
1. The preoperative phase encompasses which period of
time? 1)
Entry to the operating suite until admission to postanesthesia care
2)
Entry into the operating suite until discharge from the hospital
3)
The decision to have surgery until admission to postanesthesia care
4)
The decision to have surgery until entry to the operating suite
ANS: 4
The preoperative phase begins with the decision to have surgery and ends when the patient
enters the operating room. The intraoperative phase begins when the patient enters the
operating suite and ends when the patient is admitted to the postanesthesia care unit.
PTS:1DIF:EasyREF:p 1448
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
2. A 2-year-old child is scheduled for a tonsillectomy. When determining the
plan of care, the nurse should:
1)
Include the parents or caregivers in the plan of care.
2)
Explain to the child that she will have a sore throat after surgery.
3)
Tell the child that she can have her favorite foods for the first 24 hours after surgery.
4)
Prepare the child for discharge from the hospital as soon as she is alert.
ANS: 1
It is developmentally normal for toddlers to experience anxiety with separation from
parents or caregivers. Be sure to include these people in the plan of care.
Developmentally, a 2-year-old lives in the here and now and wouldnt grasp an intangible
concept, such as pain in the future. The toddler would take liquids and soft foods within
the first 24 hours when her throat is sore during swallowing. She should not eat foods that
are rough and crunchy because they may scratch her throat and cause bleeding. After a
tonsillectomy, the child will need to be monitored for bleeding and stable vital signs;
therefore, she will not be discharged as soon as she is alert.
PTS: 1 DIF: Moderate REF: dm 1449, 1455
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Synthesis
3. Which of the following is the most appropriate nursing goal for a 2-year-old
who is to have a tonsillectomy?
1)
Separation anxiety will be minimal.
2)
The child will verbalize understanding of expected pain.
3)
The child will tolerate a normal diet 24 hours after surgery.
4)
The parent will indicate readiness to assume the childs care.
ANS: 1
The only concrete information in this question is that the child is 2 years old. Therefore,
the only problem the nurse can reasonably predict from this would be developmental in
nature. It is developmentally normal for toddlers to experience anxiety with separation
from parents or caregivers. Minimizing anxiety by involving the parents or caregivers
would be the appropriate goal for separation anxiety. A 2-year-old child would not be
expected to verbalize understanding of expected pain. The toddler would take liquids and
soft foods within the first 24 hours when her throat is sore during swallowing. She should
not eat foods that are rough and crunchy because they may scratch her throat and cause
bleeding. Nurses should encourage parental involvement, but parents should not be
expected to assume the childs care.
PTS:1DIFifficult
REF: p. 1449; critical-thinking question requiring synthesis of previously learned
knowledge
KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application
4. The focus of nursing activities in the preoperative phase is
to: 1)
Admit the patient to the surgical suite.
2)
Prepare the patient mentally and physically for surgery.
3)
Set up the sterile field in the operating room.
4)
Perform the primary surgical scrub to the surgical site.
ANS: 2
The nursing focus in the preoperative phase is to prepare the patient mentally and
physically for surgery. The patient is in the intraoperative phase when admitted to the
surgical suite. The sterile field and the surgical scrub would be performed in the surgery
suite during the intraoperative phase.
PTS:1DIF:EasyREF:p. 1451
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
5. A patient is scheduled for abdominal surgery tomorrow. While gathering
preoperative data, the nurse learns that the patient takes the following medications daily:
an anticoagulant, a multivitamin, and vitamin E 1,500 IU. The patient reports that he
stopped taking the anticoagulant 4 days ago as instructed by the surgeon. He has
continued to take the multivitamin and vitamin E. Based on the information given, the
nurse notifies the surgeon because she:
1)
Needs an order to restart the anticoagulant.
2)
Is concerned about continued use of the multivitamin. 3)
Is concerned about the vitamin E dosage.
4)
Has canceled the surgery so more lab tests can be done.
ANS: 3
Both prescribed and over-the-counter medications may increase surgical risk. Many herbs
can cause potassium loss and increase the risk for cardiac arrhythmias. High doses of
vitamin E may increase the risk for bleeding. This patients use of 1,500 IU of vitamin E
daily exceeds the recommended dosage, so the nurse should inform the surgeon of the
vitamin E intake. Generally, the surgeon or anesthesiologist instructs patients to continue
or discontinue taking their prescribed medicines. However, it is important to assess use of
supplements and over-the-counter medicines. The nurse cannot cancel surgery without an
order from the surgeon, who determines whether the surgery should be delayed or whether
it is so urgent that it needs to continue as scheduled, even with the additional risk factor of
the vitamin E dosage.
PTS:1DIFifficultREF:p. 1450
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
6. A patient is admitted for hip surgery. The patient usually takes the following
medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. He stopped
taking his anticoagulant 4 days ago as instructed by his surgeon, but has continued to take
the multivitamin and vitamin E. An important problem for this patient is which of the
following?
1)
Potential complication: anemia
2)
Risk for infection related to inadequate anticoagulant dosage 3)
Risk for noncompliance related to inability to follow instructions
4)
Risk for bleeding
ANS: 4
The patient is at an increased risk for bleeding due to his intake of vitamin E. He may be
at risk for anemia if he experiences a large blood loss in surgery; however, this problem
is not appropriate before he experiences the blood loss. This patient does not have a
higher-than-average risk for infection because he is not having surgery involving a
contaminated system (e.g., the gastrointestinal system). There is no evidence to suggest
that this patient is noncompliant simply because he stopped taking his anticoagulant as
ordered.
PTS:1DIFifficultREF:p. 1450
KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis
7. A patient is admitted from a local skilled nursing facility to the outpatient
surgery center for surgical dbridement of a stage IV sacral pressure ulcer. The
perioperative nurse discovers that the patient does not have a signed consent form for the
surgery on the chart or in the surgery center. The patient says that she has not talked to the
surgeon and that she has many questions regarding her surgery. When informed of this, the
surgeon tells the nurse to have the patient sign the informed consent form, and he will
review it prior to the surgery. What should the nurse do?
1)
Follow the surgeons orders, and ask the patient to sign the surgical consent form.
2)
Inform the surgeon that she will have the patient sign after he discusses the surgery with
the patient.
3)
Ensure that the signed surgical consent is witnessed by two nurses, because the surgeon is
not available.
4)
Cancel the surgery and transfer the patient back to the long-term care facility.
ANS: 2
Informed surgical consent requires that the surgeon present information about the surgery
to the patient, that the patient understands the information and agrees to the surgery, and
that the patient has not been coerced to give consent. As a patient advocate, the nurse
should verify with the patient that the surgeon has explained the procedure and answered
all her questions. The surgeon is responsible for giving the patient the necessary
information and determining the patients competence to make an informed decision about
the surgery. If the patient has further questions, the nurse should notify the surgeon and
delay sending the patient to surgery until an informed consent is obtained.
PTS:1DIFifficultREF:p. 1455, 1458
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
8. Identify the type of surgery a terminally ill patient will undergo if the purpose
is removal of tissue to relieve pain.
1)
Procurement
2)
Ablative
3)
Palliative
4)
Diagnostic
ANS: 3
Palliative surgery alleviates discomfort or other disease symptoms without producing a
cure. Procurement surgery occurs when an organ or tissue is harvested for transplantation
into another. Ablative surgery involves removal of a body part. Diagnostic surgery
confirms or negates a diagnosis.
PTS:1DIF:EasyREF:p. 1449
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
9. A patient had a hiatal hernia repair earlier today and is now in the postanesthesia
care unit (PACU). The family asks the nurse why the patient is in the PACU rather than
back in his room on the postsurgical unit. The nurse should inform the family that:
1)
Patients who have had surgical complications are observed in the PACU until they are
stable enough to return to the floor.
2)
Patients recover from the effects of anesthesia in the PACU and then return to the
postsurgical unit for further care.
3)
The PACU is a holding area for patients awaiting a surgical unit bed or awaiting adequate
staff to provide care on the postsurgical unit.
4)
The nurse will ask the surgeon explain to them why the patient is not on the postsurgical
unit, as is the usual procedure.
ANS: 2
A client remains in the PACU until he has recovered from the effects of anesthesia. In the
PACU, the client is assessed every 5 to 15 minutes in order to quickly identify surgical or
anesthesia-related problems. Most surgical units routinely admit patients to the PACU for
a period of observation. Admission to the PACU does not indicate surgical complications
or imply that a holding area is required. There is no reason the surgeon would need to
explain this to the family, as the nurse could communicate the procedure. It is not usual
procedure for a patient to be transferred directly from surgery to the postsurgical unit.
PTS:1DIF:ModerateREF:p. 1471
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
10. The focus of nursing care in the intraoperative phase is
to: 1)
Prepare the patient for surgery.
2)
Maintain the sterile field.
3)
Ensure patient safety during the surgery.
4)
Obtain a signed informed consent.
ANS: 3
The intraoperative phase begins when the patient enters the operating suite and ends
when the patient is admitted to the postanesthesia care unit. The nursing focus is to
ensure patient safety during the surgical procedure by functioning as an advocate when
clients cannot advocate for themselves and by monitoring the client and surgical
environment throughout the procedure. Although the sterile field must be maintained in
this phase and sterility contributes to patient safety, the focus of care is broader than the
maintenance of sterility. Obtaining informed consent and preparing the patient for
surgery are activities associated with the preoperative phase.
PTS:1DIF:EasyREF:p. 1463
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension
11. The nurse has a prescription to give a series of medications on an on call
basis. The nurse realizes that these medications will be given:
1)
In the postanesthesia recovery unit.
2)
At the time specified in the order.
3)
On the patients arrival in the surgery suite.
4)
When the OR staff notify the nurse to do so.
ANS: 4
The anesthesia team may order medications to be given on call if the surgery time is likely
to vary. The nurse will give on call medications when he is notified to do so by the OR
staff.
PTS:1DIF:EasyREF:p. 1460
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
12. A patient has chronic confusion secondary to dementia. As a result, he is
unable to sign an informed consent for surgery. In this situation:
1)
An informed consent is not needed.
2)
Two nurses may sign the informed consent for the patient.
3)
The surgeon must sign the informed consent.
4)
A family member will be asked to sign the informed consent.
ANS: 4
In most states, a family member, conservator, or legal guardian may give consent for a
procedure if a patient is not capable of giving an informed consent or if the patient is a
minor.
PTS:1DIF:ModerateREF:p. 1458
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
13. The patient tells the nurse, Im so nervous. I want to be knocked out for the
surgery so that I dont know what is going on. When the nurse communicates with the
surgeon and anesthetist, she tells them that the patient desires which type of anesthesia?
1)
Conscious sedation
2)
General anesthesia
3)
Local anesthesia 4)
Regional anesthesia
ANS: 2
General anesthesia produces rapid unconsciousness and loss of sensation. During
conscious sedation, the client feels sleepy but is easily aroused by touch or speech.
Regional anesthesia interrupts nerve impulses to and from the affected area, but the
patient remains alert. Local anesthesia produces loss of pain sensation at the desired site
and is typically used for minor procedures. The client remains alert during local
anesthesia.
PTS:1DIF:EasyREF:p. 1464
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
14. A patient is to have a sequential compression device (SCD) applied on the
postoperative unit. The patient is wearing knee-high elastic (antiembolism) stockings.
When applying the SCD, what should the nurse do?
1)
Remove the antiembolism stockings and not replace them.
2)
Replace the knee-high stockings with thigh-high stockings.
3)
Notify the surgeon that the patient is wearing antiembolism stockings.
4)
Apply the SCD over the knee-high antiembolism stockings.
ANS: 4
If elastic stockings have been ordered with the sequential compression device, leave them
in place; if the patient is not yet wearing them, obtain them and put them on the patient.
Knee-high stockings do not need to be replaced with thigh-high stockings. Some research
has shown knee-high stockings to be equally effective. There is no need to notify the
surgeon, as patients commonly return from surgery wearing antiembolism stockings, as
prescribed.
PTS: 1 DIF: Moderate REF: p. 1490
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Surgeries are commonly classified by which of the following? Choose all
that apply.
1)
Acuity
2)
Level of urgency
3)
Length of surgery
4)
Organ involved
ANS: 1, 2
Surgeries can be classified by body systems, purpose, level of urgency, and degree of
seriousness (acuity). The length of surgery and organ involved are not used for
classifying surgeries.
PTS:1DIF:ModerateREF:p. 1449
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis
2. Which of the following describes the Perioperative Nursing Data Set? Choose
all that apply.
1)
A standardized tool for assessing high-risk surgical patients
2)
A standardized vocabulary encompassing all surgical patient outcomes
3)
The first specialized nursing language recognized by the ANA
4)
A standardized language designed to describe the care of perioperative patients
ANS: 3, 4
The Perioperative Nursing Data Set (PNDS) is a standardized vocabulary specifically
designed to describe the care of perioperative clients. It consists of 74 nursing diagnoses,
133 nursing interventions, and 28 nurse-sensitive patient outcomes appropriate for use in
any surgical setting. It was the first specialty language recognized by the ANA.
PTS:1DIFifficultREF:p. 1451
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
3. The nurse is caring for a patient who had abdominal surgery 3 days ago and
will be discharged home later today. The nurse will know that teaching is effective if the
patient does which of the following? Choose all that apply.
1)
Describes clinical findings associated with infection
2)
Performs the dressing change as prescribed
3)
Demonstrates absence of surgical incision pain
4)
Completes the regimen of prescribed antibiotics
ANS: 1, 2, 4
The nurse would know that patient teaching was effective if the patient verbalizes signs
and symptoms of infection, can perform the ordered dressing change, and completes the
regimen of ordered antibiotics. Nurses cannot teach a patient to be free of pain. Pain is
subjective. The nurse can teach the patient strategies to assist with pain, but they may not
remove the pain completely.
PTS:1DIF:ModerateREF:p. 1481
KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application
4. Which of the following members of the operative team use sterile
technique during the surgical procedure? Choose all that apply.
1)
Surgeon
2)
Anesthetist
3)
Scrub nurse
4)
Registered nurse first assistant
ANS: 1, 3, 4
The anesthetist is a member of the clean team and remains outside the sterile field.
Members of the sterile team include the surgeon, the scrub nurse, and the registered first
nurse assistant.
PTS:1DIF:ModerateREF:p. 1463
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall
5. A young adult woman is scheduled for a bilateral breast reduction under
general anesthesia. She is normally healthy and takes no daily medications. Identify the
preoperative screening tests appropriate for this patient. Choose all that apply.
1)
Urinalysis
2)
EKG
3)
Creatinine clearance
4)
CBC
ANS:1, 4
Preoperative screening tests are ordered to determine if the client has undetected
underlying health concerns. Most institutions require a complete blood count (CBC) and
urinalysis prior to all surgical procedures. Generally, an electrocardiograph (ECG) is
ordered for clients over the age of 50 years or with known cardiac disease. A creatinine
clearance is not a routine presurgical screening test.
PTS: 1 DIF: Moderate REF: dm 1451, 1454
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
6. Identify the desired effects of general anesthesia. Choose all that
apply. 1)
Reduction of risk
2)
Analgesia
3)
Amnesia
4)
Muscle relaxation
ANS: 2, 3, 4
General anesthesia is used to control pain (analgesia), relax muscles, and promote
amnesia. Anesthesia is not used for the purpose of obtaining a reduction in risk potential;
however, surgical risk is influenced by the type of anesthesia used.
PTS: 1 DIF: Moderate REF: p. 1464
KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension
7. The preoperative nurse is preparing a patient for surgery. Identify
the interventions the nurse will perform. Choose all that apply.
1)
Inform the family to wait in the surgical waiting room.
2)
Prepare the surgical suite for the operation.
3)
Remove the patients dentures and contact lenses.
4)
Assist the patient to complete a living will.
ANS: 1, 3
Before being transported to the operating suite, the patient must remove all artificial body
parts, such as dentures, artificial limbs, or contact lenses. Wigs, eyeglasses, makeup, and
jewelry must also be removed. The nurse will also inform the patients relatives where they
may wait during the surgery. The surgical suite will be prepared by the surgical team. It is
not necessary to have a living will prior to surgery. However, the nurse will ask the patient
if there is one when obtaining the nursing history.
PTS:1DIF:ModerateREF:p. 1459
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
8. A patient had a colon resection for removal of a cancerous tumor.
Postoperatively, on the surgical floor which of the following activities would the nurse
perform for the purpose of decreasing the risk of postoperative complications? Choose all
that apply.
1)
Assist the patient to turn, breathe deeply, and cough every 2 hours.
2)
Teach the patient about the type of tumor removed. 3)
Assess the drainage from the surgical site.
4)
Monitor vital signs on a regular basis.
ANS: 1, 3, 4
The nurse assists the patient to turn, breathe deeply, and cough every 2 hours in order to
decrease the risk of postoperative atelectasis or pneumonia. The nurse assesses the wound
drainage to monitor for signs of bleeding, infection, or wound complications. Vital signs
are monitored to detect the potential for infection or hemorrhage, not to prevent them.
The nurse may teach the patient about cancerous tumors; however, this intervention will
not decrease the risk of postoperative complications.
PTS:1DIF:ModerateREF:p. 1472
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
9. A patient returns from surgery with a nasogastric tube and intermittent gastric
suction to provide abdominal decompression. Which of the following are correct nursing
activities for managing the equipment and drainage? Choose all that apply.
1)
Wear nonsterile procedure gloves when emptying the drainage container.
2)
When irrigating the nasogastric tube, use sterile water.
3)
Wear sterile gloves when irrigating the nasogastric tube.
4)
Apply water-soluble lubricant if the patients lips are dry.
ANS: 1, 4
Nonsterile procedure gloves are to protect the nurse and other patients against
microorganisms that might be present in body fluids; wearing them is in observance of
standard precautions. For patients with an NG tube, frequent oral care, including watersoluble lubricant for dry lips, is important. Sterile gloves are not needed for irrigating the
NG tube because the nasal passages, esophagus, and stomach are not sterile. Sterile
normal saline and a sterile syringe are used for irrigation, however. Sterile water is not
used; saline compensates for electrolytes lost through NG drainage.
Chapter 39 Leading & Managing
Identify the choice that best completes the statement or answers the question.
1. Theories that focus on what the leader does are
called: 1)
Trait theories.
2)
Behavioral theories.
3)
Situational theories.
4)
Transformational theories.
ANS: 2
Behavioral theories are concerned with what a leader does, whereas trait theories are
concerned with what a leader is. Situational theories recognize that each situation is
different and that leaders must consider a number of factors when deciding how to take
action. Transformational theories focus on the ability of the leader to communicate her
vision in such a way that it inspires commitment among workers.
PTS:1DIF:ModerateREF:p. 3
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
2. At a recent nurse staff meeting, the chief nursing officer (CNO) announced
that all nursing staff would work 12-hour shifts on a daynight rotation schedule that
would alternate every 6 weeks. The CNO announced that she made this decision as a
means to solve discord between the day- and night-shift nurses. She explained that this
plan will allow the staff to experience the work on each shift and to appreciate the
various job responsibilities on each shift. What type of leadership is the CNO
displaying?
1)
Management
2)
Laissez-faire
3)
Democratic
4)
Authoritarian
ANS: 4
The authoritarian leader makes decisions for the group as a whole, gives orders, and bears
most of the responsibility for the outcomes. A laissez-faire leader postpones making
decisions or may never make a decision at all. Thus, laissez-faire leadership is really a lack
of leadership. A democratic leader shares the planning, decision making, and responsibility
for outcomes with other members of the group. This type of leader tends to provide
guidance rather than control. There is no leadership style called management.
PTS:1DIF:ModerateREF:p. 3
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:
Application
3. A graduate nurse completed her nursing education 3 weeks ago and has just
begun work at the local hospital. She is orienting to her new position with an experienced
nurse, one who has been an RN for 15 years and an employee at the hospital for 7 years.
She will provide guidance and practical teaching to the new graduate as she assumes a
new position in the nursing unit. What role is the experienced RN assuming?
1)
Mentor
2)
Manager
3)
Preceptor
4)
Leader
ANS: 3
A preceptor is someone with more experience who provides practical teaching and
guidance for a student or new employee. In contrast, a mentor is someone more
experienced who provides career development information and serves as a role model. A
manager is an employee of an organization who has the power, authority, and
responsibility for planning, organizing, coordinating, and directing the work of others. A
leader is someone who has the ability to influence others and commit them to action.
PTS:1DIF:ModerateREF:p. 7
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:
Application
4. What is the first stage of the complex process of
change? 1)
Recognizing resistance
2)
Unfreezing
3)
Forming a comfort zone
4)
Actively resisting
ANS: 2
The first stage in the change process is unfreezing. In this stage, the person leaves the
stable comfort zone that has existed and begins to make changes. Recognizing resistance
and actively resisting are activities associated with change, but they are not the first stage
of the process.
PTS:1DIF:ModerateREF:p. 13
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
5. Within the past month, there has been a change in the nursing documentation
requirements at the hospital. The nurses have been trained in the new requirements and are
documenting as requested, with the exception of one nurse. This nurse has been unable to
attend any of the documentation in-service meetings and has been too busy to attend a
private training session with the nurse manager. Meanwhile, she continues to use the old
documentation process. What do the nurses actions illustrate?
1)
Unfreezing
2)
Active resistance
3)
Passive resistance
4)
Comfort zone
ANS: 3
Passive resistance behaviors include avoidance; canceling appointments to discuss
implementing change; being too busy to make the change; agreeing to the change but
doing nothing to change; and simply ignoring the entire process as much as possible. In
the above situation, the nurse is not actively refusing to comply with the new
documentation requirements; however, her actions are a passive approach to resisting
change. When a person knows what to expect and how to deal with whatever problems
arise in the course of a day, that person is operating within her comfort zone. The first
stage in the change process is when the person begins moving out of the comfort zone,
unfreezing. This nurse is resisting, not unfreezing.
PTS:1DIF:ModerateREF:p. 13
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
6. The surgical unit is experiencing difficulty recruiting new RNs, although the
hospital has an excellent reputation in the community and has no difficulty recruiting
nurses for other units. A task force has been formed, consisting of one nurse from each
shift on the unit, the unit manager, and the hospital nurse recruiter. The group has
gathered data and identified the problem. What is the next step in this process?
1)
Generate possible solutions.
2)
Evaluate whether the problem has been resolved.
3)
Implement the solution changes.
4)
Evaluate suggested solutions.
ANS: 1
The next step in the process is to generate possible solutions. Once several possibilities
have been identified, each of the suggested solutions should be evaluated. From among
that list, the best solution is chosen and then implemented. Finally, the task force
critiques the process by evaluating whether the problem has been resolved.
PTS:1DIFifficultREF:dm 15-16
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
7. A nurse with 2 years experience frequently appears stressed and has difficulty
completing his work. He is clocking out 30 to 45 minutes late every day, even when his
assignment load is light. The charge nurse describes his problem as running from one
duty to the next and having no organization or daily routine. Which situation most likely
describes this nurse?
1)
Has time management problems
2)
Has a heavy patient load
3)
Works at a hospital that is understaffed
4)
Is in a management position
ANS: 1
This nurse most likely has trouble managing his time. Time management entails setting
your own goals and organizing your work. Although there will be difficult days, the nurse
who consistently finishes late and has no organization to his daily schedule has a problem
managing time. Time management includes efficiently meeting clients care needs during
a nursing shift and organizing ones workload.
PTS:1DIF:EasyREF:dm 16-17
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
8. An expert nurse feels confident in her role as a clinician on the unit. The
nurse enjoys her work and feels in charge of her career. Which leadership state is she
experiencing?
1)
Power-based authority
2)
Effective management skills
3)
Empowerment in her role
4)
Followership skills
ANS: 3
Empowerment is a psychological state, a feeling of competence, control, and entitlement
that a person experiences. Empowerment refers to feelings, whereas power refers to action.
The person who feels empowered has feelings of self-determination, meaning,
competence, and impact. This nurse may have power on the unit because of her expertise,
but there is no evidence that she is an authority figure. Empowerment is not always
associated with management. Managers have authority by virtue of their position but do
not always thrive in that role. There is not enough information in the scenario to judge the
nurses followership skills.
PTS:1DIFifficultREF:p. 10
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
9. The physical therapy department and the nursing department at a local
rehabilitation hospital are in conflict over which department is responsible for
transporting patients to and from therapy appointments. The members of the therapy
department state they do not have sufficient time to come to the nursing unit to pick up
the patients and that patients often are not ready to be transported. Nursing staff members
state that they do not have the time to transport the patients from the unit and this leaves a
shortage of nursing personnel on the floor. Managers from both departments have
attempted to resolve the conflict with input from nursing and therapy staff members. All
attempts at conflict resolution have failed. What is the next step the managers should
take?
1)
Inform the nurses that they must take the patients to and from therapy.
2)
Inform the therapists that they must take the patients to and from therapy.
3)
Ask the hospital administrator to make an unbiased decision.
4)
Begin informal negotiation between the two departments.
ANS: 4
One of a managers responsibilities is to function as an informal negotiator when a
resolution to conflict cannot be reached.
PTS:1DIF:ModerateREF:dm 15-16
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
10. The manager is conducting an informal negotiation between two staff members
who have had ongoing difficulty working together peacefully. Most recently there was an
argument about who would be scheduled for first lunch each day. At this stage of the
informal negotiation, the manager is focusing on managing the emotions and setting the
ground rules. Which stage does this demonstrate?
1)
Setting the stage
2)
Conducting the negotiation
3)
Making offers and counteroffers 4)
Agreeing on resolution of the conflict
ANS: 2
The manager has begun conducting informal negotiation. This includes managing the
emotions, setting ground rules, and clarifying the problem. The first step of conflict
resolution is introspective and is similar to data gathering. The negotiator thinks, What am
I trying to achieve? What problems am I likely to encounter? The next step, setting the
stage, may involve confronting the two parties with their behavior toward one another and
making direct statements designed to open communication and challenge them to seek
resolution of the situation. After conducting the negotiation, the parties move to making
offers and counteroffers, and then to agreeing on the resolution of the conflict.
PTS:1DIF:ModerateREF:p. 16
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:
Application
11. A nurse observes a nursing assistant (NAP) fail to wash her hands before and
after placing a patient on a bedpan. When giving negative feedback to the NAP, the nurse
should:
1)
Be certain to offer constructive criticism about the task and do so in private.
2)
Ask the unit manager to be present to document responses of both parties.
3)
Call a meeting of all NAPs and stress hand washing to the entire group.
4)
Keep a record of the NAPs actions and save them for her annual formal review.
ANS: 1
It is important to provide negative feedback in private. It is not necessary for the nurse
manager to be present because staff nurses are responsible for delegating to and
supervision of NAPs. The nurse should not call a meeting. It would be a waste of time for
those who are already washing their hands properly, and it dilutes the effect of the
feedback to the NAP who is not washing her hands. She might think, Oh, everybody does
it; no big deal. It is important to allow some time every day for timely feedback. This
allows the worker to know what she is doing right and wrong, and allows her to make
corrective actions. The nurse should not allow this NAP to continue with her hand washing
errors until her annual formal review because this can pose a threat to patient safety and
increase the risk of transmitting infectious microbes.
PTS: 1 DIF: Moderate REF: dm 7-8
KEY: Nursing process: Implementation | Client need: SECE | Cognitive level:
Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which of the following are characteristics of an effective nurse manager?
Choose all that apply.
1)
Clinical expertise
2)
Business sense
3)
Masters degree 4)
Leadership skills
ANS: 1, 2, 4
An effective nurse manager possesses a combination of qualities: leadership skills,
clinical expertise, and business sense. It is the combination of all these that prepares a
person for the complex task of managing a group or team of healthcare providers. The
extent of education that a person has does not determine her effectiveness as a manager.
PTS:1DIF:ModerateREF:p. 5
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
2. Which of the following activities is/are involved when delegating tasks to
other members of the nursing team? Choose all that apply.
1)
Supervising patient care that is given
2)
Determining the skill mix of unit personnel
3)
Assessing the needs of the clients involved
4)
Deciding which tasks to assign to a team member
ANS: 1, 2, 3, 4
Delegation of patient care tasks to other healthcare workers is one of the most important
responsibilities of the registered nurse. When delegating tasks, the nurse must take into
consideration the skills and competency of the team members as well as the condition and
needs of the clients receiving care. The nurse is also responsible for supervising patient
care to ensure that it is competently delivered.
PTS:1DIFifficultREF:dm 12-13
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
3. An experienced nurse serves as a mentor to a new graduate. Which of the
following are responsibilities of the person being mentored? Choose all that apply.
1)
Demonstrates an ability to move toward independence
2)
Has the ability to encourage excellence in others
3)
Seeks feedback and uses it to modify behaviors
4)
Demonstrates flexibility and an ability to change
ANS: 1, 3, 4
The ability to encourage excellence in others is a responsibility of the mentor.
Responsibilities of the person being mentored are the following: demonstrates an ability
to move toward independence; seeks feedback and uses it to modify behaviors; and
demonstrates flexibility and an ability to change.
PTS:1DIF:ModerateREF:p. 8; Box 45-2
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
Completion
Complete each statement.
is the ability to influence
•
Compared with management,
other people with or without an official appointment to a position in the
organization.
ANS: leadership
PTS: 1 DIF: Easy REF: p. 2
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
is the ability to influence other people despite resistance
•
from them. Said another way, it is the ability of one person or group to impose his,
or their, will on another person or group.
ANS: Power
PTS:1DIF:ModerateREF:p. 10
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
•
A(n) is someone with more experience who provides career
development behaviors.
ANS: mentor
PTS:1DIF:EasyREF:dm 6-7
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
•
A(n) is an employee of an organization who has the power,
authority, and responsibility for planning, organizing, coordinating, and directing
the work of others.
ANS: manager
Chapter 37 Community & Home Health Nursing
Identify the choice that best completes the statement or answers the question.
1. The inhabitants of Yulupa, California, form which of the
following? 1)
Aggregate
2)
Community
3)
Population
4)
Vulnerable population
ANS: 3
A population is all of the people inhabiting a specified area. In contrast, a community is a
group of like-minded individuals or one whose members have a common purpose, and an
aggregate has shared characteristics. A vulnerable population is an aggregate with
increased risk for poor health outcomes.
PTS: 1 DIF: Moderate REF: p. 1499
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
2. A community health nurse prepares for a new assignment. She has been
assigned census tracts 131 and 132. This large area crosses the border of two towns and
includes 4,000 people. What components of the community must the community health
nurse assess prior to beginning her new assignment?
1)
Income levels, health status, and relationships among groups
2)
Structure of the tracts, effectiveness of the community, and current status
3)
Number of clients with health problems compared to the number of healthcare providers
4)
Community organizations and beliefs about their role in the community
ANS: 2
To understand a community and its needs, the nurse must assess the communitys structure,
status (the biological, social, and emotional outcome components of the community), and
process (overall effectiveness of the community). Income level and demographic data,
such as community organizations and healthcare providers, are included in the assessment
of the community structure. The number of clients with health problems is only a part of
the assessment of the community status.
PTS:1DIFifficultREF:p. 1500
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Analysis
3. A community health nurse is evaluating the current health programs in
the community. Which of these outcomes would indicate a healthy community?
1)
Ninety percent of members report adequate access to primary care services.
2)
Immunization services are available at hospitals and clinics.
3)
Affordable housing in the community is under construction.
4)
Mortality rates have been stable over the past 5 years.
ANS: 1
Evidence of health in a community can be judged by examining progress in the focus
areas delineated in Healthy People 2020. Access to primary care services is a measurable
outcome that provides evidence of effectiveness of health programs. The availability of
immunization services at the hospital or at many offices does not provide evidence that
these services are being utilized. Similarly, the fact that affordable housing is under
construction does not mean that it is being accepted and used or that enough is being built.
Mortality rates may be stable but could be quite high and within unacceptable parameters.
PTS:1DIFifficultREF:p. 1500
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis
4. What is the type of nursing with a focus on the community as a whole and
the health status of individuals as an aggregate?
1)
School nursing 2)
Community health nursing 3)
Community-oriented nursing
4)
Public health nursing
ANS: 4
Public health nursing focuses on the community at large and the eventual effect of the
communitys health status on the health of individuals, families, and groups. Community
health nursing focuses on the health of individuals, families, and groups and on how their
health affects the health of the community. Community-oriented care combines elements
of community health nursing and public health. School nursing focuses on optimizing
health for a community of students in a school setting.
PTS: 1 DIF: Moderate REF: p. 1501
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
5. The community health nurse is working with the residents of governmentsubsidized senior housing. She meets with them regularly to discuss concerns and
evaluate whether they receive healthcare that meets their needs. Which of the following
nursing roles best describes these actions?
1)
Case manager
2)
Client advocate 3)
Collaborator
4)
Counselor
5)
Educator
ANS: 3
As a collaborator, the nurse forges partnerships and coalitions that can effectively address
common concerns among different communities. In this role, the nurse facilitates
discussion to work toward problem resolution. As a case manager, the nurse makes
referrals to or collaborates with other health and social agencies. In the client advocate
role, the nurse supports the identified or voiced concerns of the client or community. As an
educator, the nurse focuses on wellness and disease prevention through patient teaching. A
counselor offers practical solutions to resolve problems.
PTS:1DIF:ModerateREF:p. 1502
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
6. A community health nurse gathers information about how individuals in a
low- income neighborhood perceive the community and its state of health. Which of the
following assessment strategies would be appropriate?
1)
Conducting a windshield survey while driving
2)
Reviewing a multitude of community databases
3)
Interviewing residents living on every fifth block
4)
Analyzing demographic data on the community
ANS: 3
To assess community perceptions, the nurse will need to interact with a cross-section of
the community. Interviewing residents is one way to find out about community concerns
and opinions. The other methods are assessment strategies that will provide data about the
community but do not offer information on how community members view the
community.
PTS:1DIF:ModerateREF:dm 1506-1507
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
7. The community health nurse has gathered data about the community. She
identifies many weaknesses in the community health system that contribute to poor health
outcomes. What should be her next step?
1)
Prioritize the list of problems.
2)
Validate the data.
3)
Evaluate the effectiveness of the interventions.
4)
Plan the care.
ANS: 1
After a thorough assessment, the nurse compiles a list of community strengths and
weaknesses. Once this list is in place, the nurse must prioritize the list considering the
client needs, funding, and political feasibility.
PTS:1DIF:ModerateREF:p. 1507
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
8. The similarities between the Omaha System and the NANDA-I taxonomy
are that both contain which of the following?
1)
Evaluation tools expressed in standardized language
2)
Nursing diagnoses expressed in standardized language
3)
Diagnoses, outcomes, and interventions
4)
Labels that are intended for use in any healthcare setting
ANS: 2
NANDA-I and the Omaha System both contain nursing diagnoses expressed in
standardized language. The Omaha System also contains outcomes and interventions.
The Omaha System was developed for use in community settings, whereas NANDA-I
may be used in all settings.
PTS:1DIF:ModerateREF:p. 1507
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
9. A nurse serving the community in a public health role would likely
perform which of the following functions within a particular community?
1)
Tracking the prevalence of gonorrhea between January and June
2)
Screening for scoliosis among 12- to 14-year-old girls in middle school
3)
Weighing premature infants receiving phototherapy at home
4)
Giving the H1N1 vaccine to fire and police personnel
ANS: 1
Public health nursing focuses on the community at large and the eventual effect of the
communitys health status on the health of individuals, families, and groups. The goal of
public health is to prevent individual disease and disability, in addition to promoting and
protecting the health of the community as a whole, such as tracking the prevalence of
disease. Activities, such as scoliosis screening, home care, and vaccination program, are
examples of community health nursing.
PTS:1DIF:ModerateREF:p. 1501
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
10. A community health nurse planning a new program for teen pregnancy
prevention designs a community assessment covering the structure of her target. Which
of the following areas would she include?
1)
Number of residential and commercial buildings
2)
Demographic data of the residents 3)
Morbidity and mortality rates of the population
4)
Common strategies for conflict resolution
ANS: 2
Structure refers to the general characteristics of a community. These include demographic
data, such as gender, age, ethnicity, and educational and income levels, as well as data
about healthcare services, such as the number of primary care providers or emergency
departments in the area.
PTS:1DIF:ModerateREF:p. 1500
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application
11. A patient was involved in a motor vehicle accident that resulted in multiple
traumatic injuries. He was hospitalized for 8 days in the intensive care unit and 3 days on
the surgical floor. He has been discharged home with home health support. Identify the
primary goal of his home care:
1)
Provide comprehensive direct care.
2)
Promote sleep and rest for healing.
3)
Teach the patient and family how to provide care. 4)
Explain how home care differs from hospital care.
ANS: 3
The primary goal in home healthcare is to promote self-care. Nursing activities are
directed at fostering independence or teaching the family or other caregivers to assist the
client with ongoing needs. Care continues to be comprehensive; however, rather than
providing direct care for all needs, the emphasis shifts toward fostering independence.
PTS:1DIF:ModerateREF:p. 1510
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
12. Today is the last day of work on the medical-surgical unit for a nurse who has
decided to work in home care. A patient asks her why she is going to home care. Select a
response that best illustrates the advantages of home care.
1)
Care is much more comprehensive and unhurried in the home; it is more enjoyable for
nurses to work in home care.
2)
Home care is much more organized than hospital care; you have access to the whole
team, and there is less interference from others.
3)
A home health nurse has more autonomy and skills than a hospital nurse; Ill get to do
more.
4)
In home care I can see my patients in their personal environment; this will help me
understand them more and allow me to give personalized care.
ANS: 4
The home is the clients personal environment: a window into the patients life. The nurse is
able to see how the patient lives, interacts, and negotiates the world. Care, in the home and
hospital, is comprehensive. In both locations, the nurse has obligations to other patients
and will need to watch her schedule. The level of enjoyment a nurse has with her job is
dependent on many factors. A disadvantage to home care is the lack of immediate
assistance from other members of the health team. Home care nurses may be more
autonomous than hospital nurses; however, their scope of practice is identical.
PTS:1DIF:ModerateREF:p. 1511
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
13. A 56-year-old man is hospitalized because of poorly controlled diabetes and a
leg ulcer that developed as a complication of diabetes. He is awake, alert, and oriented but
fatigued and in need of wound care. In the hospital, he was placed on insulin and started
on a variety of oral medications. He is learning how to check his blood sugar and
administer insulin. He has never given himself insulin, and he does not understand how to
interpret his blood sugar readings. The physician has prescribed discharge from the
hospital with home health follow-up. Is this an appropriate referral?
1)
Yes; the patient is in need of skilled services and, therefore, is eligible for home care
services.
2)
Yes; the patient has been unable to control his diabetes, is noncompliant, and needs to be
monitored.
3)
No; the patient should remain hospitalized; he has too many needs for home care
services.
4)
No; the patient is relatively young and oriented; he should be able to provide his own
care.
ANS: 1
A client must require skilled services in order to be eligible for home care services. This
patient needs wound care, to be taught about diabetes care, and to be monitored. These are
all skilled services. All of these needs can be met with home care services. He is alert and
oriented, which is important for planning teaching sessions.
PTS:1DIFifficultREF:p. 1511
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Synthesis
14. A home health nurse is working with a physical therapist and home health
aides to work out a schedule for their visits that will best address the patients needs.
Which nursing role does this demonstrate?
1)
Direct care provider
2)
Client and family educator
3)
Client advocate 4)
Care coordinator
ANS: 4
A care coordinator manages and coordinates the services of members of the healthcare
team and develops a plan of care that addresses the clients needs. Direct care involves
hands-on tasks, such as dressing wounds and administering medications. The educator
role involves communicating with clients and families to help them develop the skills
involved to administer self-care. A client advocate supports the clients right to make
decisions and protects the client from harm if he is unable to make decisions.
PTS:1DIF:EasyREF:p. 1512
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
15. A home health nurse has called his patient to arrange an initial home visit and
has driven to the home. What is the nurses objective in the first few minutes of the visit?
1)
Develop rapport and trust with the patient and family.
2)
Gather demographic data and complete the referral form.
3)
Assess the patients most important health needs.
4)
Determine the patients needs for ongoing care.
ANS: 1
All of these objectives are appropriate for the home health visit. However, the first few
minutes of the initial visit set the tone for the relationship among client, nurse, family, and
agency. In that time, the nurse focuses on developing rapport and trust. Once rapport and
trust have been developed, the nurse can gather data, assess the client, and determine the
need for ongoing care.
PTS: 1 DIF: Moderate REF: p. 1516
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Synthesis
16. Documentation in home healthcare may take many forms. Some nurses use
NANDA-I terminology for diagnoses, whereas others use the Clinical Care Classification
(CCC) system. The chief benefit of the CCC system is that it:
1)
Contains diagnoses specific to home care, whereas NANDA-I does not.
2)
Is simpler to use and more readily understood by other disciplines.
3)
Is linked to the OASIS reporting forms required by Medicare.
4)
Uses standardized terminology, whereas NANDA-I does not.
ANS: 3
Home care nurses more commonly use the CCC because it is linked to the OASIS
reporting forms required by Medicare. The CCC was developed for use in home care;
however, the diagnoses themselves are not specific to home care. They can be used in any
setting. NANDA-I, NIC, and NOC all use standardized language that may be used in any
setting, including home healthcare. NIC and NOC have some interventions and outcomes
that are specific to home care use.
PTS:1DIF:ModerateREF:p. 1517
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
17. A 56-year-old woman provides care to her 91-year-old widowed father. She
says she is frequently fatigued and that she no longer socializes with her friends. Im so
busy taking care of my dad. Its really hard work because he is bedridden. Sometimes it
breaks my heart when I have to feed and bathe him. He always seemed so strong when I
was a child. The most appropriate nursing diagnosis for this woman is:
1)
Caregiver Role Strain
2)
Impaired Home Maintenance
3)
Interrupted Family Processes
4)
Risk for Caregiver Role Strain
ANS: 1
This caregiver is experiencing fatigue, isolation, and difficulty adjusting to role changes.
These are signs of Caregiver Role Strain. Because symptoms exist, this is an actual
problem as opposed to a potential problem. There is no evidence of Impaired Home
Maintenance. Although family processes have been altered, this is not the best nursing
diagnosis based on the defining characteristics given.
PTS: 1 DIF: Moderate REF: p. 1517
KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application
18. The nurse is visiting a patient who lives in a single-room occupancy hotel. The
patient requires wound care and medication management. There is no running water in the
room, and the bathroom down the hall is in disrepair and filthy. The patients room is not
clean. What supplies would be essential for the nurse to bring with him when visiting this
client?
1)
All wound care supplies needed for the duration of the care
2)
Reclosable plastic bags for disposal of old dressings
3)
Small, biohazard sharps container to be left in the room
4)
Waterless, antibacterial hand sanitizer solution
ANS: 4
The nurse should use a waterless antibacterial hand sanitizer in place of soap and water
because there is no sink and conditions are filthy. The nurse should limit the supplies
brought into the home if the conditions are not clean. Wound care supplies, for example,
would be ordered and kept in the home. Old dressings should be double-bagged to
prevent leakage, and discarded in the home. There is no evidence that a sharps disposal
container is needed.
PTS: 1 DIF: Moderate REF: p. 1520
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
19. Which of the following unique aspects of home care do Medicare
reimbursement regulations require that the nurse include in documentation?
1)
Patient assessment data and interventions performed
2)
Patient response to care and assessment of environment
3)
Evidence of homebound status and continued need for skilled care
4)
Skilled care delivered and communication with other providers
ANS: 3
All of the aspects mentioned should be documented. However, the unique requirements
of home care include documentation of homebound status and the continued need for
skilled care.
PTS:1DIF:ModerateREF:p. 1513
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application
20. At a home visit, the nurse asks the patient, Have you taken your blood pressure
medicine today? The patient replies, I dont remember. Maybe. On the table are several
bottles of medication, some open, some not. They have all been prescribed for the patient.
The patient cannot say how often to take each one, when asked. A compartmentalized
medication organizer is on the table, with a few capsules in it, and some compartments left
open. What should the nurse do?
1)
Show the patient how to put the medications in the organizer for the next 2 days, and
observe while he fills the rest of the organizer.
2)
Arrange for a home health aide to come each day to show the patient which pills to take.
3)
Administer todays medications and arrange for the pharmacy to put medications in easyto-open containers in the future.
4)
Fill the organizer for each day of the week, explain how to use it, and return in a day or
two to evaluate
ANS: 4
From the cues given, it seems likely the patient would not be able to accurately load the
medication organizerand, in fact, may not be able to use it properly to take the correct
medications at the correct time. The nurse would need to return every day or so until he is
certain that the patient can actually administer his own meds after someone else loads the
organizer. Showing the patient how to load the organizer solves part of the problem;
however, this would not allow the nurse to evaluate whether the patient would then know
to take the medications each day. Home health aides cannot be responsible for patient
medications. There is no indication that the patient is having difficulty opening his
medication containers, so there is no need to talk to the pharmacy.
PTS:1DIFifficult
REF: p. 1519; critical thinking needed to answer question
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
21. A family caregiver is learning to administer insulin injections to her
homebound sister. What should the nurse advise her to do with the used needles?
1)
Discard the needle and syringe in a thick plastic milk jug with a lid.
2)
Securely recap them and place them a paper bag in the household trash.
3)
Remove the needle and put it in a coffee can with a lid; put the syringe in the trash.
4)
Do not recap the needle; break it by bending it on the tabletop.
ANS: 1
The caregiver should discard the syringe and needle in a thick plastic milk jug with a lid,
a metal coffee can with a lid, or a commercial sharps container. Patients and caregivers
should not recap used needles. They should not remove the needle from the syringe or
attempt to break it because this increases the risk of needlestick injury.
PTS:1DIF:ModerateREF:p. 1520
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. A community health nurse prepares for a new assignment. She has been assigned
census tracts 131 and 132. This large area crosses the border of two towns and includes
4,000 people. As a community health nurse, she recognizes that assignments are based on
census tracts because census tracts do which of the following? Choose all that apply.
1)
Define the geopolitical boundaries of a community. 2)
Are made up of persons who share a common heritage and customs.
3)
Divide populations into smaller groups that can be assessed more readily.
4)
Are natural divisions in communities that are based on voting patterns.
ANS: 1, 3
Census tracts are derived from the national census. They typically include 1,500 to 8,000
people. The area of the tract varies based on the density. Census tracts show geopolitical
boundaries that are useful to anyone who studies the characteristics and concerns of
smaller groups of people.
PTS:1DIF:ModerateREF:p. 1499
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level:
Comprehension
2. A community health nurse is assigned to work in a different area of the
city. Which of the following assessment techniques would she likely use to develop
an overview of the community? Choose all that apply.
1)
Windshield survey
2)
Review of demographic data
3)
Physical assessment of a sample of the inhabitants
4)
Review of the records of area providers
ANS: 1, 2
A windshield survey and review of demographic data provide data about the community.
She may interview area residents about their experiences or ideas about this community;
however, physical examination of a sample of the inhabitants would not give her
community-level data. Similarly, she may wish to meet with area providers, but
reviewing their records violates HIPAA laws and assumes that the records accurately
reflect the health concerns of the population.
PTS:1DIF:ModerateREF:p. 1506
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
3. Which of the following groups represents a vulnerable population? Choose
all that apply.
1)
Homeless persons with no known illnesses
2)
Women who have experienced domestic violence
3)
Fifth-grade students at the local elementary school
4)
Persons with type 1 diabetes mellitus
ANS: 1, 2, 4
Vulnerable populations include those with limited economic or social resources, the very
young and the very old, those with chronic disease, and people who have experienced
abuse or trauma.
PTS:1DIF:ModerateREF:dm 1500-1501
KEY: Nursing process: Assessment | Client need: Physiological Integrity | Cognitive
level: Application
4. Which of the following is a primary intervention? Choose all that
apply. 1)
Immunization for meningitis of college-bound students
2)
Safer sex education for high school students
3)
Lobbying for health education in the schools
4)
Tuberculosis screening via PPD testing
ANS: 1, 2, 3
Primary interventions are interventions that occur before disease appears. The goal of
primary interventions is to promote health and prevent disease. Secondary interventions
aim to reduce the impact of the disease process by early detection and treatment. Tertiary
interventions aim to halt disease progression and restore client functioning.
PTS:1DIF:ModerateREF:p. 1503
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
5. Identify the nurse who is acting as a community health nurse. Choose all
that apply.
1)
School nurse who provides screening and direct care in the elementary school
2)
Parish nurse who offers health education after services each Sunday
3)
Nurse who works for the Red Cross by providing disaster relief 4)
A nurse administering vaccines to inmates in a correctional facility
ANS: 1, 2, 3, 4
Community health nurses function as client advocates, counselors, case managers,
educators, and collaborators for patients and their families in the community setting. All
of these nurses are working in community health settings in roles as school nurse, parish
nurse, disaster nurse, and prison nurse.
PTS: 1 DIF: Easy REF: dm 1501-1503
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
6. Which of the following interventions has a public health focus? Choose all
that apply.
1)
Controlling the blood sugar of a diabetic client with cardiovascular disease
2)
Assisting with the launch of an after-school program in a high-crime neighborhood 3)
Providing an influenza vaccination program for seniors and persons with chronic illness
4)
Offering counseling to the family of a child with severe cognitive deficits
ANS: 2, 3
Public health nursing focuses on the community at large and the eventual effect of the
communitys health status on the health of individuals and families. Diabetic care is
focused on individual health. Family counseling is focused on family health.
PTS:1DIF:Moderate
REF:p. 1501; question involves critical thinking with synthesis of information acquired
from reading this passage
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application
7. Which of the following clients would most likely require home health
services? Choose all that apply.
1)
45-year-old man with an injured rotator cuff that requires surgery
2)
32-year-old terminally ill woman with a supportive family
3)
92-year-old man living independently with multiple medical problems
4)
6-year-old with a fractured hip requiring a leg and pelvic cast
ANS: 2, 3
Home care is appropriate for a client with health needs that exceed the abilities of family
and friends. Older adults who wish to avoid placement in a skilled nursing facility, those
who require ongoing skilled care after discharge from the hospital, the terminally ill, and
persons with chronic illness that must be monitored to avoid hospitalization are the most
likely home health clients.
PTS:1DIF:Moderate
REF: p. 1510; critical-thinking item requires synthesis of knowledge acquired from
passage
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
8. Which of the following services are provided by home health agencies?
Choose all that apply.
1)
Direct care of clients in the home, performing treatments
2)
Indirect care such as provision of medication and supplies
3)
Acute care services for clients with complex diseases
4)
Respite care of clients to relieve family caregivers
ANS: 1, 2, 4
Home care agencies provide direct, indirect, and respite care in the home. Acute care
services are provided in the hospital.
PTS:1DIF:ModerateREF:p. 1511
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
9. Home healthcare and home hospice care are two different types of home
health services. What are the differences between these services? Choose all that apply.
1)
Home healthcare promotes independence in clients; home hospice care promotes comfort
and quality of life.
2)
Home healthcare promotes comfort and symptom management; hospice care promotes
self-care.
3)
Home healthcare is focused on teaching self-care; home hospice care is focused on
teaching skilled care to caregivers.
4)
Home hospice care is focused on managing symptoms; home healthcare is focused on
fostering independence.
ANS: 1, 4
The purpose of home healthcare is to promote self-care and foster independence. The
purpose of home hospice care is to promote comfort and quality of life by managing
symptoms.
PTS: 1 DIF: Moderate REF: p. 1512
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
10. The nurse has been assigned to a caseload of home health clients.
Before making home visits, which two planning activities must she perform first?
1)
Order supplies for the home care services.
2)
Review the cases to determine the reasons for the visits.
3)
Contact the clients to arrange for the visits.
4)
Develop a schedule for the day so that all visits can be made.
ANS: 2, 3
All of these interventions are appropriate. However, it is essential to determine the nature
of the visits and to secure permission for visiting before the nurse can order supplies and
plan her day.
PTS: 1 DIF: Difficult REF: p. 1514
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
11. The nurse is visiting a client who resides in a single-room occupancy hotel.
Groups of people are leaning against the building and smoking on the steps. There is
obvious drug abuse occurring in the lobby and halls of the building. There is no running
water in the room, and the bathroom down the hall is in disrepair and filthy. A primary
concern that the nurse must consider when making this visit is safety. Which of the
following actions are appropriate safety measures? Choose all that apply.
1)
Notify the police that the nurse plans to visit this site.
2)
Carry something that can be used as a weapon if necessary.
3)
Inform the home health agency of the nurses route and time of visit.
4)
Do not visit if the nurse senses danger when he arrives at the site.
ANS: 3, 4
Safety is a primary consideration in home care. The nurse should file a route and planned
schedule with the agency. In addition, he should not enter the building if he feels he may
be in danger. He should notify the police if he senses danger, but not to tell them of a
planned visit. The nurse should always carry a cell phone to alert police when security is
threatened. It is not recommended that the nurse carry a weapon.
PTS:1DIF:ModerateREF:dm 1514-1515
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
12. The nurse is visiting a patient who lives alone in a two-room house. The
patient requires wound care and medication management, but his health is not expected to
improve much, even with care. There is no running water in the house, and the bathroom
is in disrepair and filthy. At the first home visit, which of the following should the nurse
assess? Choose all that apply.
1)
Wound status
2)
Patient concerns 3)
Ability to perform care independently
4)
End-of-life planning
ANS: 1, 2, 3
The nurse should assess the patients status, condition of the wound, concerns, and ability
to perform care independently. End-of-life care is a topic the nurse may wish to explore
after a relationship has developed.
PTS:1DIF:Easy
REF:dm 1516-1517; critical-thinking item requiring synthesis of previously acquired
knowledge
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
True/False
Indicate whether the statement is true or false.
1. Florence Nightingale is known as the first community health
nurse. ANS: F
Florence Nightingale was influential in community health because she established the
importance of promoting health by manipulating the environment. Lillian Wald is known
as the first community health nurse.
Chapter 40 Ethics & Values for Nursing Practice
Identify the choice that best completes the statement or answers the question.
1. A 77-year-old woman with an inoperable brain tumor has been hospitalized for
the past 5 days. Her daughter comes to visit her. The patient has asked that her daughter
not be told her diagnosis. After visiting with her mother, the daughter asks to speak to the
nurse. She says, My mother claims she has pneumonia, but I know she is not telling me
the truth. The daughter asks the nurse to tell her what is truly wrong with her mother. The
nurse should tell her that:
1)
Her mother has an inoperable brain tumor, but does not wish anyone to know.
2)
She needs to speak to the physician in charge of her mothers care.
3)
Her mother has requested that her case not be discussed with anyone, not even family.
4)
Her mother is very sick with a serious case of pneumonia that could lead to death.
ANS: 3
The nurses first allegiance is to the patient and her desire for confidentiality. Telling the
daughter to speak to the physician would place the physician in the same position as the
nurse. Telling her that her mother has pneumonia would be a lie. The nurse, of course,
should inform the physician of the patients wishes so that he will be prepared if the
daughter questions him about her mothers health condition.
PTS:1DIF:ModerateREF:p. 1529
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
2. Which of the following terms refers to the ethical questions that arise out
of nursing practice?
1)
Nursing ethics
2)
Bioethics
3)
Ethical dilemma 4)
Moral distress
ANS: 1
Nursing ethics refers to ethical questions that arise out of nursing practice. Bioethics is a
broader field that refers to the application of ethics to healthcare. An ethical dilemma
occurs when a choice must be made between two equally undesirable actions, and there is
no clearly right or wrong option. Moral distress occurs when someone is unable to carry
out his or her moral decision.
PTS:1DIF:ModerateREF:V1, p. 1526
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
3. A belief about the worth of something that serves as a principle or a standard
that influences decision making is called which of the following?
1)
Morals
2)
Attitudes
3)
Beliefs
4)
Values
ANS: 4
A value is a belief you have about the worth of something that serves as a principle or a
standard that influences decision making. Morals are private, personal, or group standards
of right and wrong. Attitudes are mental dispositions or feelings toward a person, object, or
idea. A belief is something that one accepts as true.
PTS: 1 DIF: Difficult REF: p. 1530
KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall
4. A 45-year-old patient is ventilator dependent after a high cervical neck injury.
He is conscious and competent and has decided that he wants to be removed from the
ventilator. His family and the multidisciplinary team agree. The nurse believes the patient
intends suicide and would prefer he choose differently but says nothing. The nurse
remains at the bedside holding the patients hand. In this instance the nurse is displaying
which of the following?
1)
Value set
2)
Value system
3)
Value neutrality
4)
Value awareness
ANS: 3
Value neutrality occurs when we put aside our own values regarding an issue in order to
provide nonjudgmental care to clients. A value set is your list of values. A value system is
your value set with the values ranked on a continuum from most important to least
important.
PTS:1DIF:ModerateREF:p. 1532
KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application
5. A 45-year-old patient is ventilator dependent after a high cervical neck injury.
He is alert and oriented and, after giving it much thought, has decided that he wants to be
removed from the ventilator. The nurse believes the patient intends suicide but supports
his final decision. When the ventilator is removed, the nurse remains with the patient to
support him. The nurses action demonstrates respect for what moral principle?
1)
Nonmaleficence
2)
Autonomy
3)
Beneficence
4)
Fidelity
ANS: 2
Autonomy refers to a persons right to choose and his ability to act on that choice. In this
case, the nurse respects the patients right to choose to die. Nonmaleficence is the twofold
principle of doing no harm and preventing harm. Beneficence is the duty to do or promote
good. Fidelity is the obligation to keep promises.
PTS:1DIF:ModerateREF:p. 1534
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
6. Which of the following consequentialist theories takes the position that the
value of an action is determined by its usefulness?
1)
Ethics of care
2)
Utilitarianism
3)
Deontology
4)
Categorical imperative
ANS: 2
Utilitarianism is a consequentialist theory that takes the position that the value of an action
is determined by its usefulness. An ethics of care is a nursing philosophy that directs
attention to the specific situations of individual patients viewed within the context of their
life narrative. Deontology considers an action to be right or wrong independent of its
consequences. A categorical imperative is a principle, established by Immanuel Kant, that
states that one should act only if the action is based on a principle that is universal.
PTS:1DIF:EasyREF:p. 1532
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
7. The ability of nurses to base their practice on professional standards of ethical
conduct and to participate in ethical decision making is known as which of the following?
1)
Ethical agency
2)
Attitudes
3)
Belief
4)
Value neutrality
ANS: 1
Ethical agency is the ability of nurses to base their practice on professional standards of
ethical conduct and to participate in ethical decision making. Attitudes are mental
dispositions or feelings toward a person, object, or idea. A belief is something that one
accepts as true. Value neutrality is when we attempt to understand our own values
regarding an issue and to know when to put them aside, if necessary, to become
nonjudgmental when providing care to clients.
PTS: 1 DIF: Moderate REF: p. 1527
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
8. Identify the third step in the MORAL decision-making
model. 1)
Reassess the dilemma
2)
Resolve the dilemma
3)
Review the problem
4)
Recall the history of the problem
ANS: 2
MORAL is an acronym for the following steps: M, Massage the dilemma; O, Outline the
options; R, Resolve the dilemma; A, Act by applying the chosen option; L, Look back and
evaluate.
PTS: 1 DIF: Easy REF: dm 1540-1541
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
9. A patient has asked the nurse to explain her laboratory results. The nurse
informs the patient that he must first assist another patient to the bathroom and then he
will explain the results. The nurse assists the other patient to the bathroom and then
returns to explain the results to the patient. What moral principle has the nurse displayed?
1)
Nonmaleficence
2)
Autonomy
3)
Beneficence
4)
Fidelity
ANS: 4
Fidelity is the obligation to keep promises. Autonomy refers to a persons right to choose
and his ability to act on that choice. Nonmaleficence is the twofold principle of doing no
harm and preventing harm. Beneficence is the duty to do or promote good.
PTS:1DIF:ModerateREF:p. 1535
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
10. The nurse is a member of the ethics committee. An alert, oriented, and
competent 87-year-old man has asked to have a DNAR order put on his chart. The
patients family does not agree with his decision and requests the ethics committee to
intervene on their behalf. The ethics committee would most likely use which model in
this patients case?
1)
Social justice
2)
Patient benefit
3)
Autonomy
4)
DNAR determination
ANS: 3
The autonomy model is useful when the patient is competent to decide. This model
emphasizes patient autonomy and choice as the highest values. The patient benefit model
assists in decision making for the incompetent patient by using substituted judgment. The
social justice model focuses more on broad social issues involving the entire institution
rather than on a single patient issue. There is no DNAR determination model.
PTS:1DIF:ModerateREF:p. 1542
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Synthesis
11. A 60-year-old patient with a treatable form of breast cancer has decided not
to pursue radiation or chemotherapy. The nurse believes that the patient should be
treated. She coerces her into receiving treatment by continuing to remind the patient
about her responsibilities for raising her children. What type of behavior has the nurse
displayed? 1)
Nonmaleficence
2)
Autonomy
3)
Paternalism
4)
Beneficence
ANS: 3
Paternalistic behavior occurs when the nurse thinks she knows what is best for a
competent patient and coerces the patient to act as she wishes rather than to act as the
patient originally desired. Autonomy refers to a persons right to choose and his ability to
act on that choice. Nonmaleficence is the twofold principle of doing no harm and
preventing harm. Beneficence is the duty to do or promote good.
PTS:1DIF:ModerateREF:p. 1535
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
12. Nursing codes are:
1)
Legally binding.
2)
Not legally binding.
3)
Legally binding in some circumstances.
4)
Not admissible in court.
ANS: 2
Codes of ethics are open to public scrutiny. The ethical aspects of nursing work, just like
the technical aspects, are subject to review by professional groups and licensure boards,
which may use sanctions to punish code violations. However, nursing codes are not
legally binding.
PTS:1DIFifficultREF:p. 1536
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
13. An alert, oriented, and competent frail older adult man has been told that he is
dying and has asked to have a DNAR order put on his chart. The patients family does not
agree with his decision and asks the healthcare team to ignore the request. After a great
deal of discussion among the physician, nurse, and family, they are no closer to resolution
of the conflict. The nurse asks the hospital chaplain to come and help the
family and the team understand each others opposing views. Which step of the MORAL
model does this illustrate?
1)
MMassage the dilemma
2)
OOutline the options
3)
RResolve the dilemma
4)
LLook back and evaluate
ANS: 2
This illustrates the Outlining-options step. In Massaging the dilemma, the team would
already have identified and defined the issues in the dilemma, and considered the values
and options of all the major players. At the Outlining the options step, someone should
delineate all of the options to all parties, including those that are less realistic and
conflicting. In that step, someone often asks a member of the ethics committee or the
hospital chaplain to help the parties understand the opposing viewpoints. Resolving the
dilemma is the step in which all the options are reviewed and basic moral principles and
frameworks are applied to arrive at a decision. Looking back to evaluate is done after a
decision has been made and acted on. At that time, the entire process, including the
consequences, is evaluated to determine how well it worked.
PTS: 1 DIF: Difficult REF: dm 1540-1541
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
14. An alert, oriented, and competent frail older adult man has been told that he is
dying, and has asked to have a DNAR order put on his chart. The patients family does not
agree with his decision and asks the healthcare team to ignore the request. The healthcare
team does not comply with the familys wishes, and after several days the family takes the
matter to court. The court sides with the family and orders the healthcare team to remove
the DNAR order. This is an example of which of the following?
1)
An integrity-producing (good) compromise
2)
An ethically sound compromise
3)
Settlement of an issue by force
4)
An effort to keep peace on the unit
ANS: 3
This is clearly an example of settling an issue by force, bringing in a more powerful
entity (the court) to force the healthcare team to do what the family wants. It is not a
compromiseof any sortbecause neither party backed away from its original position, and
the action that was taken was not agreed on by both parties. This was not an effort to
keep peace. The familys effort was to settle the disagreement in their favor. If the
healthcare teams goal had been to keep peace on the unit, they would have acceded to the
familys wishes without the need for court order.
PTS:1DIFifficultREF:p. 1542
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which of the following is an example of whistle-blowing? Choose all that
apply. 1)
Reporting fraudulent billing practices
2)
Reporting patients health status against the patients wishes
3)
Reporting unsafe work practices
4)
Reporting a coworker for working under the influence of drugs
ANS: 1, 3, 4
Reporting a patients health status against the patients wishes is a breach of patient
confidentiality. Whistle-blowing is identifying incompetent, unethical, or illegal situations
or actions of others in the workplace and reporting to someone who may be in a position to
rectify the situation. Fraudulent billing practices are illegal and unethical; unsafe work
practices are unethical and illegal; and a coworker under the influence of drugs is a risk to
patients, as well acting in an illegal and unethical manner.
PTS: 1 DIF: Moderate REF: p. 1528; requires critical thinking
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis
2. The nurses obligations in ethical decisions include which of the
following? Choose all that apply.
1)
Be a patient advocate.
2)
Involve institutional ethics committees.
3)
Improve ones own ethical decision making.
4)
Respect patient confidentiality.
ANS: 1, 2, 3, 4
The nurses obligations in ethical decisions include being a patient advocate, using and
participating in institutional ethics committees, and improving ethical decision making.
Confidentiality is a basic patient right. The nurses role is to uphold that right.
Chapter 41 Legal Accountability
Identify the choice that best completes the statement or answers the question.
1. A pregnant 15-year-old girl presents to the emergency department (ED) of the
local private hospital. She has been transported by her mother and appears to be in active
labor. The girl is crying uncontrollably and says she is scared and experiencing painful
contractions. Her mother states, We dont have any money or insurance, but this hospital is
closer than the public hospital, and she needs help now. What is the first step that the ED
staff should take?
1)
Arrange for an ambulance to transport her to the nearest public hospital.
2)
Explain to the girl and her mother that the hospital only accepts patients who can pay the
hospital bill.
3)
Examine her to determine if her condition is stable or if she requires immediate medical
attention.
4)
Inform her mother that she will need to transport her daughter to the nearest public
hospital.
ANS: 3
When a client comes to the ED requesting examination or treatment for an emergency
medical condition (including labor), the hospital must provide stabilizing treatment; the
client cannot be transferred until she is stable.
PTS:1DIF:ModerateREF:p. 1550
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
2. For the patient with no healthcare coverage who is seeking medical care, the
emergency department staff members decide whether to provide care or transport to a
public facility based on which law, enacted by Congress in 1986 and updated in 2003?
1)
Health Care Quality Improvement Act (HCQIA)
2)
Patient Self-Determination Act (PSDA)
3)
Newborns and Mothers Health Protection Act (NMHPA)
4)
Emergency Medical Treatment and Active Labor Act (EMTALA)
ANS: 4
The intent of the Emergency Medical Treatment and Active Labor Act (EMTALA) is to
ensure public access to emergency services regardless of ability to pay. The EMTALA
prohibits patient dumping, which is transferring indigent or uninsured patients from a
private hospital to a public hospital without appropriate screening and stabilization. An
exception is made if a hospital does not have the capability to stabilize a patient or if the
patient requests a transfer.
PTS:1DIFifficultREF:p. 1550
KEY:Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
3. A patient tells you that chart entries made by the nurse from the previous day
indicate he was uncooperative when asked to ambulate. He says this is not true and asks
his record be corrected. You understand that, if what he says is accurate, he has the right
to have the documentation error corrected based on which of the following regulations?
1)
Americans with Disabilities Act (ADA)
2)
Patient Self-Determination Act (PSDA)
3)
Health Insurance Portability and Accountability Act (HIPAA)
4)
Health Care Quality Improvement Act (HCQIA)
ANS: 3
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule of 2004
provides comprehensive protection for the privacy of protected health information
(confidentiality of patient records). In addition, patients have the right to see and copy
their medical records and to reconcile incorrect information.
PTS:1DIF:ModerateREF:p. 1550
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
4. Upon initial assessment of a 75-year-old patient, you identify bruises and
scratches on the patients arms, legs, and trunk in various stages of healing. You notify
your supervisor when you suspect the patient may be a victim of physical abuse. You are
complying with which of the following state laws?
1)
Good Samaritan Law
2)
Mandatory Reporting Law
3)
Nurse Practice Act
4)
Nursing Standards of Practice
ANS: 2
Under state mandatory reporting laws, nurses must report to designated authorities (e.g.,
Adult Protective Services) suspected physical, sexual, emotional, or verbal abuse or
neglect by healthcare workers or family members. In general, nurses who fail to report
suspected abuse or neglect may be held criminally or civilly liable.
PTS:1DIF:ModerateREF:p. 1552
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application
5. Nursing codes of ethics support which of the
following? 1)
Patients can receive emergency treatment regardless of their ability to pay.
2)
Nurses will educate patients about advance directives.
3)
Nurses with HIV must disclose their condition to their employer.
4)
Patients have the right to dignity, privacy, and safety.
ANS: 4
In the Patient Bill of Rights, patients have the right to dignity, privacy, and safety.
Although they are not laws, nursing codes of ethics specify ethical duties of the nurse to
the patient as related to corresponding patient rights. Although patients do have a right to
receive emergency medical care regardless of their ability to pay, this is not part of the
nursing code of ethics. Likewise, a nurses role is to educate patients about advance
directives; this is a goal supported by nursing organizations but is not part of the code of
ethics.
PTS:1DIF:ModerateREF:p. 1553
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
6. The charge nurse in a progressive care unit assigns the care of a patient receiving
hemodialysis to a newly hired licensed practical nurse (LPN) without checking to see that
the nurse has been determined competent to care for hemodialysis patients. The LPN is in
orientation and fails to inform the charge nurse that she does not have experience with this
type of patient. The actions of the charge nurse would be considered to be which of the
following?
1)
Malpractice
2)
Incompetence
3)
Negligence
4)
Abandonment
ANS: 3
Negligence is the failure to use ordinary or reasonable care or the failure to act in a
reasonable and prudent (careful) manner. It is negligent to assign a nurse to care for a
patient without verifying the nurse has training, experience, and clinical competence in
caring for such patients.
PTS:1DIF:ModerateREF:p. 1557
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
7. In which of the following circumstances might the nurse defer
obtaining informed consent for care and treatment of a patient?
1)
The patient is confused and cannot understand or sign the consent form.
2)
The patient is brought to the emergency department in cardiac arrest; no family is
present.
3)
The surgeon requests that the patient be sent to the surgical suite before you get the
consent form signed.
4)
An unconscious patient is admitted to your unit; he is alone.
ANS: 2
Informed consent is the necessary authorization by the patient for any and all types of care
and must be written and signed by the patient or the person legally responsible for the
patient for hospital admission and for invasive or specialized treatments or diagnostic
procedures. Written consent is not necessary in an emergency if experts agree that there
was an immediate threat to life or health. The physician responsible for the care of the
patient has the duty to obtain informed consent from the patient.
PTS:1DIF:ModerateREF:p. 1563
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
8. A 4-year-old child is brought to the emergency department by his mother. He has
a large bruise in his left chest and multiple contusions on his face. His mother tells you her
boyfriend intentionally pushed the child down the stairs in anger. The child appears to be
in a great deal of pain. Which of the following four items should the nurse do first?
1)
Notify the nursing supervisor of the suspected physical abuse.
2)
Complete a physical assessment of the child.
3)
Obtain an order for pain medication.
4)
Notify Child Protective Services of the suspected abuse.
ANS: 2
Although the nurse must report to designated authorities (Child Protective Services)
suspected physical abuse, the primary responsibility of the nurse in this situation is to
evaluate the patients physical condition and extent of his injuries in order for appropriate
medical treatment to be provided. Pain medication should not be administered prior to a
thorough physical assessment. The nurse should always notify the nursing supervisor if
any outside agencies may need to be contacted.
PTS:1DIF:Moderate
REF: p. 1552; critical-thinking item requires synthesis of previously acquired knowledge
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
9. You are caring for an alert, oriented 47-year-old patient who is recovering from
abdominal surgery. The patient becomes angry and upset and says, Im leaving this
hospital. Remove my IV and surgical drains or I will do it myself. In order to keep him
from removing his lines and leaving the hospital, you apply bilateral wrist restraints until
you can contact the physician for an order for patient restraint. This is an example of
which of the following?
1)
Assault and battery
2)
Felony
3)
False imprisonment
4)
Quasi-intentional tort
ANS: 3
False imprisonment involves an intentional or willful detention of a patient without
consent or authority to do so. Restraining a patient without consent is another form of civil
false imprisonment. Competent patients have a right to leave an institution, even if it is
harmful to their health. Whenever possible, have the person sign a form stating that he is
aware that he is leaving against medical advice.
PTS:1DIF:ModerateREF:p. 1557
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
10. A registered nurse forgot to put the side rails up for a confused patient.
The patient fell out of bed and fractured his hip. The patient sues and wins a judgment
(award) for $2 million. The nurse has an occurrence policy with double limit coverage of
$3 million/$10 million that covered the time period when the incident occurred. The
statement that best describes the nurses situation is that her insurance policy will:
1)
Not cover her.
2)
Pay $4 million.
3)
Pay $2 million.
4)
Pay 75% of the $2 million
ANS: 3
An occurrence policy will cover those claims that occurred during the time the policy was
in effect. However, the policy will pay up to $3 million per claim; because the amount
awarded does not exceed this, the nurse is covered.
PTS:1DIFifficultREF:dm 1566-1567
KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis
11. A registered nurse administers the wrong medication to a patient. She does not
notify anyone of the error and documents that the correct medication was administered.
The nurse was reported to the state board of nursing. Which of the following actions can
the state board of nursing take against the nurse in this situation?
1)
Disciplinary action against the nurses license to practice
2)
Criminal misdemeanor charges against the nurse
3)
Medical malpractice lawsuit against the nurse
4)
Employment release from the institution
ANS: 1
The state board of nursing is empowered to initiate disciplinary action against the nurses
license for professional misconduct. The board does not bring criminal charges or
sentence the nurse to jail; that is the parameter of the state prosecutor and judge. A
patient or the person harmed can bring medical malpractice lawsuits against the nurse.
PTS: 1 DIF: Moderate
REF:dm 1553, 1555
KEY: Nursing process: Intervention | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which of the following are examples of invasion of privacy by nurses?
Choose all that apply.
1)
Searching a patients belongings without permission
2)
Reviewing the plan for patient care in the lunchroom
3)
Discussing healthcare issues for an unconscious patient with his power of attorney
4)
Releasing patient health information to local newspaper reporters
ANS: 1, 2, 4
Invasion of privacy violates a persons right to be free from unwanted interference in her
private affairs, such as occurs in discussing patient matters in a public setting; searching
patients private items without their permission; and releasing private information to the
public. A durable power of attorney is a document empowering a person selected by the
patient to make healthcare decisions in the event that the patient is unable to do so. It is
permissible to discuss pertinent issues related to the welfare of the patient with the person
holding a power of attorney.
PTS:1DIF:EasyREF:p. 1557
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
2. While you are admitting an adult patient, he asks you whether he should create
an advance directive. To provide him adequate information to make an informed
decision, you should tell the patient which of the following? Choose all that apply.
1)
If he is unable to communicate, his family may make changes to his advance directive.
2)
Once he signs an advance directive, no further care will be provided to him.
3)
He may change his advance directive by telling his physician or by making changes in
writing.
4)
An advance directive will ensure he gets as much or as little care as he wishes.
ANS: 3, 4
Advance directives include living wills and durable powers of attorney. A living will
establishes the patients wishes regarding future healthcare should he become unable to
give instructions. A patient may specify actions in a living will that are not supported by
family members, such as a desire for a do not resuscitate order, or for as much or as little
care as he wishes. A person may change or revoke an advance directive at any time.
Changes and written revocation should be signed and dated and shared with the patients
physician. Even without an official written change, orally expressed direction to the
physician generally has priority over any statement made in an advance directive as long
as the patient is able to decide for himself and can communicate his wishes.
PTS:1DIF:ModerateREF:dm 1550-1551
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application
3. What do negligence and malpractice have in common? Choose all that
apply. 1)
Negligence and malpractice are non-intentional torts.
2)
Negligence and malpractice are felonies.
3)
Malpractice is the professional form of negligence.
4)
Negligence and malpractice involve the intent to do harm to a patient.
ANS: 1, 3
Negligence and malpractice are non-intentional tortsnurses can be negligent without
intending to do harm. Negligence is simply the failure to use ordinary or reasonable care
as dictated by the standards of practice and/or by what a reasonable and prudent nurse
would do in the same or similar circumstances. Intent is not an element of negligence.
When a nurse or other licensed professional healthcare provider is negligent and fails to
exercise ordinary care, it is called malpractice. Malpractice is the professional form of
negligence.
PTS: 1 DIF: Moderate REF: p. 1557
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis
4. You are caring for a patient with renal failure. His morning laboratory results
reveal an abnormal potassium level of 6.8. This value is more elevated than on the
previous day, when the level was within normal limits. You page the patients physician,
but he does not return your call right away. You become busy with another patient and
forget to notify the physician again and fail to mention the critical laboratory value to the
oncoming nurse during shift report. Which of the following does this scenario illustrate?
Choose all that apply.
1)
Failure to implement a plan of care
2)
Failure to evaluate
3)
Malpractice
4)
Failure to assess and diagnose
ANS: 1, 2, 4
Failure to implement a plan of care and failure to evaluate are two of the most common
causes of nursing malpractice claims. The above scenario represents a failure to follow
standards of care, failure to communicate, and failure to document, which are in the
category of failure to implement a plan of care. It also represents a failure to assess and
report a significant change in the patients condition, which is part of the category
of failure to evaluate. The nurse did assess the potassium level and recognize that it was
too high.
PTS: 1 DIF: Difficult REF: dm 1559-1560
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
Completion
Complete each statement.
1.The American Nurses Association (ANA) believes nurses should not participate in
active euthanasia (and assisted suicide) because such acts violate
.
•
the Patient Self-Determination Act
•
civil laws
•
the Good Samaritan laws
•
the Code
of Ethics for Nurses
ANS: 4
The ANA defines assisted suicide, a form of active euthanasia, as providing a patient the
means to end his life, with full knowledge of the patients intentions to do so. The ANA
believes that participation in active euthanasia violates the Code of Ethics for Nurses and
the ethical traditions of the profession.
PTS: 1 DIF: Moderate
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Recall
2.Prioritize the following guidelines for nursing practice in order of specificity (14, with
4 being the most specific).
State laws
•
Institutional policies and procedures
•
Federal laws
•
•
State nurse practice acts
ANS: 3, 1, 4, 2
Institutional policies and procedures are usually more specific and detailed than standards
set by professional organizations. State nurse practice acts identify the minimum level of
nursing care for a specific patient in specific situations. Standards in nurse practice acts are
set forth in statutes and enforced by authority granted by the state. Federal laws, both
constitutional and statutory, affect nursing practice in the most general terms.
Chapter 38 Informatics
Identify the choice that best completes the statement or answers the question.
1. In informatics, raw, unprocessed numbers, symbols, or words that have
no meaning by themselves are called which of the following?
1)
Information
2)
Data
3)
Knowledge
4)
Wisdom
ANS: 2
Data are raw, unprocessed numbers, symbols, or words that have no meaning by
themselves. Information consists of groupings of data processed into a meaningful,
structured form. Knowledge is formed when data are grouped, creating meaningful
information and relationships, which are then added to other structured information.
Wisdom is the appropriate use of knowledge in managing or solving human problems.
PTS:1DIF:EasyREF: p. 1572
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
2. Which informatics concept concerns the appropriate use of knowledge
in managing or solving human problems?
1)
Wisdom
2)
Data
3)
Knowledge
4)
Information
ANS: 1
Wisdom is the appropriate use of knowledge in managing or solving human problems.
Data are raw, unprocessed numbers, symbols, or words that have no meaning by
themselves. Information consists of groupings of data processed into a meaningful,
structured form. Knowledge is formed when data are grouped, creating meaningful
information and relationships, which are then added to other structured information.
PTS:1DIF:EasyREF:p. 1573
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
3. Computers are important for evidence-based practice
because: 1)
They are available in all healthcare institutions.
2)
Extra training is not required for information retrieval.
3)
Information can be accessed and managed more efficiently.
4)
All of the best evidence is located on a computer.
ANS: 3
To incorporate the current, best evidence in your nursing practice, you must be able to
locate the evidence, evaluate its quality and relevance to the problem, and apply the
solution to clinical care. Computers are useful for data access, management, storage, and
retrieval when conducting research or reviewing research findings. Specialized software
aids in statistical analysis of research data. Computers are not available to all personnel in
all healthcare institutions nor can the entirety of best evidence be found electronically.
Training and experience are required to learn how to use a computer as well as how to
conduct a literature search.
PTS:1DIF:ModerateREF:p. 1582
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
4. You are a preceptor for a new nursing employee at the local hospital. She
needs to access a patients electronic health record (EHR) to retrieve laboratory results;
however, the newly hired nurse has not yet received a computer password. What action
should you take?
1)
Give her your password to use until she obtains her own password.
2)
Log on and remain with her while she views the record.
3)
Notify your supervisor that the new employee needs a password.
4)
Inform her that she will not receive a password until her orientation is complete.
ANS: 3
Never share your password with another person or log on to a computer to allow another
access to information. Instead, notify your supervisor that the new employee needs a
password. In most hospitals, nurses are given a password during their orientation.
PTS:1DIF:ModerateREF:p. 1581
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
5. Review the following: 38 years old; growth in height to 52; female
gender; weight gain of 15 pounds. This list can be referred to as which of the
following?
1)
Information
2)
Knowledge
3)
Data
4)
Patient record
ANS: 1
The segments are grouped into a meaningful, structured form and are considered together
as information. However, 38, 52, female, 15 standing alone would be examples of raw,
unprocessed numbers, symbols, or words that have no meaning by themselves and
therefore would be data.
PTS:1DIF:ModerateREF:p. 1572
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis
6. CINAHL is a(n):
1)
Popular periodical.
2)
Internet site.
3)
Scholarly journal.
4)
Literature database
ANS: 4
CINAHL, The Cumulative Index of Nursing and Allied Health Literature, is a literature
database covering nursing, allied health, biomedical, and consumer health journal
articles. CINAHL may be accessed by the Internet or in hard copy in most libraries.
PTS: 1 DIF: Easy REF: p. 1583
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
7. A nurse is entering a pharmacy request for patient medication in the patients
electronic health record (EHR) while seated at a computer in the nursing station. A
physician approaches her and asks her to access another patients EHR so that he can look
at the patients laboratory report. Which of the following is the best action for the nurse to
take?
1)
Access the lab report for the physician.
2)
Log off the computer before proceeding.
3)
Quickly finish the pharmacy requisition before the physician logs on.
4)
Allow the physician to access the laboratory report without logging out.
ANS: 2
The nurse should log off the computer and then allow the physician to log on under his
own password. Accessing information that is not relevant to the care that the nurse is
providing is a HIPAA violation. Rushing to complete a pharmacy request for patient
medication is a situation of risk for medication error. The nurse should never hurriedly
order or administer medication because that is when errors are more likely to occur. The
nurse should never allow anyone to use her password to access information.
PTS:1DIFifficult
REF: p. 1581; critical thinking item requiring synthesis of knowledge acquired from text
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
8. What is (are) the primary benefit(s) of computer physician order entry
(CPOE)? 1)
Increased privacy
2)
Improved access to patient data
3)
Cost savings 4)
Reduced medication errors
ANS: 4
Computer physician order entry (CPOE) is technology that allows healthcare providers to
enter orders into a computerized prescribing system instead of handwriting them. Orders
are integrated with patient information, including allergy history and laboratory and other
prescription data. The new order is then automatically checked for potential errors or
problems. This reduces prescription errors resulting from illegible penmanship. It can
detect dosing errors by flagging medication dilution or dosages that fall outside normal
dosing standards. The system warns about the possibility of a drug interaction, allergy, or
incorrect dose. As some drug names sound like other drugs, CPOE can alert prescribers
and potentially avoid a drug error that could be serious or fatal. Although the efficiencies
of the CPOE reduce costs, it is not the primary benefit of the system. Likewise, orders
entered into the computer are more conveniently accessed by nurses and pharmacists, but
the most important benefit of CPOE is to reduce errors.
PTS:1DIFifficultREF:p. 1578
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which of the following are main functions of a computer? Choose all that
apply. 1)
Process
2)
Storage
3)
Memory
4)
Output ANS:
1, 2, 4
Memory refers to the amount of space available for storage of digital information on a
computer. The four main functions of a computer are input, process, output, and storage.
PTS: 1 DIF: Moderate REF: p. 1573
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
2. Which of the following aspects of a computer determine its power? Choose
all that apply.
1)
User friendliness
2)
Speed of operations
3)
Accessibility for the user
4)
Data storage capacity
ANS: 2, 4
The power of a computer is determined by its speed, accuracy, reliability, and data
storage and processing capabilities. Although ease of use and accessibility are important
features for users, these factors do not determine the power of a computer.
PTS:1DIFifficultREF:p. 1573
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
3. Which of the following health information is protected in the electronic
health record? Choose all that apply.
1)
Social Security number
2)
Insurance information
3)
Physicians name
4)
Laboratory results
ANS: 1, 2, 4
A patients protected health information includes any individually identifiable health
information; current, past, or potential physical or mental conditions; and any payment
information, such as Social Security numbers or insurance.
PTS: 1 DIF: Moderate REF: p. 1574
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
4. The nurse is preparing to pass the 0900 medications prescribed for her patients.
She removes the medications from the automated dispensing unit. When scanning the
medication, an alert notifies the nurse that the patient is allergic to this medication. What
action should the nurse take? Choose all that apply.
1)
Override the alert and administer the medication.
2)
Confirm the patients allergies and type of reaction.
3)
Notify the prescriber of the patient medication allergy.
4)
Be sure an antidote is available at the patients bedside.
ANS: 2, 3
Alerts are configured to notify the nurse of potential adverse effects before the patient
receives the medication. Sometimes patients state they are allergic to a medication when,
in reality, they may only have experienced a side effect. The physician or pharmacist can
be instrumental in discerning if the patients reaction was a true allergy. The physician
should always be notified before administering medications when an allergy error has been
received. Although an antidote to a medication could be useful in the event of a harmful
effect, the medication in the situation should not be given, and therefore, the antidote
would not be necessary.
PTS:1DIFifficult
REF: p. 1580; critical thinking is necessary to answer question
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application
Completion
Complete each statement.
is the managing and processing of information necessary
•
to make decisions.
ANS: Informatics
PTS: 1 DIF: Moderate REF: p. 1572
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
is the use of telecommunication to send
•
healthcare information between patients and professionals at different
locations.
ANS: Telehealth
PTS:1DIF:ModerateREF:p. 1575
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
tools. ANS: social
3.Facebook, MySpace, and LinkedIn are examples of
networking
PTS:1DIF:EasyREF:dm 1574-1575
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 4.
such as NIC, NOC, NANDA-I, and PNDS can be used to describe the unique
nursing contributions to patient care.
ANS: Standardized nursing languages
Standardized nursing languages communicate health information, promote evidencebased practice using health records, decrease medical error, and protect patient privacy
and confidentiality. However, no single nursing language currently describes all of the
aspects of nursings contribution to care. Use of standardized terminology helps to match
like terms within the electronic medical record.
Chapter 12 Spirituality
Identify the choice that best completes the statement or answers the question.
1. The concept of holism focuses on which of the
following? 1)
Relationship between nurse and patient
2)
Practice of spiritualism
3)
Relationships among all living things
4)
Totality of the body
ANS: 3
The concept of holism focuses on the relationships among all living things.
PTS:1DIFifficultREF:p. 2
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
2. A patient is receiving healthcare focused on his illness and counteracting
his symptoms. What type of healthcare is he receiving?
1)
Holistic
2)
Integrative
3)
Complementary
4)
Allopathic
ANS: 4
Allopathic care is conventional medical care focused on counteracting symptoms.
Holistic healthcare uses the concept of holism to focus on the relationships among all
living things. Integrative healthcare encompasses all traditional and alternative health
practices used by a patient. Complementary healthcare is alternative care used in
conjunction with traditional medical care.
PTS: 1 DIF: Moderate REF: p. 3
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
3. A client has a diagnosis of chronic pain. The physician has prescribed tramadol
hydrochloride (Ultram) for the pain. The patient also receives therapeutic touch (TT)
from a practitioner three times a week. In this situation, TT is considered to be which of
the following?
1)
A complementary modality
2)
An alternative modality
3)
A placebo response
4)
Holistic healthcare
ANS: 1
A complementary modality is one that is used alongside traditional medical care. The
patient receives prescription medication from a physician as well as receiving TT. An
alternative modality is one that is used instead of traditional medical care. A placebo
response is the clients expectation that a treatment will be effective. Holistic healthcare
uses the concept of holism to focus on the relationships among all living things.
PTS: 1 DIF: Moderate REF: p. 3
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
4. A client tells the nurse that he is having difficulty sleeping. He says, I dont
want to use sleeping pills, but Im thinking about getting some melatonin. Which of the
following is most important for the nurse to include in a response to the client?
1)
Melatonin is an effective treatment for certain sleep disorders.
2)
Melatonin appears to be a relatively safe sleep aid for most people.
3)
You may experience some side effects, such as elevated blood pressure. 4)
Before taking melatonin, you should consult your primary care provider.
ANS: 4
All of the statements are true about melatonin; however, side effects are rare. It is most
important to consult the primary care provider because melatonin is known to interact
with other medications, including prescription medications. Therefore, the client should
talk with the provider about this possibility.
PTS:1DIFifficultREF:p. 14
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
5. A woman is receiving physical therapy after surgery to repair a hip fracture. She
tells the therapist before therapy begins that she expects therapy to be very painful. She
rates her pain as 1 on a scale of 1 to 10 before therapy. Three minutes into the treatment
session, the patient complains of excruciating pain rated as 10 and says she cannot
tolerate exercise any longer. The therapist is concerned with the amount of pain, because
severe pain is not expected during that form of exercise. The therapist considers the
patient could be experiencing:
1)
Phantom limb pain.
2)
Ineffective pain medication. 3)
A nocebo effect. 4)
A complication from the surgery.
ANS: 3
The nocebo effect is a demonstration of the power of the mind to create bodily distress.
The patient was expecting the treatment to be very painful, and this tends to increase the
treatment discomfort. Phantom limb pain is sometimes experienced after an amputation
but has nothing to do with surgery to repair a hip fracture. There is no evidence that the
patients pain medication is ineffective or that she is experiencing a complication from
surgery.
PTS:1DIF:ModerateREF:p. 3
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis
6. Identify the holistic nursing theorist who describes disease as
disequilibrium, which stimulates the person toward growth and regaining wholeness.
1)
Jean Watson 2)
Margaret Newman 3)
Martha Rogers
4)
Charles Darwin
ANS: 2
Margaret Newman identifies disease as disequilibrium, which stimulates the person
toward growth and regaining wholeness. Jean Watson identifies caring as the primary
focus of nursing. Martha Rogers states that the environmental energy field is in constant
and meaningful interaction with the human energy field. Charles Darwin created the
theory of natural selection. He is not a nursing theorist.
PTS:1DIFifficultREF:p. 5
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
7. A client wishes to avoid taking blood pressure medications. He is eating a
healthy diet and exercising regularly. In addition, a CAM therapist has recommended an
alternative therapy that will allow him to learn voluntary control over his blood pressure.
What type of therapy is the therapist probably recommending?
1)
Homeopathy
2)
Naturopathy
3)
Biofeedback
4)
Hypnosis
ANS: 3
Biofeedback is a technique by which people learn voluntary control over typically
involuntary activities. Homeopathy is based on an understanding of how the body heals
itself and an acceptance that all symptoms represent the bodys attempt to restore itself to
health. Naturopathy is the belief that nature and each living being have the innate ability to
establish, maintain, and restore health. Hypnosis is a trancelike state characterized by
relaxed brain waves, hypersuggestibility, and heightened imagination. Hypnosis has been
used to promote relaxation, weight loss, and smoking cessation and to suppress various
symptoms.
PTS:1DIF:ModerateREF:dm 9-10
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
8. What is the best rationale to gather data about patients use of herbal
products? 1)
The nurse practice act requires RNs to monitor all drug dosages.
2)
Herbal products need to be evaluated for research purposes.
3)
Patients medication records must be kept accurate.
4)
Many herbs are known to interact with medications.
ANS: 4
Many herbs are known to interact with medications and to affect some disease processes
adversely. Nurse practice acts do require RNs to assess patients but do not specifically
require monitoring of drug dosages. Herbal products do need to be evaluated in research,
and medication records must be accurate, but they do not provide the rationale for patient
data collection.
PTS:1DIF:ModerateREF:p. 11
KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application
9. A patient at the Integrative Health Clinic is scheduled for a massage
technique that promotes unblocking of a terminal nerve in order to improve function
along that nerve pathway. What type of therapy is he receiving?
1)
Myofascial release
2)
Shiatsu massage
3)
Swedish massage
4)
Reflexology
ANS: 4
Reflexology is a massage technique that promotes unblocking of a terminal nerve in order
to improve function along that nerve pathway. Myofascial release restores balance,
alignment, and mobility to the body by releasing tension in the soft connective fasciae.
Shiatsu massage is a finger pressure method that balances the energy force in the body.
Swedish massage is used to induce relaxation and restore flexibility.
PTS:1DIF:ModerateREF:p. 15
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level:
Comprehension
10. Therapeutic touch, Reiki, and Qigong are examples
of: 1)
Energy therapies.
2)
Manipulative therapies.
3)
Biologically based therapies.
4)
Mindbody interventions.
ANS: 1
Therapeutic touch, Reiki, and Qigong involve manipulation of energy fields and are
classified as energy therapies. Manipulative therapies focus on body manipulation and
movement to improve health. Biologically based therapies use substances found in
nature, such as food, herbs, vitamins, and aromatherapy. Mindbody therapies are based
on awareness of the unity of the mind and body and on the ability of social, familial, and
economic factors to affect all aspects of health and illness.
PTS: 1 DIF: Moderate REF: dm 15-17
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level:
Comprehension
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which of the following beliefs is an essential component of holistic
healthcare? Choose all that apply.
1)
Illness occurs when there is a shift in an individuals balance.
2)
Regardless of the type of care received, ultimately all healing is self-healing.
3)
More healthcare resources should be focused on alternative healers.
4)
Illness can create an opportunity for personal and spiritual growth.
ANS: 1, 2, 4
Foundational beliefs of holistic care include the following: illness reflects a shift in
balance, all healing is self-healing, and illness creates an opportunity for growth.
Although holistic healthcare includes the use of alternative modalities, it does not
emphasize the use of healthcare resources (money, time, etc.) for alternative healers.
PTS: 1 DIF: Moderate REF: p. 3
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Synthesis
2. Which of the following complementary and alternative modalities may
be considered alternative medical systems? Choose all that apply.
1)
Acupuncture
2)
Prayer
3)
Ayurveda
4)
Aromatherapy
ANS: 1, 3
Acupuncture and Ayurveda are considered alternative medical systems. Prayer is a
mindbody intervention, and aromatherapy is a biologically based therapy.
PTS:1DIF:EasyREF:dm 5-7
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension
3. Which of the following are reasons for the popularity of biologically based
therapies, such as dietary supplements and herbal products? Choose all that apply.
1)
They are almost all readily available to consumers.
2)
They can be practiced as self-care measures.
3)
It is easy to know what dosage you are obtaining from a product.
4)
Products on the market have been proven to be safe to use.
ANS: 1, 2
Biologically based therapies use substances found in nature, such as food, herbs, vitamins,
and aromatherapy. These therapies are readily available and are often practiced as self-care
measures, so people who do not wish to see a practitioner may not need to do so. The U.S.
Food and Drug Administration (FDA) regulates biologically based therapies and is
developing guidelines for good manufacturing practices (GMPs). However, dosage and
manufacturing processes are not standardized. The Federal Trade Commission monitors
dietary supplements for truth in advertising. At present, it is difficult to know what dosage
you are obtaining from a product, and safety cannot always be guaranteed.
PTS:1DIF:ModerateREF:p. 10
KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis
4. An elderly client with a history of COPD is having difficulty sleeping and does
not wish to see a medical practitioner. Which of the following strategies should the nurse
discourage the client from using, or urge him to see a physician before beginning the
therapy? The client has not used any of these therapies in the past. Choose all that apply.
1)
Aromatherapy
2)
Tai chi 3)
Yoga
4)
Melatonin
ANS: 3, 4
Aromatherapy is known to be safe, and may be effective. Tai chi is safe for older adults
and may be effective for sleep. Yoga is possibly effective for sleep, but it is physically
rigorous, so it has the potential to be harmful for older adults, who may have a variety of
chronic conditions. The client should see a physician before beginning yoga. Melatonin is
effective for certain sleep disorders, but it does interact with several prescription drugs.
Therefore, the client should not take melatonin without consulting a physician.
PTS:1DIFifficult
REF: dm 9, 11, 14, 15; not stated directly in text: critical thinking required
KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application
Completion
Complete each statement.
is the vital process of discovering meaning,
•
purpose, fulfillment, and values in life.
ANS: Spirituality
PTS:1DIFifficultREF:p. 4
KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Recall
, specifically for health reasons, is probably the
•
most commonly used CAM therapy.
ANS: Prayer